JAPAN P& I CLUBVol.40 September 2017

P&I Loss Prevention Bulletin
The Japan Ship Owners’
Mutual Protection & Indemnity Association Loss Prevention and Ship Inspection Department

CASE STUDY
Collision

EngineOil Spill

TroubleAccident

JAPAN P& I CLUBP&I Loss Prevention Bulletin

Contents
Introduction…………………………………………………… 1§3

Traffic Systems of the Kii Suido (Strait)
and Tokyo Bay …………………………………… 36§1

What is Safety?…………………………………… 1§1-1

What is Safety?…………………………………… 1§1-2

Safety and Technicians…………………………… 2§1-3

Safety and Culture………………………………… 3§3-1	The Kii Suido (Strait)(See Fig. 30: Attachment ①

Traffic System Chart Enlargement)………………… 36§3-2

Management) /ETM (Engine-room Team

§4

Engine Trouble and Oil Spill Accidents……… 40

Management)……………………………………… 7§4-1

Feature of Trouble and Damages (Attachment ③§1-5	BTM・ETM：From Grave-post Type to

See ‘4 Cycle Diesel Engine of vessel’)……………… 40

Preventative Type Analysis/Counter Measure…… 8§4-1-1

Damage that Affects Ship Operation……………… 40

Training of Inexperienced Officers and Engineers§4-1-2

Damage Characteristics - by Equipment ………… 41

with Low Skill Levels……………………………… 13§2

Collision…………………………………………… 15§2-1

Summary of Accident……………………………… 15§2-2	Analysis of Accident Cause by Japan Transport§4-2

Cases……………………………………………… 43§4-2-1Case ①

Applicable Navigation Act………………………… 20§4-2-2

Case ②

Crank Pin Bearing Damage Accident…… 46§4-2-3

Case ③

Oil Spill Accidents……………………… 47§4-3

Accident Analysis in Accordancewith Error Chain…………………………………… 53§4-3-1Case ①§2-2-3	Analysis of Accident Cause by Japan Transport
Safety Board (Marine Sub-committees)………… 22§2-2-4	Preventive Measures by Japan Transport Safety
Board………………………………………………… 23§2-3	Analysis Combining Human Characteristics andPreventive Measures……………………………… 23§2-3-1Analysis of Accident Causes……………………… 23

Piston Seizing and Piston Skirt
Broken Damage………………………… 53§2-2-2	Analysis of Accident by Japan Transport Safety
Board ……………………………………………… 21

Piston Seizing and Piston Skirt
Broken Damage Accidents…………… 43

Safety Board (Marine Sub-committees)………… 20§2-2-1Tokyo Bay (See Fig. 31: Attachment ②
Tokyo Bay Traffic System Chart Enlargement)…… 38§1-4	Human Characteristics and BTM (Bridge Team

§1-6

The Kii Suido (Strait)§4-3-2

Case ②

Crank Pin Bearing Damage Accident…… 57§4-3-3

Case ③

Oil Spill Accident……………………… 60§4-4A nalysis with an ETM(Engine-room Team Management) Overview…… 65§4-5

Preventive Measures……………………………… 67§4-5-1

Relationship between Accidents and Causes…… 67§4-5-2Preventive Measures……………………………… 72§4-6

Proposals for Vessels with a Tight Operation
Schedule…………………………………………… 73§2-3-2	Analysis of Accident Causes which can be
Commonly Seen Regarding the Third Officers

Conclusion…………………………………………………… 74

of Vessel A and B…………………………………… 27

List of References…………………………………………… 74§2-3-3	Analysis According to Human Characteristics
for the Masters of Vessel A and B………………… 32

Attachments…………………………………………………… 75
Attachment ①：The Kii Suido (Strait) Traffic System Chart(Enlarged drawing of Fig. 30)……………………… 75§2-4

Preventive Measures……………………………… 33§2-4-1The Third Officers of Vessels A and B…………… 33§2-4-2The Masters of Vessels A and B………………… 34

Attachment ③：4 Cycle Diesel Engine of Vessel…………… 77§2-4-3

Management on Shore

Attachment ④：Cases of Additional Engine Troubles(Ship Management Company)…………………… 35

Attachment ②：Tokyo Bay  Traffic System Chart(Enlarged drawing of Fig. 31)……………………… 76(3 Cases) …………………………………………… 78

JAPAN P& I CLUBIntroduction
There are many kinds of maritime accidents such as collisions, groundings, fires, sinkings, damage to harbour facilities, oil spills and engine troubles. However, about 90% of the causes of these maritime accidents are said to be due tohuman error. In this bulletin, we will introduce case studies which are based on real incidents that incurred collisions,engine troubles and oil spills. Along with these, ‘Preventive Measures’ will be analyzed from the viewpoint of humanerror.

§1

What is Safety?
§1-1

What is Safety?

On May 2015, we held a seminar entitled ‘Thinking Safety’
which was issued in the P&I Loss Prevention Bulletin
Vol.35. Before introducing the actual incident cases, wewould first like to review ‘what safety is’. (Please refer tothe above P&I Loss Prevention Bulletin Vol.35.)
Seafarers are always expected to operate their vessel in asafe condition, which never causes any accidents.
Expressions such as ‘Safe Operation’ and ‘we pray for yoursafe voyage’ are used frequently, however the meaning of‘Safety’ is somewhat unclear.
We found an interesting ‘definition of Safety’, according to
the English psychologist Reason:

Fig. 1San Francisco Golden Gate Bridge

Safety ： Having resistance to danger to which an organization is constantly exposed.

－1－

JAPAN P& I CLUBP&I Loss Prevention Bulletin

More specifically, postulating that this world is exposed to threat, Reason defines `Safety` as the ability of an individualor the capacity of an organization to confront the threat.

Also Helen Adams Keller said:
Security is mostly a superstition. It does not exist in nature, nor do thechildren of men as a whole experience it. Avoiding danger is no safer inthe long run than outright exposure to danger.
That is to say ‘safety’ is simply the result of danger avoidance. Therefore, I believe that it is correct to assume that‘there is no such thing as safety’ in the world.

§1-2 Safety and Technicians
If we consider safety from the point of view that, not only the captain and chief engineer, but also the entire crew,
comprise a collection of technicians, there are many who view safety as being at the leading edge of technology, andan extension of technology itself. In other words, many are of the opinion that as ‘vessel technology’ and ‘skill of thecrew members’ are improved, it automatically maintains safety’.
It must be simply stated that this way of thinking is incorrect and dangerous. Japanese psychologist Professor Isao
Kuroda, Japan Human Factor Institute, emphasized‘Safety must be thought of as being a social value
beyond technology, a dimension beyond technology’. On the other hand, from the view point of technology
based on moving things, including vessels, it is specific to various fields, for example, technology employed in a
vessel, railway and vehicle operation: each is simply a means by which our lives are more enriched.
Thus, it is necessary to consider that, unless the crew at the frontline of safety in operating the vessel separate safety
and technology, unless they have a different dimension to safety, safety cannot be maintained.
However, when an accident occurs, the focus is on preventing a reoccurrence, and there is a strong tendency toanalyze it from a technical perspective. Thus, measures developed against reoccurrence are taken from a technicalperspective.
For example, a Maritime Accident Inquiry is held following a collision accident, and the vessel is found to be inbreach of Clause XX of the Maritime Collision Prevention Act. Consequently, the accident is the responsibility of theperson in contravention of the legislation, and that person is then subject to suspension of his/her license for a specified number of days. In other words, the focus is commonly on ‘who was responsible’, and the person in question ispunished, and everyone moves on. (The Maritime Accident Inquiry Law was revised in 2008 and the objective of thelaw is for disciplinary action to be taken against the designated marine officer who caused a maritime accident, whilst
Japan Transport Safety Board is in charge of analyzing preventive measures, also.)
However, this approach ‘does not investigate and analyze in practical detail’, when focusing on ‘the cause of theaccident’. For example, in the event of a collision caused by crossing vessels, all watch-keepers at brigde, who holda license and whom do not remember the clause completely, should know that ‘the vessel which has the other on her－2－

JAPAN P& I CLUBown starboard side shall keep out of the way’.
However, if we do not investigate and analyze in practicaldetail as to ‘why the marine officers did not or could
not take action to avoid the collision despite having
knowledge of these regulations’, without considerationof the human factors, ‘the measures developed to prevent
reoccurrence’, simply become a patch on the problem,
and a similar kind of accident is likely to reoccur as aresult.
Professor Kuroda referred to this as the ‘grave-post type’of safety measure, i.e. a safety measure which commemorates the accident, calls an end to it, and moves on,
without any connection to preventing reoccurrence.
Fig. 2

SMS Manual (Japanese only)

In fact, what we should really consider are social considerations, for example, ensuring that no lives are lost, or that no pollution occurs. It is necessary to consider safety fromthe point of view of preventative measures to ensure that the accident does not reoccur. Professor Kuroda referred tothis as the ‘preventative type’ of safety measure.
When we consider operation of a vessel, we focus on existing dangers for example, the danger of collision, the dangerof a cargo accident, the danger of damage to harbor facilities, and the danger of engine failure. We therefore see ‘how
to avoid these dangers’ as being associated with safety. As human beings, we face these dangers, and engage in activities to avoid them.

According to the above, ‘safety’ can be defined as:‘a conclusion or evaluation of the results on avoidance of these dangers'.

§1-3

Safety and Culture

Considerable energy is required to activate the system developed within safety management such as SMS manual(Safety Management System manual). This energy must be seen and derived from the safety culture. When we
consider this culture, we must see it in terms of the following three components. (See Fig. 3)－3－

JAPAN P& I CLUBP&I Loss Prevention Bulletin

１ Science
While this goes without saying, a theoreticalknowledge (e.g. physics) is necessary in the worldof ships. For example, why does a ship, which ismade of iron, float (Archimedes’principle), or
when stopping the vessel by astern engine, anunderstanding of acceleration is necessary tounderstand how far the vessel will move ahead

Technician

with a given horsepower applied, and how many
minutes it will take. Also, dynamics on how to loadcargo through weight distribution, so as not tobreak the hull, are involved.

2

Skill

Skill is the ability to use scientific theory. Skill

Technology

differs with the manner in which it is used. Skill isa methodology for effective use for the benefit ofsociety, and a means of taking scientific principles
to society. Similar to nuclear power, for instance,
the technology we end up utilizing depends on how
we utilize the science: it can be an atomic bomb or
a nuclear power plant, or a reactor powered vessel,

Scienceeven though the principles are same.

3

Technicians

Technicians are persons making the best use of theskills with a methodology derived from the technology. Persons who operate the safety management
system are also considered technicians.
Fig. 3Pyramid of Science, Technology (Engineering) and Technician（Maritime Officer）

Electronic Chart Display and Information Systems(ECDIS), GPS, AIS, Automatic Radar Plotting Aid(ARPA) and unmanned engine room operation (M0operation) have been introduced at a rate hitherto
unimaginable, and provide a much greater volume
of information than in previous visual format. In
addition, sounding alarms are also installed in thesedevices to notify the bridge of vessels which are at
risk of collision.

Fig. 4 Integrated Bridge System－4－

JAPAN P& I CLUBAt the same time, technicians are responsible for setting the point at which alarms are set, and for the decision as
to whether or not to use the various forms of information displayed.These devices do not automatically allow thevessel to avoid dangers in navigation. Until the development or the robotic vessel (unmanned vessel) of the future,
the captain and officers as technicians, will conduct an overall evaluation of the provided information and operate thevessel accordingly. In addition, vessels employing M0 operation are increasing in the engine room, and a considerable
proportion of operation is now automated. However, even if operation of individual engines can be automated, chiefengineer and engineers as technicians view the entire engine room as a plant that operates using the five senses toprevent problems, are still necessary. Also maintaining ‘Safety’ (avoidance of danger) should be done by humans(technicians).
Technicians are therefore required to acquire knowledge
and skills for safe operation of the vessel and machinery toensure safety, and obtain a seamen’s license as evidence of
having such knowledge and skills. In other words, because
safe operation of the vessel and machinery is extremelycomplex and difficult, ‘the scope of individual discretion’naturally becomes wider as a result of carrying out suchactivities.
It is, therefore, natural to consider a seaman’s license a
qualification that authorizes the holder to carry out theFig. 5 Seaman's License (Japanese)
above duties. However, there seem to be many officers andengineers that tend to believe that ‘they are not required toundergo further training, because they graduated’, once they succeeded in passing examinations and obtaining theirlicenses. But it must be simply stated that this way of thinking is incorrect. As described above, crew having boarded
the vessel after obtaining their licenses as first time officers and/or engineers, will have much technical experience tolearn, more than what the examination covers and will continue to improve their skills by themselves. Therefore wehave to consider them ‘not as graduates but simply as those who just started their seafaring life’.
‘Safe operation of the vessel, machinery and maintenance of the vessel’s schedule’ is the subject of much expectationfrom the wider society, but once they have trouble and fail to keep the vessel on schedule, there is not only economic
loss but credibility lost, also. For example, in the case that a container vessel sailing from Los Angeles, USA, witha large load of grapefruits in the reefer containers, sustained engine trouble en route in the Pacific Ocean and finallycould not arrive at Tokyo, Japan on schedule, there would be no grapefruits available at the market place in Tokyo.
While this was occurring, consumers that went to a supermarket to buy a grapefruit would discover that the supermarket had sold out. Then the consumer would instead visit a department store to find a grapefruit. However, the price ofthe grapefruit would be USD 30/pc. Finally the consumer would give up on purchasing one. Then, the consumer will
be disappointed because he/she cannot eat a grapefruit. On finding out through the newspapers that the reason why
grapefruits are not available in the market was the result of a container vessel’s engine trouble, he/she may lose faith
in the shipping company.
This is an extreme example, but we can understand that the ‘safe operation of the ship and its machinery’ is the subjectof much expectation from the wider society, and from this point of view, the following are required in Figs. 6 and 7:－5－

JAPAN P& I CLUBP&I Loss Prevention Bulletin

Mission of a Technician◉ Lifelong Learning◉ Calm evaluation of one’s own personality

Reform of sense
Fig. 6 Mission of a Technician

Once a technical framework has been established, think
about what is most important when it comes to using theframework in practice.
Be conscious about prevention and prediction all of the timein order to not cause an accident.

Concept of “ 5 W 1 H + 2 F ”
Fig. 7 Prevention and Prediction

In order to be more aware of prevention and prediction, it is required that ‘5 W 1 H + 2 F ’ are considered. 5W1H
refers to Fig. 8 below:

５Ｗ１Ｈ

When ?

Who ?

What ?

Where ?

Why ?

How ?

Fig. 8

5W1H

Recently, adding 2F (Fig. 9) is favored:

２Ｆ

For Whom ?

Fig. 9For What ?

+2F

In case of an accident occurring, the person in breach of the legislation is punished and the case is closed. But it is required that ‘For Whom’ is not only ‘for the person in contravention’ but also ‘for the company’ and also ‘for society’,and ‘For What’ is ‘for no more accidents concerning 5W1H’.
On the other hand, the question arises as to why a technician holding a ship officer’s license (Certificate of Competency: COC) causes the same types of accidents. It is because many technicians still believe that improved technology－6－

JAPAN P& I CLUBleads to improved safety, that safety is a result of technological advances. As already described before, ‘safety must be
thought of as a social entity that extends beyond the realm of technology’.
The ‘human factor’ and ‘human error’ must be introduced into the counter measure, so as for there ‘never to be areoccurrence of the same type of accident’, in the analysis. Rather, preventative type of safety measures are necessary
where we ask questions as to why the accident occurred, about the surrounding circumstances of the accident, andconsider the best means to prevent reoccurrence.

When formulating a countermeasure to prevent reoccurence, consider

Human Characteristcs
and analyse as to why such an action that led to an accident was taken.
Fig. 10 Human Characteristics§1-4

Human Characteristics andBTM (Bridge Team Management) /ETM (Engine Room Team Management)
If we assume that ‘humans are error-prone, including experts’, preventing human error is a matter of BTM and ETM
which have been designed to achieve safe vessel operation by raising awareness of bridge and engine room teams.
Before an explanation of BTM and ETM, let’s consider ‘Human Characteristics’.

(Human Characteristics)
The following are the “Human Characteristics” that can hinder appropriate procedures and judgment. (from Nihon
VM centte “Anzen no Komado” No.18 30/6/2002)

Twelve human characteristics❶ Human beings sometimes make mistakes❷ Human beings are sometimes careless❸ Human beings sometimes forget❹ Human beings sometimes do not notice❺ Human beings have moments of inattention❻ H uman beings are sometimes only able to❼ Human beings are sometimes in a hurry❽ Human beings sometimes become emotional❾ Human beings sometimes make assumptions
 Human beings are sometimes lazy
 Human beings sometimes panic H uman beings sometimes transgress whensee or think about one thing at a time

no one is looking

If we consider the above, it appears that human beings are nothing but a collection of defects and shortcomings, andit also even seems that human behaviour is in danger of re-occurrence. However, from another point of view, these
defects can be seen as ‘wonderful abilities of human beings’. The ‘human behaviour characteristic’ can consist ofadvantages and disadvantages, as follows.
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JAPAN P& I CLUBP&I Loss Prevention Bulletin
Simultaneously perform multiple tasks❶

Attention dispersal model⇔❷

Evaluate and act on assumptions⇔

Able to make overall decisions⇔

Able to make decisions efficiently❸❹

Make decisions on limited
information

Haphazard behavior⇔

effectively

Able to make flexible responses to suitthe conditions

However, human beings have a wide range of information input systems, along with a single system capable ofprocessing and judging. This system is easily interrupted, and the focus easily switched.
Furthermore, human beings tend to seek the comfortable option, to have real intentions and stated reasons, to be
sleepy in time zones, and to find work harder as they become older. These problems are controlled with ‘attentiveness’and ‘awareness’ as information processing sources, however they are limited and become causes of an inability to
avoid errors. For example, an investigation of the time zones in which vessel collisions occur show that they are mostcommon between 2am and 6am, and 2pm and 4pm, which means collisions are likely due to these factors.

§1-5 BTM・ETM ：From Grave-post Type to Preventative Type Analysis/Counter Measure
The basic concept of BTM is the same as ETM. This configuration is shown by the M-SHELL Model as follows.
As shown in Fig. 11, the person at the center (L: person responsible for the accident) is surrounded by thoseresources such as: ‘H: Hardware’, ‘S: Software’, ‘E: Environment’, and ‘L: Persons other than the person
responsible for the accident.’ Each resource is always in a state of change. This situation can be shown in termsof quivering rectangles. Here, if communication and cooperation between the person ‘L’ and those resources are insufficient, ‘L’ is unable to have sufficient contact with others and human error occurs; in consequence, safety is no longer
assured. To ensure that an error by a single individual does not create a hazardous situation, it is necessary to spot theerror quickly and work as a team to support one another and correct it. This is the basic concept of BTM and ETM.
As described above, all resources are never static. All resources function to ensure good mutual communication,
eliminate causes leading to the 12 characteristics of human beings or change point of view to achieve wonderfulability, and suppress the occurrence of errors. Even if L (You) and other resources generate human error, it is possible
to manage them in order to prevent errors in the communication gap of the entire team when it is being managed by
BTM or ETM.

－8－

JAPAN P& I CLUBIf there is a gap in the system,
an error will occur

L : You
H : Hardware
S : Software

M

Error

E : Environment
L : People Around You

M ： Management（managing and utilizing ＳＨＥＬＬ）
Fig.11

M-SHELL Model

BTM(Why are BTM and ETM not well-known?)
Despite 20 years having elapsed since the introduction of BRM, neither BRM nor ERM
have become popular. Possible causes are given below.

Root causes that are not well-known1） If technical skills are at a high level, it isassumed that‘safety is guaranteed’.

2） Management is not seen as a skill, and the

traditional idea of separate deck and engineering sections remains strongly entrenched.

3） Crew training is primarily OJT, where responsibility is left to the site.

A revolution in awareness is required in light of this way of thinking, ‘the way of thinking of safety’, ‘the question ofwhat management is’, and ‘the reconsideration of OJT’.
－9－JAPAN P& I CLUBP&I Loss Prevention Bulletin

The captain, chief engineer, and the company are required to develop ‘an atmosphere in which subordinates (i.e. teammembers) are able to speak up on matters of safety operation’. This is the foundation of effective use of BTM andETM.
In comparison with the shipping industry, CRM (Crew Resource Management) appears to be running smoothly in theairline industry. When we compare the two, it appears the difference lies in the level of technology. In an aircraft, thedifference in level of skill between the captain and the co-pilot appears to be less than that between a ship’s captainand chief officer, or between a chief engineer and engineer.
For example, if the captain of an aircraft were incapacitated in flight at an altitude 30,000 feet, the co-pilot should becapable of landing.
On the other hand, can a third officer operate his vessel safely to its destination? There is a major difference between
ships and aircrafts in terms of the methodology of crew training, including up-skilling. Therefore, we can think thattraining of inexperienced officers also is an important element when utilizing BTM and ETM.
Furthermore, ‘threats’ are sources of errors. With BRM and ERM, if threats are considered as elements which increase
the possibility of errors, the following can be noted.

Elements which increase the possibility of human errors1） A large volume of work (i.e. not enoughpersonnel available to do the work)2） Time pressure (when the leader is in a rushand this is picked up by team members, it will
leave everybody unsettled)3） Pressure from superior (in particular, regularly
shouting at subordinates, scaring them intosilence, and inhibiting operation of BRM andERM)4） Fatigue and stress (attention is distracted

when fatigued, and external stress is a causeof deterioration in abilities)

In other words, unless BRM and ERM can operate properly, not only will errors occur, but stress will develop
between the leader and team members, giving rise to a vicious cycle.

－ 10 －JAPAN P& I CLUB

Visious Cycle
Captain/Chief Engineer

becomes emotional due to stressInexperidenced navigation officer/engineer
becomes scared to speak out, and communication deteriorates.
Fig. 12 Vicious Cycle(From Grave-post type to Preventative type analysis/counter measure)
As described before, in case of a risk of collision by a crossing situation, all watch-keepers at brigde, who have alicense and who do not remember the COLREGs clause completely, know COLREGs clause 15 ‘the vessel which has
the other on her own starboard side shall keep out of the way’, and also knows clause 5 ‘Look-out’ is one of the mostimportant clauses. However, although they know these clauses, sometimes they neglect the Look-out, ‘Why did they
not take action to avoid the collision’, and finally why did they cause a collision accident?
By considering ‘Human Characteristics’, it is necessary to analyze as to why they took dangerous action and establish
preventative type countermeasures based on the background information of the accident and consider the best means
to prevent reoccurrence. Thus it is necessary to change the analysis and countermeasure from the Grave post type to
the Preventative type, shown in Figs. 13 and 14;

Grave-Post TypeInsufficient Look-out

Punishment of P.I.C.

Introduce Case Study and Enforce ‘Sufficient Watch-keeping’Consider ‘Why Insufficient Look-out Occurred'Fig. 13

Grave - Post Type－ 11 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

P r e v e n t a t i v e Typ e
Cause of Insufficient Look-out
Check necessity of individual documents

Paperwork during duty
watch
Falling asleep

Check amount of work that triggers
falling asleep

Collapse of BTM

Although duty officers understandNon compliance withobservance of COLREGs

analyse as to ‘why the duty officers

COLREGs and the concept of BTM,
failed to take necessary action'.

Exclusion of Root Cause
Too much paperwork

Review the volumeof paperwork

Reduce work load

▶ Abolish unnecessary and non-urgent documents▶ Review SMS Manual▶ Prohibit doing of Paper Work during duty watch and control work andrest hours (including falling asleep countermeasures)▶ Set priority for various kinds of paperwork
Collapse of BTM
Non compliance withobservance of COLREGs

Pertinent:‘Human beings
sometimes forget’in Human Characteristics▶ Re-education▶ Supervise continuously (Brief before boarding)Fig. 14

Preventative Type－ 12 －

RemindJAPAN P& I CLUB

§1-6 Training of Inexperienced Officers and Engineers with Low Skill Levels
To prevent errors, inexperienced officers and engineers with low skill levels must individually and objectively evaluate and understand the skills with which they are deficient, and endeavor to reach the level of an experienced captain/
officer or chief engineer/engineer as soon as possible. OJT and training on shore are methods used in training theseofficers and engineers. However, the awareness and motivation of the trainee is important. If we consider the level towhich skills can be raised with OJT and shore training, Student Oriented (in Fig. 15 below) provides guidelines.

Student Oriented Extent to which skills are acquired
With written texts

10％

With audio-visual materials (e.g. videos)30％

Coach leads by example

50％

Trainee tries by him/herself

70％

Individualreform of sense

Fig.15

100％70% achievable withcram-style education

A change in awareness of
the individual is important.
Guidance must be accompanied with motivation.

Student Oriented

Approximately 10% of skills are considered to be learned in classroom lessons using written texts. These skills consist
primarily of fundamental theory and knowledge.
Use of videos, PCs, and the Internet as ‘audio-visual materials’ are considered to raise the skill level to approximately
30%. Think of a merchant ship school as being the last step before actually doing the real thing on board a vessel.
Subsequent practice and OJT in which the coach demonstrates is considered to increase the skill level to 50%. Further
use of simulators and OJT after having entered the company to provide the student with experience is considered toincrease the skill level to 70%. In summary, pushing the student is effective to a certain degree, however the attainment of 100% skill is required on-site.

－ 13 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

Increasing the remaining 30% skill level is fundamentally a matter of ‘individual reform of sense’. Education at thisstage is primarily focused on OJT, and coaching is required to raise the motivation of the student. Also, again, it isnecessary to understand the fundamental idea behind ‘5W1H + 2F’. ‘2F’ is especially important in the training field.
And, as mentioned above, it is important to be aware of the fact that behavioral characteristics of people deemed to be
defects could be turned into wonderful abilities.
For example, the author had the following experience while aboard a vessel as Master. I feel embarrassed just remembering the event.

On one occasion, the mooring winch on the Forecastle broke down. Immediately, repair workneeded to be carried out and I (Master) requested that the chief engineer, the chief officer andthe boatswain repair it. I was also required to attend the repair work. In order to repair it, firstof all we had to remove the nut that attached the cover, but the chief officer provided only
spanners of the wrong sizes .
I was aware of‘Human Characteristics No. ⑨ Human beings sometimes make assumptions’andsmoked down the chief officer‘Why did you not bring various size spanners well in advance?’
without realizing‘No. ⑧ Human beings sometimes become emotional’myself.
Even after completion of the repair work, the chief officer was disappointed for a while. However,if the spanner that he prepared for repairing was of the correct size and he had commenced
the work without trouble, it would have been possible to observe that he was able to makeoverall decisions manifesting wonderful ability, contrary to No. ⑨ Human beings sometimes makeassumptions. Remembering this story, I still feel regret towards him, even though more than 10
years had passed.

Considering ‘What is safety’ and ‘Human Characteristics’ (described above), let’s study the counter measures in orderto prevent recurrence through the following three accident case studies.

－ 14 －JAPAN P& I CLUBCollision

§2

§2-1

Summary of Accident

Date and time of occurrence:  
On an unspecified day of October 2013, approximately 21: 01 Japan time (JST)

Accident site:  Southwest area of Kii Suido (Strait), north-northeastern area of I-shima

Vessels concerned:
Container Vessel A (50,686 G/T, Loa 292m)  
▶

During navigation from Kobe Port to the Port of Busan in South Korea on the southern routes along Shikoku▶

Crew members (21 members on board)▶

South Africa

×5 (including Master)

India

×2

Ukraine×3

Romania

×1

U.K.

×1

The Philippines

×8

Russia×1

The third officer keeping watch was present at the collision accident at that time.
Bridge Watch personnel constituted one A/B and one cadet respectively. The Master was handling paperwork
in his cabin.
The Master, age 52, was assigned to Master in 1994. Following shore duty as marine superintendent anddesignated person ashore, the Master came aboard the current vessel. The Master had, on four occasions,navigating experience of this area of sea.
It was the third officer’s (Officer of the Watch, age 27, South African) second vessel as navigation officer. As
third officer, the officer had, on five occasions, navigating experience in this area of sea.

▶

Cargo and draft: 2,500 loaded containers with a Draft Even Keel of 11.39m.

Cargo ship B (4,594 G/T, Loa 110m)▶

Bound for Mikawa Port from South Korea via Naruto Strait of the Seto Inland Sea－ 15 －JAPAN P& I CLUBP&I Loss Prevention Bulletin▶

Crew members (13 members on board)
Korea

×3 (including Master)Indonesia

×3

The Philippines

×4

China

×1

Burma

×2

▶

 he third officer and one A/B watch-keeper were present at the collision accident at that time. The MasterT
was taking a rest in his cabin. The Master, age 50, had 10 years of experience as an officer and 5 years of experience as a master. The Master had extensive experience of navigating between China/Korea and Japan.
The third officer, (Officer of the Watch, age 24, Filipino) had been on board both a Filipino coaster vessel in Japan and an ocean-going vessel for 16 months. It was his first time to board as third officer. As a cadet, the officer had, on ten occasions, navigating experience in this area of sea.

▶

Cargo and draft: 5,350 K/T loaded with steel. Draft Fore 5.60m, Aft 6.85m(Summary of Accident)
The accident occurred at night off the north-northeastern sea coast of I-shima on the Kii Suido (Strait) while Vessel
A was sailing southward on a course of <190>, after pilot disembarkation, having just passed Tomogashima Strait,
when cargo ship B was navigating southeast on a course of <140> towards Kii Hinomisaki coast having passed the
Naruto Strait. In addition, as for the state of the surrounding environment at that time, there were no other ships in thevicinity, which would have affected either vessel’s operations, and there was good visibility.

There were no other vessels concerned which may haveaffected navigation, as long as one could see the informationon the AIS and reports from the related party.
Fig. 16 Surrounding Environment

When both vessels approached cutting across each other’s courses, the third officer of Vessel A noticed that there wasa risk of collision with Vessel B due to the approach alarm sounded by the ARPA and informed that she (Vessel A)
would pass the astern of Vessel B via VHF. However, he continued to navigate on the same course and speed, withthe exception of altering course to starboard 6 degrees. Also, after the third officer of Vessel B noticed the Closest
Point of Approach (CPA) which indicated zero on the ARPA, he altered course to starboard 5 degrees, but still sailed
continuing on the same course and speed.
As a result, both vessels kept closing head-on to each other. Although it steered immediately to avoid collision immediately before the collision, the starboard side bow of Vessel A collided with the port side astern of Vessel B.
Both vessels sustained damage to the hull, however, there were personal injuries. Please see Figs. 17, 18 and 19 andTable 20 for collision details and the actions that were taken by both Vessels.

－ 16 －JAPAN P& I CLUB

Voyage Route

:00

18

0

18:3

18:15

17:15

18:

45

Inland Sea
Harima Nada

19

:15

Osaka Bay

0
5

to

18:4

Tomogashima Strait

19:45

ru

18:3

Na

18:1

5

19:30

ra

St

20:00

5

20:15

:4
19

:00

20

20:30

5
0:1

2

20:45

:30

20

:45

Collision postion
2013 Oct., XXth
21:01 JST Collision

21:00

19

Vessel ‘B’

Vessel ‘A’

it

:30

20

Tokushima Pref.
Anan city

Kii Strait
Kii Hinomisaki Lighthouse
I Shima Lighthouse
10

10

0

60km

0

30m

Fig. 17

Voyage Route－ 17 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

Voyage Route 12 min. before collision
:42

20

3
0:4

2

Vessel ‘B’

4

:4
20

20:51

:46

20

:47

20

20:52

8

:4
20

20:53

:49

20

:50

20

‘A’

20:5

5

20

20

:53

20

:56

:54

20

:56
:57

20

3rd VHF.

20
:58

‘A’

‘B’

:00

20
20:59

:59

21

:03

21:02

21

‘A’

‘A’

:58

20

3rd VHF.

‘B’

:57

:55

20

‘A’

2nd VHF.

20

20

2nd VHF.

‘B’

‘B’

4

:51
:52

‘A’

First VHF.

20:5

20

First VHF.

‘B’

Vessel ‘A’

20:50

:45

20

‘B’

20:49

4th VHF.

‘A’‘B’

Collision postion 2013 Oct., XXth 21:01 JST Collision
1000

0

1

3000m

0

Fig. 1830m

Details of Voyage Route

Vessel ‘B’

Vessel ‘A’

1000
0.1

600ｍ

0
0

0.3M

Fig. 19

Details of Voyage Route－ 18 －JAPAN P& I CLUB

Weather and sea conditions

Weather：fine, NW wind, wind force１, visibility: approximately ten(10) nautical miles

Vessel ‘A’ (Container vessel)
Watch arrangemet atthe collision accident
at that timeThree in total: the third officer (South African),a Cadet and an AB.

Vessel ‘B’ (Cargo ship)
Two in total: the third officer (Filipino) and an
AB.

The Chief Officer took over the watch from the Master.

At around 19:50, the Chief Officer took over thewatch from the Master.

Course <190>, speed 16.0 kts.

Course <140>, speed 12.5 kts.

The third officer together with other two crew
members started watch-keeping.

The third officer together with another crew
member started watch-keeping. After verifying
the state of the surrounding environment, theMaster left the bridge.

Two radars were in use: Automatic Radar Plotting
Aid (ARPA: off-centre) and ECDIS.

Two radars were in use: Automatic Radar
Plotting Aid (ARPA: off-centre) and ECDIS.

One radar used a range of 6 nautical miles and theother a range of 12 nautical miles.

One radar used a range of 6 nautical miles andthe other a range of 12 nautical miles.

The Master left the bridge having commanded hiscrew to be on alert during the watch.

-

Vessel B was observed at 7.5 nautical miles. 51
degrees with bearing of <245> off of its starboard
bow. Supplemented at 5 nautical miles with ARPA.
Verified with the screen that indicated a course of<135> and a speed of 13.0 kts.

-

At the same time, Vessel B’s white, white and red
lights were visibly confirmed

-

20:47
(approximately)

CPA alarm sounded at a distance of 3.0 nautical
miles (the alarm setting was unknown).

-

20:50
(approximately)

Vessel A was captured on the monitor at 70
degrees on her port side at approximately 3.0
Vessel B was observed at 52 degrees with a bearing
nautical miles via AIS (superimposed in ECDIS).
of <248> on her starboard bow at 2.3 nautical miles
Visibly confirmed as the CPA indicated it at 0.2
via ARPA.
nautical miles. Recognized white, white andgreen lights of Vessel A.

19:54

20:00

20:10

20:25
(approximately)

20:53(approximately)
20:56(approximately)
20:57(approximately)
21:01

Responded to a call from Vessel B via VHF andcommunicated that Vessel A would pass the sternof Vessel B. Altered course to starboard 6 degrees.
Set the new course <196>.

Contacted Vessel A via VHF and confirmed she
was going to pass the stern of Vessel B. Vessel
B believed Vessel A was heading toward thestern.

Confirmed Vessel B at 54 degrees with a bearing of<250> on her starboard bow at 1.7 nautical miles
via ARPA.

Confirmed Vessel A at 70 degrees with abearing of <070> on her starboard bow at 1.7
nautical miles via AIS.

Course <196>, speed 15.0 kts.

Course <140>, speed 12.0 kts.

Furthermore, officer B requested that Vessel A alter
As the AIS data disappeared, officer B
course to starboard via VHF. Gradually started altering requested that Vessel A alter her course further
course to starboard, the distance was 1 nautical mile. to starboard side via VHF.
Confirmed Vessel B at a bearing of <252> at 0.8
nautical miles via ARPA.
Steered hard to starboard.
Collision at 14.6 knots, when bow direction was at<266>.

Started altering course steering hard to
starboard.
Collision at 8.6 knots, when bow direction was
at <250>.

Table 20 Sequence of Events－ 19 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

Vessel "A" Damage Diagram

Vessel "B" Damage Diagram

Fig. 21

Damage Diagram= Communications via VHF =At around 20:50 (approximately 11 minutes before the collision), the VHF communication (VDR information ofVessel B) transmitted the following (The information of Vessel A was not available from the VDR):
At 20:51:47,

Vessel B contacted Vessel A and inquired her intention.
’Vessel A, What is your intention?’

At 20:52:28,

A fter Vessel B confirmed A’s intention, Vessel B answered back that she also changed hercourse to starboard side.
’Vessel A, Pass my stern? OK, Thank you. You are going to my stern.’‘Vessel A, I will going to alter course to starboard side also, Thank you.’

Both sides of the conversation are unknown, because the communication history from Vessel A is not available.
Although Vessel A was supposed to have replied that it would change its course to starboard side and navigate inorder to pass the astern of Vessel B, the question still remains as to why Vessel B replied that she (Vessel B) also
would alter her course to starboard side.

§2-2

Analysis of Accident Cause by Japan Transport Safety Board(Marine Sub-committees)§2-2-1

Applicable Navigation Act

Japan Transport Safety Board determined Rule 15 (Crossing Situation) COLREGs to be the appropriate navigationact.

－ 20 －JAPAN P& I CLUBRule 15：Crossing Situation on International Regulations for Preventing Collisions at Sea(COLREGs)
When two power-driven vessels are crossing so as to involve risk of collision, the vessel which has the otheron her own starboard side shall keep out of the way and shall, if the circumstances of the case admit, avoid
crossing ahead of the other vessel.

In addition, Rule 16 (Give-way Vessel) of COLREGs was applied to Vessel A and Rule 17 (Stand-on Vessel) wasapplied to Vessel B.
Rule 16: Action by Give-way Vessel
Every vessel which is directed to keep out of the way of another vessel shall, so far as possible, take earlyand substantial action to keep well clear.

Rule 17: Action by Stand-on Vessel(i) Where one of two vessels is to keep out of the way the other shall keep her course and speed.
(ii) T he latter vessel may however take action to avoid collision by her manoeuvre alone, as soon as it
becomes apparent to her that the vessel required to keep out of the way is not taking appropriate
action in compliance with these Rules. In this case, if the requirements of Rule 15.1 apply to thesevessels, the stand-on vessel shall turn to port unless impossible.
(iii) W hen, from any cause, the vessel required to keep her course and speed finds herself so close thatcollision cannot be avoided by the action of the give-way vessel alone, she shall take such action as
will best aid to avoid collision.

§2-2-2Analysis of Accident by Japan Transport Safety Board

Japan Transport Safety Board analyses the accident as follows.
（1）Vessel A

Vessel A(approx.) 20:25 local time on a unspecified day of October. Vessel A was heading southbound on a①

course of <190>, at a speed of 16.0 kts. In the vicinity of 16.5 nautical miles on a course of <022>from I-shima Lighthouse, a third officer detected Vessel B on radar at a distance of 8 nautical miles, 55.0
degrees with bearing of <245> on her starboard bow. It is probable that the officer visually confirmed
each of the two white mast lights and one red light (port side).
(approx.) 20:47, the third officer (Vessel A) noticed there was a‘risk of collision’with Vessel B in

response to the ARPA alarm. 3 minutes after, the third officer responded to a call from Vessel B via
VHF. The third officer communicated that Vessel A would pass the astern of Vessel B and hung up
the receiver after confirming. The third officer then, set the new course <196> by altering course②

starboard to 6 degrees, and navigated continuing on the same course and speed for approximately 4
minutes. It is probable that despite the change of course, the change of relative bearing to Vessel B was
only within 2 degrees turning to starboard side. It is thought that the third officer of Vessel A, according
to his understanding of the communication received from Vessel B, assumed that Vessel B was turning
to starboard, and therefore kept Vessel A maintaining on the same course and at the same speed.
Vessel A steered hard to starboard immediately prior to the collision, however, it was too late.

－ 21 －JAPAN P& I CLUBP&I Loss Prevention Bulletin（2）Vessel B

Vessel B(approx.) 20:50. Vessel B was navigating on a southeast course of <140> towards the Kii Suido, Kii
Hinomisaki western offshore, at a speed of about 12.0 kts. In the vicinity of 8.8 nautical miles on acourse of <017> from I-shima Lighthouse, Vessel A was noted to be navigating south on a course③

of <068> about 3 nautical miles from Vessel B at 70°on her starboard bow, according to the AIS,
which was captured on ARPA, the third officer recognized two mast lights and one green (starboard
light) of Vessel A. Because the CPA of Vessel A was indicated at 0.2 nautical miles on the ARPA
screen, third officer judged that there would be a risk of collision and confirmed the name of Vessel
A via the AIS.
The third officer contacted Vessel A on VHF and inquired her intention. As Vessel A replied with④

her intention to‘pass the astern of Vessel B’, the third officer repeated the conversation andagreed. Moreover, the third officer finished communication with Vessel A’s final confirmation andnavigated continuing on the same course and speed.
Later, the third officer noticed that CPA read zero, which was indicated on the ARPA. He thenaltered his course to starboard by approximately 5 degrees using auto pilot and set the newcourse to <145>.

⑤

Then, he sailed continuing on the same course and speed, however, at about 20:55, thinking
that the two vessels were in serious danger of colliding, he communicated via VHF with Vessel
A once again. When the third officer requested that Vessel A change course to starboard, Vessel
A respond to confirm. However, while waiting for Vessel A to change course to starboard side,
the third officer realized that the risk of collision was imminent, and although he steered hard a
starboard, it appears that a collision was unavoidable.

§2-2-3

Analysis of Accident Cause by Japan Transport Safety Board (Marine Sub-committees)

Japan Transport Safety Board analysed the cause of the accident and issued the following five reasons.
①

Vessel A contacted Vessel B via VHF and informed of her intention to navigate in order to pass the asternof Vessel B. However, after only altering course to starboard 6 degrees, the third officer assumed that
Vessel B had altered course to starboard side and navigated continuing on the same course and speed.
After cadet A of Vessel A listened to the communication via VHF about the change of course to②

starboard side by both Vessels A and B, he could not see if Vessel B had altered course to starboard
side on the ARPA monitor. Also, he considered it not sufficient enough to change heading course, andalthough he knew that the third officer had altered course to starboard by approximately 6 degrees, he
did not advise and report this to the third officer (although, this was not the direct cause of the accident).

③

The reason why Vessel A continued on the same course ＜ 196 ＞ and speed was, presumably, because,through communication with Vessel B via VHF, Vessel A understood that Vessel B was going to altercourse to starboard, even if only slightly.
After Vessel B discovered that the CPA was zero, indicated on ARPA, she altered course to starboard④

5 degrees and set a new course to ＜ 145 ＞ , however, she sailed continuing on the same course andspeed. That is to say, it is probable that the third officer may have been waiting for Vessel A to takeaction by giving way, which meant that Vessel A intended to navigate passing the astern of Vessel B
mutually communicating with Vessel A via VHF.

⑤

For both Vessels A and B, they did not adopt either warning signals or manoeuvring signals using
whistles or flashing caution signal lights.

－ 22 －JAPAN P& I CLUB

§2-2-4

Preventive Measures by Japan Transport Safety Board

Japan Transport Safety Board proposed the following preventive measures to avoid a recurrence of the incident.
（1）Vessel A

Vessel A
After the other vessel is first detected, in the event that both vessels approach cutting across eachother’s courses,/or in the event that both vessels are on a course to cross each other, regardless①of whether communication via VHF is maintained, /or regardless of whether VHF communication
takes place, at first, it is naturally expected that quick recognition of the possibility of a collision
with the other vessel is ascertained. Then, according to the Rule of the Maritime Collisions
Prevention Act (COLREGs), avoidance action should be taken in ample time and, at the same time,
dynamically so as to be easily recognised by the other vessel.

②③

In the case of noticing that there is a risk of collision, in accordance with the Rule of Maritime
Collisions Prevention Act (COLREGs), the necessary action is to be taken immediately andrecognition that it is not necessary to communicate mutually by VHF.
The watch-keeper who felt uneasy and warned about the movement of the other vessel is obliged
to immediately report it to the Officer of the Watch (OOW).

（2）Vessel B

Vessel B④

Look-out is to be adequately performed and in the event of the other vessel being detected, thecourse of the other vessel is to be accurately determined.
In the event that the stand-on vessel, which is vessel B in this case, does not understand the give-⑤

way vessel’s intention or action, warning signals are to be sent without hesitation. And, in thecase of feeling uneasy about the movement of the other vessel, the Master is to be immediately
requested to come up to the bridge.
In the case that it is obvious that the give-way vessel is not following appropriate actions in⑥

accordance with the Rules of Maritime Collisions Prevention Act (COLREGs), action to avoid acollision is to be immediately taken and recognition that it is unnecessary to communicate via VHF
accordingly.

⑦

In the case of observing the give-way vessel’s course and accurately determining whether it ispossible to avoid a collision with the give-way vessel on her present course, and in the event that itis recognised that a collision is unavoidable, take the best course of action to avoid a collision§2-3 Analysis Combining Human Characteristics and Preventive Measures§2-3-1Analysis of Accident Causes

As explained in §1-5, similar accidents are likely to reoccur without the ‘establishment of preventative safetymeasures’ according to an analysis of the accident causes that include Human Characteristics, focusing on the aspectsof ‘why the accident occurred’ and ‘why the person involved took such unsafe measures’.

－ 23 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

In other words, it is necessary to consider safety from a ‘preventative type’ perspective in order to safeguard society
against the occurrence of an accident. In this section, we are going to determine the measures necessary in order toprevent recurrence, from the viewpoint of preventive measures, of this kind of collision accident.
Firstly, let’s apply the behaviour that the third officer of Vessel A took according Human Characteristics respectively.
Table 22 shows a summary of this. We are indicating 〇 for applicable and × for not applicable.

Vessel ‘A’ 3rd Officer
Human Characteristics

Behaviour

Reason①

Human beings sometimes
make mistakes

×ー

Detected Vessel B via radar at a
distance of 8 nautical miles.

②

Human beings are
sometimes careless×ーSame as above③

Human beings sometimes
forget〇give-way vessel’s heading coursechange was six (6) degrees.

Forgot Rule 16 (give-way vessel)of Maritime Collisions Prevention
Act (COLREGs).

④

Human beings sometimes
do not notice×ーPaid attention to the other vessel’s movement.

⑤

Human beings have
moments of inattention〇

Carried out inadequate look out.

Relied solely on ARPA information.

⑥

Human beings sometimes
are only able to see orthink about one thing at
a time〇Relied solely on ARPA information.

Negligent with verifying visually.

⑦

Human beings are
sometimes in a hurry

×ーThere was no testimony attaining
to anything be conducted inhaste.

⑧

Human beings sometimes
become emotional×ー

Was not particularly emotional⑨

Human beings sometimes
make assumptions〇

Thought that all was normal, because avoidance action was taken.
Assumed that Vessel“B”would also
alter its course starboard side.

Cadet considered that the changeof heading course degrees were
not sufficient enough. (Collapse ofBTM)⑩

Human beings are
sometimes lazy〇Not verified visually.

Did not verify the other vessel’sconstant watchkeep and confirmation of change relative bearing.

⑪

Human beings sometimes
panic

〇

Continued altering course between
starboard and port sides immediately before the collision.

Even forgot about maneuveringcharacteristics.

⑫

Human beings sometimes
transgress when no one
is looking〇

Did not carry out Master's standingorder (sharp look-out).

Neglected in spite of having been
directed to be cautious of crossing vessel.

Table 22

Vessel ‘A’ 3rd Officer Human Characteristics

Similarly, we are going to analyse the third officer of vessel B as well.
－ 24 －JAPAN P& I CLUB

Vessel ‘B’ 3rd Officer
Human Characteristics

Behaviour

Reason①

Human beings sometimes
make mistakes

×ーThere was a delay in visually
verifying the other vessel, but it
was verified.

②

Human beings are sometimes
careless×ーSame as above③

Human beings sometimes
forget〇No joint action in accordancewith Maritime Collisions Prevention Act (COLREGs) (Rule 17:
Action taken by Stand-on Vessel)

Regarding the relationship between
large vessels, when they are approaching at 3 nautical miles, they
are to take joint action.

④

Human beings sometimes do
not notice〇

Did not notice until Vessel A was
3 nautical miles away.

Negligent with look-out.

⑤

Human beings have moments
of inattention〇

Was negligent during look-out.

Relied solely on ARPA information.

⑥

Human beings sometimes
are only able to see or think
about one thing at a time〇

Relied solely on ARPA information.

Negligent with verifying visually.

⑦

Human beings are sometimes
in a hurry

×ーThere was no description applicable.

⑧

Human beings sometimes
become emotional

×ーSame as above⑨

Human beings sometimes
make assumptions〇

Thought that Vessel A was going togive-way because she changed herheading course to 20-30 degrees.

Assumed Vessel A would pass
the stern via VHF.

⑩

Human beings are sometimes
lazy〇

Neglected to keep watching
the other vessel’s movement
constantly. Not verified visually.

Did not verify the other vessel’sconstant look-out or confirm
change of relative bearing.

⑪

Human beings sometimes
panic

〇

Contacted unilaterally via VHF.
Did not confirm the other vessel’s reply.

Only contacted unilaterally via
VHF.

⑫

Human beings sometimes
transgress when no one islooking〇

Transgression of master's standing order (not reported).

Master's standing order: toreport when a dangerous ship isvisually confirmed.

Table 23

Vessel ‘B’ 3rd Officer Human Characteristics

For the third officer of Vessel A, seven (7) out of the twelve (12) Human Characteristics items are applicable,
whereas, eight (8) of the Human Characteristics are applicable to the third officer of Vessel B. An analysis using the
M-SHELL model as to why such behaviour was taken in relation to these characteristics is shown in Fig. 24.
To begin with, we consider the root cause to be ‘Exclusive Node’. In spite of insufficient avoidance action (third
officer communicated that Vessel A would pass the astern of Vessel B), however in reality, Vessel A altered course to
starboard 6 degrees only (in general, Vessel A should alter her heading course to starboard 60 degrees).
Meanwhile, vessel B did not notice vessel A until she approached at a distance of 3.0 nautical miles.
If you were to take a snapshot of each manoeuvre and lay them all out on a table in card form, it would be possible totrace as to why such action was taken and find out what caused the accident.

－ 25 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

On analysing as to why the third officer of Vessel A caused the accident, firstly we can say that there was a lack ability
in recognizing the importance of look-out. Further, this was not only down to the fact that work was not prioritised appropriately, but that there was also an insufficient understanding of the Maritime Collisions Prevention Act (COLREGs).
In addition, it is clear that there were other causes, such as impatience, a lack of caution and non compliance with the
Master’s standing order.
On the other hand, when analysing the third officer of Vessel B similarly, we can conclude that the accident causes are
the same for the third officer of Vessel A. We understand that the cause was not only down to the fact that there was alack ability in recognizing the importance of look-out, but in addition, work was not prioritised appropriately. Moreover
there was insufficient understanding regarding the Maritime Collisions Prevention Act (COLREGs). It is also clear that
there were other causes, such as impatience, a lack of caution and non compliance with the Master’s standing order.

Analysis using M-SHELL model of the third ofﬁcers of both vessels A and B
Why

Why

Why

Why

Cause

Preventative typemeasures③ Human beings
sometimes forget③ Human beings
sometimes forget

Insuﬃcient
give-way action

Changed heading
course to six (6)degrees only

⑤ Human beings
have moments ofinattention⑥ Human beings
sometimes areable to see orthink about only
one thing at a time

⑨Human beings
sometimes makeassumptions

Insufficient knowledge of the importance of look-out.
Could not clarify
priority order ofwork. Insufficientunderstanding ofMaritime Collisions
Prevention Act(COLREGs). Impatient and lack of
caution, non-com-

Re-education of
Maritime Collisions
Prevention Act(COLREGs) should
be conducted.

Exclusive Node
The third oﬃcer ofVessel A

Negligence withlook-out work. Did
not verify changeof relative bearing.

⑩Human beings⑪Human beings

are sometimes lazy

sometimes panic

Not visually veriﬁed. Did not constantly carry out
look-out of the
movement of theother vessel.

Continued altering course between
starboard and portsides immediately
before the collision.

④ Human beings
sometimes do
not notice③ Human beings
sometimes forget⑤ Human beings
have moments ofinattention

Conﬁrmed theother vessel at
3 nautical miles.

No joint action
taken

Solely relied on the
ARPA information.

Thought all was
normal, because
give-way action
was taken.

⑫ Human beings
sometimes
transgress when
no one is looking

pliance with order.

Did not carryout Master's
standing order.

Re-education regarding the importance of lookout
and confirmation
by look-out andchange of relative

bearing should be
conducted by allmeans.

The third oﬃcer ofVessel B④ Human beings
sometimes do notnoticeConﬁrmed theother vessel at 3
nautical miles.

Negligence withlook-out work.
Did not verify thechange relative
bearing.

⑥ Human beings
sometimes areable to see orthink about only
one thing at a time
Solely relied on
the ARPA
information.

⑩ Human beings
are sometimes lazy

⑪ Human beings
sometimes panic

Not veriﬁed visually.
Did not constantly
carry out look-outof the movement of
the other vessel.

Contacted unilaterally via VHF.
Did not conﬁrm
the other vessel’sreply.

⑨ Human beings
sometimes makeassumptions
Thought that
Vessel A was goingto give-way because she changed
her heading course
to 20-30 degrees

Insufficient knowledge of the importance of look-out.
Could not clarify
the priority order

The Maritime Traffic
Safety Act of Maritime Collisions Prevention Act (COLREGs) should be

ing of Maritime Collisions Prevention
Act (COLREGs). Im-

Re-education regarding the importanceof look-out and con-of work. Insufficient understand-patient and lack of
caution, non-compliance with order.

re-instructed.

firmation by loo-koutand change of relative bearing should
be conducted by allmeans.

Node: Direct and indirect accident causes. (Node: A point of focus for speech, behaviour, or a decision etc.)
Fig. 24 Why-why? Model－ 26 －JAPAN P& I CLUB

§2-3-2

A nalysis of Accident Causes which can be Commonly Seen Regarding theThird Officers of Vessel A and B

There are several common points regarding the accident causes of the third officers of vessels A and B. We are goingto analyse this focusing on the ‘Why?’ of Human Characteristics. A summary of the common points regarding thethird officers of both vessels is as follows:（1） T hey relied solely on ARPA information regarding the risk of collision, and did not verify thechanges in compass bearing that the other vessel continued on ( ③ , ⑤ and ⑥ ).

Human Characteristics：❸ Human beings sometimes forget❺ Human beings have moments of inattention❻ Human beings sometimes are only able to see or think about one thing at a time

The testimony of the third officer of Vessel A is as follows:‘At approximately 20:25 (approx.36 minutes before the collsion), along with detecting Vessel B’s
starboard bow at a distance of 8 nautical miles on radar, I visually confirmed her two white mast
lights for the first time. Then I also visually confirmed one red light, and recognized that Vessel B was
navigating on a course of approximately <135> at a speed of about 13.0 kts. I continued to lookout visually using the radar, while assigning a cadet to watch the radar and the Able Seaman to lookout visually. (Approx.) 20:47, which was approximately 14 minutes before the collision, the third
officer of Vessel A noticed that there was a risk of collision with Vessel B following the ARPA alert’.
The testimony given by the third officer of Vessel B is as follows:‘At Approximately 20:50 (approx. 11 minutes before the collision), I caught Vessel A on the AIS
and recognized two white lights and one green light. Vessel A, which was heading southbound wasovertaking our vessel, at approx. 25° on her port side abeam aft, about 3 nautical miles away fromour vessel. Then, I thought there was a risk of collision, because the CPA was indicated at 0.2 nautical miles via ARPA. I obtained the information that Vessel A was navigating to pass the stern of Vessel
B via VHF, and confirmed the vessel name via AIS’.

－ 27 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

The course, speed and approaching information of both vessels according to the AIS data analysis are shown in Table
25.
Time(about)Distance
bewtween
vessels
Heading(Nautical Miles)<190>

Vessel ‘A’

Vessel ‘B’

Speed

Relative
Bearing
Bearing to
Vsl.
‘B’
Vsl.
‘B’

Heading

Speed

Bearing
Vsl.‘A’

Relative
Bearing to
Vsl.‘A’

16.0kts

<245>

<139>

12.4kts<065>

Port 74Deg.

Starb. 55Deg.

20:25:00

7.5 nm

20:30:00

6.5 nm<190>

16.0kts<245>

Starb. 55Deg.

<139>

12.3kts<065>

Port 74Deg.

20:34:59

5.5 nm<190>

15.8kts<245>

Starb. 55Deg.

<140>

12.4kts<065>

Port 75Deg.

<190>

15.9kts<246>

Starb. 56Deg.

<140>

12.2kts<066>

Port 74Deg.

<140>

12.1kts<068>

Port 72Deg.

Noticed Vessel‘B’by ARPA and Radar

20:40:00

4.5 nm

20:45:00

3.4 nm

20:50:00

2.3 nm<196>

16.1kts<248>

Starb. 52Deg.

<139>

12.0kts<068>

Port 71Deg.

20:52:00

2.0 nm<196>

16.2kts<250>

Starb. 54Deg.

<140>

12.2kts<070>

Port 70Deg.

20:53:00

1.7 nm<196>

16.2kts<250>

Starb. 54Deg.

<139>

12.4kts<070>

Port 69Deg.

20:55:00

1.3 nm

ARPA Alarm. Changed Co. 6 deg. To Starb'd<196>

16.1kts<248>

Starb. 52Deg.

Noticed Vessel‘A’by AIS and ARPA

Steered Hard Starb'd<208>

16.2kts<251>

Starb. 43Deg.

<145>

12.5kts<071>

Port 74Deg.

<212>

16.0kts<252>

Starb. 40Deg.

<151>

11.9kts<072>

Port 79Deg.

20:57:00

0.8 nm

20:58:00

0.5 nm<210>

15.8kts<250>

Starb. 40Deg.

<151>

11.8kts<070>

Port 81Deg.

20:59:00

0.4 nm<223>

15.9kts<247>

Starb. 24Deg.

<206>

10.1kts<067>

Port 139Deg.

21:00:00

0.3 nm<248>

15.2kts

<239>

Port

9Deg.

<273>

8.4kts<059>

Port 214Deg.

21:00:30

0.2 nm<257>

14.7kts

<245>

Port

12Deg.

<278>

8.1kts<065>

Port 213Deg.

21:01:00

0.2 nm<266>

14.6kts<270>

Starb.

4Deg.

<250>

8.6kts<090>

Port 160Deg.

One shot to steered port and then Hard Starb'd

Collision!
Table 25AIS Information

There was almost no change in relative bearing from approximately 20:25, when the third officer of Vessel A noted
the other vessel, until to approximately 20:40, when the approach alarm of ARPA sounded. Although Vessel A alteredcourse to starboard at around 20:40 when the distance from Vessel B was 4.5 nautical miles, she (Vessel A) set a new
course to <196> and altered course to starboard 6 degrees only. In addition, the change of relative bearing after changeof heading course was slightly astern (starboard), which shows there was no effect on the give-way vessel at thispoint.
Thus, we can ascertain that the behaviour of third officer of Vessel A led to the following errors:（1） Relied solely on ARPA infromation.

Human Characteristics ⑤
Human beings have moments of inattention

There was a change in heading course to give-way, but the（2） change in bearing was not verified. (The effectiveness of thegive-way action was not confirmed)

Human Characteristics ⑥
Human beings sometimes are only able
to see or think about one thing at a time－ 28 －JAPAN P& I CLUB

Although the vessel confirmed that it was navigating to pass
the stern of the other vessel via VHF, the other vessel felt
（3） uneasy due to such a slight veering, Under normal circumstances, the appropriate give-way vessel is to widely change
heading course to <248> to the astern of the other vessel

Human Characteristics ③
Human beings sometimes forgetThis is in violation of Rule 16 of the Maritime Collisions Prevention Act (COLREGs) (Action by Give-way Vessel)that defines: Every vessel which is directed to keep out of the way of another vessel shall, so far as possible, take earlyand substantial action to keep well clear. (See §2-2-1 Applicable Navigation Act)
Also, the following are behaviour errors regarding the third officer of vessel B.
（1）

He first only recognized vessel A on the radar when it was at
a distance of 3 nautical miles away

Human Characteristics ⑤
Human beings have moments of inattention（2） Relied solely on the ARPA information

Human Characteristics ⑤
Human beings have moments of inattention（3） He over relied on the VHF information of the other vessel.

Human Characteristics ⑥
Human beings sometimes are only able
to see or think about one thing at a time

If there is a distance of 3.0 nautical miles between large ves（4） sels and TCPA is estimated at 12-13 minutes, it is reasonabletiming to start joint action.

Human Characteristics ③
Human beings sometimes forget‘The most appropriate joint action should be taken to avoid collision with another power-driven vessel’ which is inaccordance with the Maritime Collisions Prevention Act Rule 5 (Look-out) and Rule 17 (Action by Stand-on Vessel).
(Regarding Rule 17, please see §2-2-1 Navigation Act)
(Maritime Collisions Prevention Act (COLREGs) Rule 5: Look-out)
Rule 5 requires that every vessel shall at all times maintain a proper look-out both visually
and aurally as well as by all available means appropriate in the prevailing circumstances andconditions so as to make a full appraisal of the situation and of the risk of collision.

（2）Inhibited communication because of assumptions

Human Characteristics:❾ Human beings sometimes make assumptions

Miscommunication via VHF can be one of the reasons for a collision. On account of a breakdown in ‘communication
with external information’ (one of the principles of BTM), there was information breakdown between the officers (boththird officers) on both vessels, thus it is thought that human error (making an assumption) was at fault. Namely, we
can determine that both third officers of Vessel A and B made the following assumptions.

－ 29 －JAPAN P& I CLUBP&I Loss Prevention Bulletin
The third officer of Vessel A: Thought that all was well, because avoidance
action was taken. He assumed that Vessel B would also alter her course to
starboard side by VHF communication.

The third officer
of Vessel A

The third officer of Vessel B: Assumed that Vessel A had changed hercourse to starboard side to navigate in order to pass the stern of Vessel B
because he confirmed it via VHF.

The third officer
of Vessel B

The dangers of collision avoidance using VHF, have been pointed out in ‘CAUTION ON THE USE OF VHF RADIO
IN COLLISION AVOIDANCE’ issued by The Maritime and Port Authority of Singapore (MPA) dated the 4th of July
2005.

‘CAUTION ON THE USE OF VHF RADIO IN COLLISION AVOIDANCE’
Many investigations worldwide have revealed that VHF communication is one of thecontributing factors in collisions at sea. In many of the so called‘VHF assisted’collisions, the‘VHF communication’between the bridges had created misunderstanding among the officers①

which led to close quarter situations and collisions. We are of the view that compliance with
the International Regulations for Preventing Collisions at Sea will be more effective in averting acollision rather than the use of VHF communications (based on scanty and unclear information),to avoid a close quarter situation. A recently concluded investigation showed that both vessels
were using VHF communication to agree on action to be taken in order to avoid collision,
however, many collisions occurred.

②‘VHF assisted’collisions, contacts or near misses are not uncommon occurrences at sea.
The IMO has taken a serious view of this trend.’
Based on our findings and experience in similar occurrences, we believe that such incidents
are avoidable. We wish to reinforce this learning among all the masters and navigators servingon Singaporean ships through this circular. We wish to take this opportunity to reiterate thefollowing possible dangers involved in the use of VHF communication as a means of avoiding acollision. Factors to be considered are as follows:③a.

(omitted)b.

Uncertainty over the interpretation of messages received due to language difficulties andc.

L oss of valuable time in trying to establish contact on VHF radio instead of taking

an imprecise or ambiguously expressed message;
concrete action in accordance with the Collision Regulations; andd.

The danger of agreeing to a course of action that does not comply with the Collision
Regulations resulting in a situation which the action intended avoidance of.

④ and ⑤(omitted)

Since implementation of the AIS, it is now easier to call on the other vessel via VHF. However, critical time was－ 30 －JAPAN P& I CLUBwasted when using it take avoidance action, after both vessels approached one another at a distance of 3 nautical
miles.
If using VHF, it is necessary to start communicating from a much earlier stage and only use it for reference. Thereafter, it is necessary to observe the other vessel’s action utilizing the look-out strictly in accordance with Maritime
Collisions Prevention Act (COLREGs). In addition, extra time for it shall be needed.
（3）Both Vessels A and B were in breach of the Masters’standing order.

Human Characteristics:⓬ Human beings sometimes transgress when no one is looking

The procedures of the SMS Manual for Vessel A and the Masters’ standing order for both vessels are as follows. The
fact that both of the third officers of each vessel did not fulfil this criteria can be regarded as one of the causes of thecollision. (The parts in red are considered a violation)
Vessel A: SMS Manual and Master’s standing order= SMS Manual =••Watch-keeper shall pay attention to any other vessel in sight. Please pay extra attention if there is a suddenchange in circumstances while navigating.
To keep an appropriate distance from the other vessel as always. Not to sail across the path of another vessel
within one (1) nautical mile, except when necessary.

= Master’s standing order =•••The Officer of the Watch shall proceed with the procedures described in the SMS manual.
Do not hesitate to call the Master up to the bridge, if in doubt. Even if it is too late to call the Master up to
the bridge or it is no deemed longer necessary, by all means be sure to call to the Master to the bridge assoon as possible.
Before calling the Master up to the bridge as early as possible, for safety reasons change the heading course
or stop the engine without hesitation, remembering that it will enable the Master to have extra time for situation assessment.
= Specific orders for the Master to come up to the bridge =•••When in doubt about an action being taken by the approaching vessel
When recognizing something unusual as a duty officer
When either of the duty officer or watch person of the bridge has a doubt for whatever reason. Use thepublic-address system, in the case that you cannot make a telephone call to the Master.

Vessel B: Master’s standing order•••

The Officer of the Watch is naturally expected to take action to avoid collision promptly if there is a risk of adangerous situation during navigation. Do not be too cautious when using whistle signals.
Keep appropriate look-out of the surroundings and immediately report the spotting of dangerous meetingships.
Do not think too much when taking actions to a avoid collision.

－ 31 －JAPAN P& I CLUBP&I Loss Prevention Bulletin§2-3-3

Analysis According to Human Characteristics for the Masters of Vessel A and B

The Master of Vessel A was handling e-mails in his cabin at the time of the collision accident. Meanwhile, The Masterof Vessel B was taking a rest in his cabin.
Voyage Route

:00

18

0
18:3

18:15

17:15

18:

45

Inland Sea
Harima Nada

19

:15

Osaka Bay

0
5

19:45

Tomogashima Strait

to

18:4

ru
St

20:00

ra

30

it

19:

:45

19

:00

20

Vessel ‘B’

Vessel ‘A’

20:15
20:30

5

:1
20

20:45

:30

20

:45

20

21:00

18:3

Na

18:1

5

19:30

Tokushima Pref.
Anan city

Collision postion
2013 Oct., XXth
21:01 JST Collision

Kii Strait
Kii Hinomisaki Lighthouse
I Shima Lighthouse
10

10

0

60km

0

30m

As can be seen in Fig. 26, the trafficsystem of the Kii Suido (Strait) isa sea area which easily causes a
crossing situation because it has
a narrow angle for approaching‘vessels between the Naruto
Strait and Hinomisaki’ and ‘thosenavigating north to south between
the Tomogashima Strait and the Kii
Hinomisaki coast of I-shima Island’.
Also, there are a large number offishing vessels operating, along witha high volume of marine traffic.
Although it depends on the individual circumstances, if the waters
are congested and there is a narrow
channel, the Master is expected
to command by himself in a large
ocean-going vessel.
Why did both Masters of the vessels
stay in each of their cabins? We aregoing to analyse the Masters of both
vessels, according to the Human
Characteristics.

Fig.26 Voyage Route (same as Fig17)（1）The Master of vessel A was checking his e-mail in his cabin after disembarkation of the pilot.

When analysed according to Human Characteristics, the following two apply:❻ Human beings sometimes are only able to see or think about one thing at a time
❼ Human beings are sometimes in a hurry－ 32 －JAPAN P& I CLUBIt is understandable that contact with related parties needs to be made and that incoming information must be checked
without delay, having sailed out from Kobe port. However, it should be obvious that safe navigation be top priority,
when comparing the processing of e-mails with that of steering a ship through a narrow channel.
（2）The Master of vessel B was taking a rest in his cabin after having passed the Naruto Strait.
Human Characteristics：  ❿ Human beings are sometimes lazy is applicable here.

It is true that the Master would be quite fatigued, because it is easy to imagine that the Master had continuously beenin command at the bridge all the way from South Korea via the Naruto Strait of the Seto Inland Sea to Mikawa Port.
However, in navigating the approximately 25 nautical mile passage of the Kii Suido Strait (almost two hours at a
speed of 12.0 kts.) from Naruto Strait to Hinomisaki, why was the Master not in command of operation on the bridge?

§2-4Preventive Measures

These preventive measures were formulated from the point of view of preventing a similar accident through drawing
up countermeasures applicable to the third officers and Masters of the ships involved, Vessel A and Vessel B, and the
managing companies of the respective ships.

§2-4-1The Third Officers of Vessels A and B

There were similarities in the specific behaviours of the Human Characteristics involved that led to the accident.
If these specific behaviours can be eliminated, preventive measures can be formulated. These are summarized as
illustrated in Fig. 27 below:
Failure to carry out thebasic action of look-out

Insuﬃcient understandingof Maritime Collisions
Prevention Act (COLREGs)

BTM cannot be put
into practice on-siteOver-reliance on electronic charts etc.）

Re-education regarding the use ofelectronic aids

It cannot be put into practice on-site because the navigation act and law are notcompatible

Re-education ofwatch-keeping
methodUndergo training, but it

Re-education ofBTM

ic aids (ARPA, AIS, electron-cannot be put into
practice on-site

Fig. 27 Preventive Measures for the Third Officers of Vessels A and B

As the analysis in §2-3 shows, the conclusion is that the following are the root causes of the accident.

－ 33 －JAPAN P& I CLUBP&I Loss Prevention Bulletin①

A failure to carry out the basic action of a look-out.

②

A tendency to rely too heavily on ARPA, AIS, electronic charts and otherelectrical equipment.

③

Although the Maritime Collisions Prevention Act (COLREGs) is understood, it
could not be put into practice on-site.

④

There was failure in implementing the BTM despite the presence of the A/B(able seaman) and a cadet on the bridge.

In order to achieve improvements in the above, retraining in all of these areas is necessary. As obvious as it may
appear, this is an important measure in order to prevent similar accidents occurring again.

§2-4-2The Masters of Vessels A and B

Despite the fact that the Kii Strait is congested with a narrow channel, the fact that the Masters were not on theirrespective bridges is one of the reasons for the collision. This is summarized as illustrated in Fig. 28 below.
The reasons behind the fact that the respective Masters left their bridges are as follows: the Master of Vessel A wasconcerned about dealing with e-mails and other paperwork, and put priority on this rather than steering the ship
through the narrow channel.
In addition, it is also a fact that the Master of Vessel B did not give priority to manoeuvring the ship through thenarrow channel over taking a break. Therefore, the root cause for the accident can be taken as a lack of awarenessregarding the safe operation of the ships.
In the case of both Masters, there were no problems regarding the level of their technical skills or their ability to operate in these waters. Both Masters presumably would have felt enough regret regarding their actions, but they clearlyboth need retraining in maintaining priorities concerning the safe operation of a ship.

Why did the Master leave

Concerned with e-mails

the bridge while navigating

and paperwork, took a

the Kii Suido (Strait)?

rest

priority order of work

Reform of sense regard-

Re-education for the safe

ing the safe operation

operation of the ship

Fig. 28

Could not clarify theof the ship

Preventive Measures for the Masters of Vessels A and B－ 34 －JAPAN P& I CLUB

§2-4-3

Management on Shore (Ship Management Company)

The author also understands that the Master of Vessel A went back to his cabin, because he was concerned about email checking and paperwork. However, as a fundamental measure to improve this situation it is important to set up asystem where this kind of pressure is avoided.
Because the implementation of the ISM code, SMS, and the use of e-mails have led to advances in communication
technology, the amount of paperwork a Master has to deal with has increased enormously. Moreover, there is now
great pressure from the organisation for the strict adherence to deadlines for the submission of various reports.
However, in considering priorities of ‘what is the most important right now’, it is clear that the most important duty of
the Master is to command the ship safely through a narrow channel. Therefore, it is of importance that the organisation
implements improvement measures in order to reduce pressure on the Master, and does not just leave the situation in
the hands of those on the ship.
Moreover, in the case of the Master of Vessel B, he was suffering from accumulated fatigue because he had to command the ship for a long time going from the Kanmon Strait to the Naruto Strait. The summary of this is shown in Fig.
29. There is therefore also a need to implement safety measures, such as the efficient use of inland sea pilots, in orderto reduce the amount of time the Master has to spend commanding the ship.

Non compliance withSMS Manual
is found here and there
Fig. 29

SMS Manual
evaluation of remedial action

Preventive Measures for Management on Shore (Ship Management Company) of Vessels A and B

Since the introduction of the ISM code and SMS, although there have been reviews regarding ways of effective
implementation, the results of these reviews show that the contents of the SMS manuals have actually increased
enormously. The situation would therefore seem to have become one whereby people have to operate within theframework of the SMS, and the basic procedures for the safe operation of the ship are being neglected in the process.
Against this backdrop, and in order to return to the original way of thinking, it should be identified as to what is actually necessary to allow the carrying out of basic operations, and the safe operation of the ship. The time has now cometo consider taking the corrective action of simplifying the SMS manuals.

－ 35 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

Traffic Systems of the Kii§3
Suido (Strait) and Tokyo Bay
We referred to the traffic system in §2-3-3, and the author conducted BTM briefings for navigation officers when they
are operating in the sea area. We are pleased to introduce these to you for your reference.

§3-1(See Fig. 30: Attachment ①

The Kii Suido (Strait)

The Kii Suido (Strait)

Traffic System Chart Enlargement)This sea area can be roughly divided into the following two sea routes:①

The route that goes to and from Osaka Bay via the Tomogashima Strait (indicated by the red
green

②

and

lines on the map).

The area off the Kii Peninsula – Naruto Strait route (only suitable for small vessels under 5,000 GT)

When going to and from the Seto Inland Sea, these voyage routes are measurably shorter than going through the
Akashi Strait (which takes an indirect route around Awaji Island).

17 to 19
nautical miles
I ShimaHino-Misaki

Fig. 30

The Kii Suido (Strait)－ 36 －

Traffic System Chart

JAPAN P& I CLUB

Because these two traffic systems are crossing in the Kii Suido (Strait), this means that this is an area in which it is necessary to be on the alert at all times. Article 15 of COLREGs (Crossing Situation) was most generally applied in this area.
However, as can be seen on the map, the crossing of vessels in this area takes place at an angle close to overtaking, and if thegive-way vessel uses a change of course in order to avoid collision, she is forced to use a large angle to change course.
In the case explained in this report, if Vessel A used a momentary heading manoeuvre in the direction of the astern ofVessel B in order to avoid collision, she would have to change course from 190 to 248 degrees.
When a large angle to change course of this type is performed in these waters, as in the case of Vessel A, the bow of
the give-away vessel ended up pointing in the direction of Tokushima. Naturally, even if she turns towards the asternof the other vessel, the give-way vessel can be manoeuvred in such a way as to follow the astern, making it possible
to return reasonably quickly to her original course. Therefore, the deviation of the give-way vessel from the originalcourse is not that great. However, psychologically, this means heading the vessel straight towards the coast, navigation
officers without much experience and whose technical skills are not sufficient can hesitate to carry out such an avoidance action. In view of this, and as seen in the accident presented in this report, this allows some understanding of thefact that the third officer of Vessel A in question only changed heading course by 6 degrees.
If the vessel in question is heading towards Osaka Bay, she can navigate following the traffic system leading towards
the Naruto Strait. The vessel can successfully fade out from the sea off Hinomisaki and head towards TomogashimaIsland. This is not a particularly difficult manoeuvre.
A vessel heading towards Osaka Bay from the sea off Muroto and navigating along the coast of the Kii Peninsula
in a north-easterly direction can see another vessel heading towards the Naruto Strait (north-west operation vessel
indicated by the blue line on the map) on her starboard side. This makes the vessel heading towards Osaka the giveway vessel.
Especially in the area between Shionomi and the Naruto Strait, the many coaster vessels navigate in a line, so thecrews of these vessels must experience difficulties in trying to avoid collisions with other vessels.
If a vessel trying to push across from I-shima Island to Hinomisaki is in danger of being hit in the sea off Hinomisaki
by a crossing vessel heading towards the Naruto Strait, the said vessel will have to make a wide turn to starboard at
the mouth of the Kii Suido (Strait). However, as the coast is visibly very close, it is difficult to find a stretch of waterthat will allow her to alter her course to starboard side in order take avoidance action.
Therefore, one suggestion when navigating in the wide sea area heading from the sea off Cape Muroto to Osaka Bay,
would be to follow the traffic system from Shionomi to the Naruto Strait, and to position the vessel in the wide waters
to the south of Hinomisaki, and to then take a course allowing a successful fade out in the sea area off Hinomisaki.
It is true that the vessels heading towards the Naruto Strait navigate in a line, but as in the same way as a car trying to
get on to an express way, it is possible to find gaps in the traffic.
An additional fact is that there are many fishing vessels in the waters in this sea area. Vessels also come and go fromthe ports of Wakayama and Komatsushima, meaning that this sea area can be described as being congested. The point
where pilots who navigate Osaka Bay are taken on board is about 1.5 nautical miles from the Tomogashima Strait. In
order to board the pilots who will navigate the Osaka Bay, many vessels have to slow down and prepare the engines(S/B Eng.). It may be because of this that, vessels in the area have to change heading course broadly in order to avoid
collision in these, as mentioned above, congested sea areas. This causes a disruption to the whole sea traffic system (asthe same would happen in the case of a motor vehicle changing lanes suddenly).

－ 37 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

Therefore, when preparing to enter the Osaka Bay, at a point of 5 nautical miles from Hinomisaki, it is important tohave the engines on standby ready to use at any time and to reduce speed in order to be able to carry out avoidance
action at any time.
Moreover, when leaving Osaka Bay and heading southbound, until the vessel is clear of the traffic system between the
Naruto Strait and Shionomisaki, the engines should be in S/B mode. It goes without saying that the Master should be incommand of operations, and depending on the circumstances, it will be necessary to utilise sub-officer of the watch andadditional lookouts as reinforcements.

(See Fig. 31: Attachment ②§3-2

Tokyo Bay

Tokyo Bay

Traffic System Chart Enlargement)This sea area has a higher volume of marine traffic than Osaka Bay. Also, there are several complicated traffic routes
such as a vessel heading towards Tohoku along Chiba Prefecture at the entrance of Tokyo Bay, a vessel crossing the
Pacific Ocean from the sea off Nojima-Saki, and a ship navigating the O-Shima northern route and another ship sailing the O-Shima southern route. And these vessels concentrate in the sea off the coast of Tsurugi-Saki in the southeastof the Miura Peninsula.
There is more complicated movement of vessels found at the point of embarkation or disembarkation for pilots inTokyo Bay: because this point is approximately 1.0 to 1.5 nautical miles south of the Uraga Suido Traffic RouteNo.1 buoy. Oceangoing vessels have no choice but to decrease speed drastically in order to let the pilot embarkation
or disembarkation in such a congested traffic system. Furthermore, in this sea area where vessels concentrate, an
unavoidable more complicated give-way takes place, as vessels are crossing and overtaking other vessels.
Generally, there are many coaster vessels that operate the O-Shima northern route. Vessels from Tohoku to Ise Bay,Kansai are (or vice versa) are crossing over the exit of Tokyo Bay off the coasts of Nojima-Saki and O-Shima in thesea area. (course shown in blue line on the chart)
Safe navigation in this sea area is to operate at S/B speed, while keeping the engine on standby all of the time because
the traffic in the sea area is congested. Many large ocean-going vessels have no choice but to make plans to slow
down towards the pilot’s embarkation point, or to start accelerating (R/Up Eng.) immediately after having let the pilot
disembark. However, in congested sea areas like these, avoidance action should be taken by reducing speed without
hesitation, just the same as with cars, and not only through taking avoidance action by changing to a wide heading
course by force. When the Author was a new Master himself, such unreasonable operations to attempt (S/B Eng.) (enter the bay) around the point of embarkation or disembarkation for pilots and to accelerate (R/UP Eng.,) immediately
after the pilot disembarked were enforced. However, as a Master and having gained experience of such an operation,
the author became more cautious and exercised safe navigation (S/B or R/UP Eng.) off Su-no-Saki.
It is necessary to fully understand these traffic systems in the Kii Suido (Strait) and Tokyo Bay, which were discussed
above. It is also necessary for managers on shore to explain sufficiently to the Masters of ocean-going vessels, who do
not have enough navigation experience in these sea areas.

－ 38 －JAPAN P& I CLUBHazard zone

Tsurugi SakiNorth of Izu O-shima Route(Mainly Coaster Vessels)

Coaster vessels

South of Izu O-shima Route(Mainly Ocean going Vessels)
East ⇔ West route which does notenter Tokyo Bay (coaster vessels)

Fig. 31

Tokyo Bay

Traffic System Chart－ 39 －

Ocean going vessels

JAPAN P& I CLUBP&I Loss Prevention Bulletin§4Engine Trouble and
Oil Spill Accidents§4-1

Feature of Trouble and Damages(Attachment ③ See‘4 Cycle Diesel Engine of vessel’)Firstly, an explanation about engine trouble in general. Please also refer to the P&I Loss Prevention Bulletin ‘Thinking
Prevention of Engine Trouble’ (Vol.38).

§4-1-1

Damage that Affects Ship Operation

The following main parts among the components of a main engine are large, both in size and weight.
（1） Power output section:‘Piston/Cylinder liner’（2） Driving mechanism:‘Connecting rod/Crankshaft’

In the event that these parts are damaged, the repair is generally large-scale. At the same time, damage to such parts
will also affect ship operation. In addition, because the repair itself is difficult, it requires experience and a high levelof skill. As a result, owing to either of the following reasons, it takes time for the vessel to be made serviceable again.
Therefore, it is necessary to lay out a framework in order to prevent accidents.
(1)‌If it is beyond the capacity of the crew, it will be necessary to arrange for the manufacturer
or a repair worker to intervene.

(2) Even‌
if the crew were to attempt a repair, they would not be so accustomed to it.

On this occasion, in order to study the accident cases, we referred to the Marine Accident and Incident Reports
regarding engine trouble and vessel damage available from Japan Transport Safety Board of Ministry of Land, Infrastructure, Transport and Tourism homepage. According to the Reports, there were 138 accounts of engine trouble anddamage over a period of eight years from January 2008 through to June 2016; these breakdowns and damage accounts
occur mainly in the following part of the main engine (except for pleasure craft and fishing boats).
Piston/Cylinder liner/Cylinder head
Turbo charger

Crankshaft bearing/Crank pin bearing

Reverse and reduction gear

Air intake & exhaust valve

Coastal vessels were mainly referred to in this report. Coastal vessels have smaller engine rooms and operate at a
－ 40 －JAPAN P& I CLUBlower output, compared with ocean going vessels. Also, most of them have 4 cycle diesel engines, not 2 cycle diesel
engines that are found on many ocean going vessels. However, the Report focuses on many themes regarding trouble
and damage to owners and ship managers of both coastal vessels and ocean going vessels.

§4-1-2

Damage Characteristics - by Equipment

Each characteristic will be described below, according to the frequency of the equipment that tends to be damaged.
（1）

Piston, Cylinder Liner and Cylinder Head(except for chain accident related with Air Intake & Exhaust Valve)

Approximately half of the damage to pistons, cylinder liners and cylinder heads were due to burnout. Most piston
structures comprise of a cooling system using lubricating oil (hereinafter LO), but burnout is caused by a short supply
of cooling oil. This shortage is also caused by a shortage of LO pressure and a blockage in the cooling oil supply
route.
Moreover, there are cases of bending damage to the push-rods because of damage sustained to the exhaust valvecaused by a strike from the piston crown due to the looseness of the fixing bolt between the piston crown and thepiston skirt. The following measures are taken:●

Crew are to understand the risk of damage to an engine when disassembling and assembling it.

●‌When disassembling and carrying out maintenance, crew should confirm and inspect theparts carefully again before assembling, in order to avoid assembly mistakes regarding important parts such as the LO channels and tightening of parts.

（2）

Crankshaft bearing/Crank pin bearing

Most damaged sustained by crankshaft bearings is due to a lack of LO.
This is because the sludge in the LO builds up in the strainer and filling pipe due to neglect of maintenance andinspection. In addition, most causes of damage to the crank pin bearing (large end of the connecting rod) come fromover-tightening, insufficient tightening or uneven tightening of the connecting rod bolt (hereinafter referred to as crank
pin bolt). The following measures are taken:●‌To comply with and carry out the tightening method and force necessary based on the manufacturer’s instruction manual.

●‌In every maintenance carried out, it is important to check for any cracks (dye penetration inspection), the bolt length (dimension measurement), length-of-use of components (comparedwith maximum hours of use) and to exchange the parts, if necessary.

（3） Turbo charger (except for air intake & exhaust valve chain accidents)

Damage to the turbo charger is related to damage sustained by the shaft (burnout of rotor shaft bearing, bending ofrotor shaft, breakage, etc.) and hole in the casing. The main cause of a hole appearing in the casing is due to thickness
depletion and corrosion sustained by long-term use. The following measures are taken:－ 41 －JAPAN P& I CLUBP&I Loss Prevention Bulletin●‌Measures taken against thickness depletion
To conduct a thickness measurement regularly and to exchange the casing based on the manufacturer’s standard.

●‌Prevention of corrosion
Carry out the quality check of cooling water (property analysis, chemical treatment, etc.) and appropriate temperature control.

（4）●Main Engine Reverse and Reduction Gear
‌There are many cases where damage to the main engine reverse and reduction gear iscaused by a problem concerning the hydraulic system. The preventive measures ensure thatthe maintenance and inspection of the hydraulic pump are carried out.

（5）

Air Intake & Exhaust Valve

The following are main damage accounts regarding air intake & exhaust valves:● B reakage of valve seat
● A‌ valve detaches from its valve shaft and falls into the cylinder. As a result, the cylinder
head, piston and cylinder liner will be damaged.
● F urthermore, the fragments of damaged parts enter the turbo charger and cause damage to it.

Approximately half of the damage accounts of the air intake & exhaust valves cause damage to the turbo charger.
Even when maintenance is implemented regularly, damage can still occur. Preventive measures are to ensure thatthe crew confirms and inspects the following states described in the manufacturer’s instruction manual, when disassembling and maintaining.
●‌ check and measure the cracks in the valve shaft and the valve seat (in order to verify
To
the wear and tear and deterioration state)●

To confirm the length-of-use of component parts (compare with maximum hours of use)

（6） Summary

Summing up each aforementioned measure, it is important that confirmation with regards to the state of the engine
and inspection are thoroughly carried out, based on the manufacturer’s instruction manual during disassembly andmaintenance work. Namely, it is as follows:● Evaluate‌and replace the component parts based on the standard. (Deterioration, cracks,
dimension measurement, wear and tear, maximum hours of use, etc.)● During‌
the assembly process, reconfirm and inspect repeatedly the same parts in order toprevent mistakes during the assembly of critical parts.

－ 42 －JAPAN P& I CLUB

§4-2

Cases

The following cases will be introduced: ① a damaged piston and crank pin bolt, which may greatly affect navigation
when damaged, ② crank pin bearing damage, and ③ oil spill accidents that cause great harm to the environment.

§4-2-1Case ①

Piston Seizing and Piston Skirt Broken Damage Accidents（1）Outline of accident＜ Vessel’s particular ＞

Tanker Main engine output 2,942kw, built in 2001
＜ Summary of accident ＞

On March 2013, a broken hole appeared in the crankcase door of the main engine No.4 cylinder during operation,
which caused LO to gush out. Immediately, the watch engineer stopped the main engine. Then, as the result of inspection that both the chief engineer and the engine officer carried out, the following accounts of damage were detected.
①

Broken damage to piston skirt②

The broken damage part dropped down

Following consultation between the Master and the chief engineer, the Master deemed that the vessel was disabled fornavigation and the vessel was towed to the nearest port.
Before analysing the causes of the accident, piston structure and the flow of LO will be explained. (Please see Figs.
32, 33-1, 33-2 and end of booklet: Reference Attachment ③：‘4 Cycle Diesel Engine of vessel’)Snap Ring

Note: Parts information of Piston diagram

Piston Crown

Crank Pin Bearing

Piston Pin

Piston Skirt
Crankshaft

Connecting Rod

Oil Hole ofConnecting Rod

Main Bearing
Lubricationof each Piston
Pin Bearing
Passage to
Piston Pin
Filling Hole

Supply to Piston Cooling Space
Fig. 32

Piston diagram and Cooling oil supply route－ 43 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

Piston Pin Metal

Snap Ring

Snap Ring

Piston Pin

Piston Pin
Piston Pin Metal

Snap Ring
Connecting Rod
Fig. 33-1

Fig. 33-2

Piston Pin Diagram

Piston Pin Diagram

The piston structure consists of two parts: an upper part and a lower part. The upper part has a special alloy pistoncrown and the lower has a cast iron piston skirt. The piston is of the assembly-type. The upper and lower parts areconnected by tightening bolts. The yellow line in Fig.32 shows the route of the cooling and lubricating oil that is
supplied from the main bearing.
The piston pin is a metallic hollow-shaped cylinder. The piston and connecting rod are connected via the boss
(borehole) in the piston skirt and a piston pin in the small end bearing of the connecting rod. Also, the piston pin (fullfloating type) has clearance between the small end bearing of the connecting rod and the piston pin boss. Both ends ofthe piston pin boss have a gutter.
As can be seen in Figs. 32, 33-1 and 33-2, the piston pin is prevented from coming adrift from the bearing by metal Cshaped retaining rings (hereinafter, snap rings) affixed in these gutter areas. In addition, there is a hole that allows for
LO (as cooling oil) to flow to the piston pin. This cooling oil is supplied from the oil hole in the connecting rod up to
the piston.
（2）The events that occurred

The sequence of the events that occurred is summarised as follows:①

Broken damage in the piston skirt of No.4 cylinder also occurred previously. Repair including the
replacement of new and remodeled parts carried out by an engine manufacturer was conducted in
October 2010.

②

Main engine LO consumption increased from around June, 2012. There is a possibility of abnormalities
at this point. Just before the accident, consumption increased by approximately three times to that ofnormal.

③This is why the chief engineer and engineer conducted the inspection of the crankcase, however, anabnormality was not detected.

④

Up until the trouble occurred, the chief engineer and engineer assumed that the cause of increased
LO consumption was down to abnormal wear of the piston rings. In fact, overhaul and maintenance
was reviewed during dock repair work that was scheduled on June 2013 (3 months later following theaccident).

－ 44 －JAPAN P& I CLUBWhen the accident occurred in March 2013, a description of the condition of No.4 cylinder is as below:（a）Piston skirt● T he lower part of the oil ring of the port side piston skirt was severely
seized and sustain broken damaged● The broken damage part dropped down
● The bottom part of the piston pin boss was broken⑤（b）Piston pin boss（c）Snap ring（d）Cylinder liner⑥● T here was a contact mark on the bow side of the piston pin boss on thefar outer side of the gutter, where the snap rings are inserted, that wascaused by surface contact from the piston pin.
● T he snap ring of the bow side piston pin was broken in the centre andhad dropped down
● H
 ad the snap ring been appropriately inserted into the snap ring gutter, acontact mark would naturally not have appeared.
● A
 vertical scratch approximately 5mm in depth sustained on the bow side
to cylinder liner

During navigation, a broken hole appeared in the crankcase door of No.4 cylinder, which caused LO
to gush out. The watch engineer stopped the main engine immediately.

（3）Analysis by Japan Transport Safety Board

Japan Transport Safety Board analysed the cause and recommended preventive measures as follows.
① Cause Analysis (Please see Figs. 32, 33-1, 33-2 and 43 on page 77 regarding diagrams)a‌
Althoughthe manufacturer carried out a repair in October 2010, the snap ring of the piston pin
boss was not fully inserted into the snap ring gutter during the assembly process. Due to this,the ring broke and dropped down during operation.

b‌
Thereby,the route for supplying LO was blocked because the piston pin moved to the axial
direction retarding the supply of LO. As a result, the piston was deprived of coolant, whichcaused it to seize and subsequently sustain broken damage to the piston skirt.

cOn the other hand, as for the time of the snap ring dropping down, it is pressumed to have occurred
around June 2012, when LO consumption had increased. Inferred grounds are as follows:●

Piston pin moved to the axial direction due to it dropping off the snap ring.

●Consequently, the following events occurred and LO consumption increased.

●

The piston pin made contact with the cylinder liner and vertical scratch damage was sustained.

Through the vertical scratch damage, cooling oil leaked into the combustion chamber and combusted.
●Because the passage to the supply of LO became blocked and the piston was in need of coolant, theheated piston evaporated the LO nearby.

② Preventive measures by Japan Transport Safety Board

Based on the above analysis, the following are recommended as preventive measures that can be applied to similar
accidents in future.
The strengthening of supervision during assemblya hile assembling the important parts of an engine, technicians are to carry out assembly correctly while under theWsupervision of a supervisor who is familiar with the work.

－ 45 －JAPAN P& I CLUBP&I Loss Prevention BulletinbTo make inquiries to the manufacturer, when an abnormality has been discovered,and investigate its cause.
In the case of an extraordinary increase in LO consumption, the crew are firmly requested to make inquiries tothe manufacturer regarding the following:●

To check as to whether the increase of LO consumption is within the acceptable range.

●

If further necessary, investigate the cause at an early stage by disassembling each part.

c R eview of inspection methods by crew●

Crew should keep in mind the following, when inspecting the crankcase.
◦

To observe carefully the state of the cylinder liner.

◦To try changing the piston position through turning for easier observation.

§4-2-2 Case ②

Crank Pin Bearing Damage Accident（1） Outline of Trouble＜ Vessel’s particulars ＞

Cargo ship Main engine output 1,080kW Built in 2004
＜ Summary of accident ＞

On October 2011, because the main engine automatically stopped with a loud sound during navigation, she dropped
anchor in an emergency at the end of the traffic lane nearby. On inspection during anchorage, the large end of theconnecting rod of No.7 cylinder passed through the crankcase door. After draw out of the No.7 piston, she shifted toanchorage by cutting operation of No. 7 cylinder. After that she was towed to port for repairing.
According to the investigation by Japan Transport Safety Board, the following accounts of damage were detected.

①

The state of the four crank pin bolts at the large end of the connecting rod of No.7 cylinder aredescribed as follows: (See Reference Picture 34)（a） Two bolts were cut at the stud bolt end（b） The other two bolts sustained bending damage in the middle section②

Broken damage of piston and cylinder liner (See Reference Pictures 35 and 36)③

Burnout of the crank pin bearing metal

Crank Pin Bolt

Reference Picture 34
Bending loss of connecting rod

Reference Picture 35

Reference Picture 36

Broken damaged cylinder liner

Broken damaged piston－ 46 －JAPAN P& I CLUB

（2）The events that occurred

The sequence of the events that occurred is summarised as follows:①

On the 4th of October in 2010 (approximately one year before the accident occurred), the crew
carried out piston draw-out of the No.7 cylinder during regular inspection. During the assembling work,
they used a torque wrench to tightening in the crank pin bolts.

②

When the accident occurred, the cylinder was found to be in the following state:③（a）

Two of the bolts at the big end of the connecting rod had snapped and the other two bolts
sustained bending damage.

（b）

The connecting rod itself sustained bending damage

When the accident occurred, the main engine automatically stopped with a loud noise. Then, thefollowing parts had been damaged.
（a）Broken damage: piston and cylinder liner（b）Burnout: crank pin bearing metal（3）Analysis by Japan Transport Safety Board

Japan Transport Safety Board analysed the cause as follows and recommended preventive measures.
① Cause Analysis

The cause was that the crank pin bolt of main engine No.7 cylinder had snapped, which led to the freeing of the large
end and the consequent disconnection of the connecting rod from the crankshaft.
② Preventive measures

Based on the above mentioned analyses, the following was recommended as a preventive measure that can be applied
to a similar accident in the future.
● I‌n the event of piston draw-out work, based on the guideline for maintenance work andstandard (instruction manual), maintenance of the crank pin bolt (replacement, dye penetration
inspection, cleaning, tightening force and so on) is to be carried out appropriately.

§4-2-3  Case ③

Oil Spill Accidents

On examination of oil spill accidents that our Club deals with, most accidents of this type which occur, excluding
collisions and those that run aground, are not cargo oil spill accident related but occur at the time of bunkering of fueloil (hereinafter FO).
（1）General Bunkering Procedure

First, an explanation of the general bunkering procedure. The vessel has FO bunkering work instructions from an environmental protection standpoint in accordance with the safety management system and manuals (hereinafter referred toas SMS). The work instructions generally consist of making a bunkering plan, a bunkering work plan, preparation forbunkering, work before oil receiving, receiving oil work, and work after bunkering. As can be seen in Table 37, the stepsof the procedure from the making of a bunkering plan to work before oil receiving are as follows.
－ 47 －JAPAN P& I CLUBP&I Loss Prevention Bulletin①【Before bunkering】
Procedure
A. Previous port -During navigation -Entry into port

Operating situation

Making of bunkering planⅠ
Ⅱa.

Confirmation of necessary bunkering amount・Decided actual measurement of each tank, calculation of estimated consumption amount andprovisional amount for bunkering
Confirmation of receivable quantity

Make a plan that does not exceed 90% of the capacity of each tankⅢ

How much bunker oil is needed in each tank?

Ⅳ・Set in order of MDO (marine diesel oil) then HFO (heavy fuel oil) and plan the refilling from aⅤ
Ⅵ

Bunkering order

far-off tank procedure.
Valve operation order

・Carry out valve opening/closing test beforehand.

Bunkering work task assignment
・Task assignment and personnel arrangements

Bunkering work arrangement
Pre-meeting among all members of engine department regarding bunkering work arrangementb.

Ⅰ・Role allotment (personnel arrangements): where, how much and into which tank the FO is tobe refilled.

・Countermeasure in state of emergency

ⅡⅢ

All attendants sign their names after a meeting
Keep all crew thoroughly informed regarding the importance of the bunkering work
arrangement.

Prepare for bunkering (the following work should be carried out, before and after port entry)
Final confirmation of the actual level and remaining quantity of all FO tanks.
・The person responsible on scene must recalculate the plan, based on the actual fuel propertyⅠ

and actual remaining quantity in the tank・Transport necessary fuel to FO settling tank.
・Lock the FO transfer pump in order for it not to start automaticallyPrepare toolsc.

・ Sounding table, specific gravity & volume conversion table, calculator, watch, stationary,
Ⅱ transceiver, etc.
・Piping diagram, fire extinguisher, oil removal material, sounding tape, thermometer, pressure
guage, tool, etc.
Ⅲ
Ⅳ

Line-up・Entirely close unnecessary valves
Set scupper plugs on deck

Ⅴ

Precision check of remote level gauge and operation check of each alarm on valve remotecontrol panel, indicating light, etc.

Ⅵ

Pressure test for bunker line during a dock or navigation before bunkering, if necessaryＢa.

Following port entry

Hoisting B flag after entering port (Red light all-round at night)

C. Bunker barge alongside
Work before oil transfera.

Ⅰ
ⅡCheck the bunker oil volume on barge
・Confirmation using sounding table of barge
Oil transfer volume
・Oil transfer capacity of barge and receivable quantity of vessel－ 48 －

RemarksJAPAN P& I CLUBa.

Ⅲ

Means of communication (transceiver etc.)

Ⅳ

Countermeasure in state of emergency

Ⅴ

After final check, a signature is required from both the barge side and vessel sideⅥ

Hose connection

Ⅶ
Ⅷ

Contents confirmation of Bunker Delivery Note(hereinafter, BDN)
・Oil type/oil quantity/oil property of fuel oil
Preparation for sample oil at collecting point

Table 37 Example of Bunkering Procedure① Making a bunkering plan

The bunkering plan is to be made by the filing in of the requirements in the list stipulated in the SMS, etc. At thisstage, in the same plan, the results of supposition calculation using figures based on previous bunkering oil temperatures, seawater temperatures, and fuel properties, etc., are filled in.
② A bunkering work plan

A person responsible on scene (generally a first engineer, described below as or hereinafter 1/E) makes a bunkering
work plan following the bunkering plan and explains it to each crew member following approval of the plan by thechief engineer. The 1/E explains the steps involved in bunkering work such as personnel arrangement, individuals
work responsibility, each work procedure, work method, countermeasure in state of emergency and so on.
③ Preparation for bunkering

In the preparation for bunkering stage, the person responsible on scene re-calculates the bunkering plan, based on theactual amount of fuel remaining in the tank and the actual fuel property just prior to bunkering. In other words, thepractice of PDCA concerning the bunkering work plan is essential④ Work prior to oil receiving

A third engineer (hereinafter 3/E) attends tank measurement on the bunker barge side or joins for reading aloud theinformation from the flow meter, and keeps a record to report to the person responsible on scene. The person responsible on scene re-calculates the requirement and completes the final bunkering plan. A point to confirm here is whether
the bunker barge retains the necessary amount and specification of fuel in accordance with the ordered amount or not.
Then, once the chief engineer approves the calculation result, the oil receiving begins.
⑤ Receiving oil work

During oil receiving acceptance, the crew of the engine department must pay attention to the following two duties.
1）To monitor oil leakage and tank liquid level

To verify any abnormality such as leakage
To carry out tank measurement regularly (Needless to say, but trim and heel correction is required when verifying the oil amount.)● A responsible person on scene is to calculate the rate of oil receiving flow. He also must know when it is time
to change tanks.
●●2）Appropriate action to be taken when there is an oil leakage●W hen an oil leakage is found, the person responsible on scene should immediately announce the order to stop
pumping, and in the event of an overboard oil spill, the crew of the engine department must report it to the C/E
and duty officer immediately.

●

All crew onboard must handle this in accordance with the oil spill control station and shipboard oil pollution
emergency plan.

－ 49 －JAPAN P& I CLUBP&I Loss Prevention Bulletin⑥ Work after bunkering

Having completed receiving work, the engine department not only submits the bunkering tank record to the deck
department, but also restores it to the normal fuel transfer line and fuel supply line promptly. Table 38 shows anexample of work instructions for both completed oil receiving work and post bunkering work.

②【During bunkering work】
Procedure
D. Commencement of bunkering

Operating situation

Oil receiving work
Ⅰ

After having started oil transfer and confirmation of any leakages of oil, gradually increase the oiltransfer volume up to the planned quota.
Check the receiving tank liquid level at regular intervals (actual measurement by sounding scale).

Ⅱ

Ⅲ

Ⅳ

・Non-receivable tank: if ‘no inflow (no change of liquid level)’ after a certain interval since
starting, continuous monitoring is not necessary
Watch system, three persons at least
・One each for manifold and sounding, and a chief engineer (high command)
When receiving to more than two tanks, pay attention to manifold pressure at the time ofswitching tanks.
(Adjust the oil transfer volume, if needed)a.

ⅤCollecting sample oil

Ⅵ

After transferring oil, carry out air blowing.
Confirmation of completion having received the arranged quantity (both for vessel and barge)

Ⅶ・Carry out tank measurement after bubbles have subsided.
・When there is no difference between receivable quantity and ordered quantity (OK), receivable
quantity will be written down on BDN and the chief engineer will sign the document.
・Issue Letter of Protest in case of shortage.
When something unusual happens, the person responsible on scene must stop the oil transfer
immediately.

Ⅷ・After confirming the cause of the abnormality and measurement carried out, oil transfer can bere-started.
Permission for restart of oil transfer by chief engineer is required.
・In the case of an oil spill into the sea, report it to both the chief engineer and to the duty
officer immediately.
Handle in accordance with oil spill control station and shipboard oil pollution emergency plan

E. Secure bunkering
Work following oil transfera.

I

Receiving oil sample for custodyII

Removal of hose

III

Secure each tool and B flag (red light)IV

At appropriate time, restore the fuel line and bunkering line of vessel side to normal

V

Submit the record, i.e. final bunkering quantity, tank condition, etc. to the deck department.

VI

Secure the sealed deck scupper

Table 38 Example of Bunkering Procedure－ 50 －

RemarksJAPAN P& I CLUB（2）Outline of accident

FO bunkering work was carried out on the vessel (approximately 8,000 GT) while it moored for cargo discharging work.
However, just at that time, the following accident occurred in the No.3 FO tank which was the last to top-up tank.

①

FO overflows from the air vent (See Reference picture 39)②

The crew could not contain the fuel on the deck and approximately 100 litters spilt into the sea(See Reference Pictures 40 and 41).

After the spill, the Japan Coast Guard and the vessel and shipowner arranged for seven work boats and cleaning
experts. The cleaning work was completed in one day. As a result, a sum total of approximately JPY 27,000,000 in
expenses was paid in insurance money for the investigation and cleaning up of the spilt FO.

Reference Picture 39
No.3

Reference Picture 40

Fuel oil tank air vent（after overflow）

Port side of upper deck

Reference Picture 41
State of oil spill overboarding－ 51 －JAPAN P& I CLUBP&I Loss Prevention Bulletin（3）The events that occurred

According to the surveyor’s report, which was arranged after the accident, it was confirmed that the following events
led to the FO spill.
①

In the work carried out at a previous port, the second engineer, (hereinafter referred to as the2/E) was planning to carry out sounding of No.3 FO tank, which was set to finalize top-up tank.
However, he failed to carry this out.

②

Without confirming the actual measurement in ① , the 1/E: the person responsible on scene, madethe bunkering plan, assuming that the tank had‘no remaining oil’. The plan for receiving oil wasscheduled to be carried out using four fuel tanks, in the following order: No.4 (port side andstarboard side), No.5 (central) and No.3 (central).

③

In addition, calculation details of the bunkering plan were not specified. The surveyor that
our Club arranged for accident investigation presumed that approximately 62KL, which isequivalent to 66% of the No.3 FO tank capacity on the bunkering plan (amount required fortank top-up), according to the investigation.

④

Although the 3/E and two oilers carried out tank measurement of the No.3 FO tank before
starting oil transfer, they did not realize how much remaining oil was left in the tank.

⑤

Also, even during receiving oil work, the 3/E and the oilers continued to measure the tankliquid level. In spite of the fact that receivable quantity was beyond the amount of the
bunkering plan, which was indicated above in ③ , they did not request that the oil transfer be
stopped. Consequently, because the receivable quantity was in excess of tank capacity, FO
overflowed from the air vent.

⑥

During tank overflow, the No.3 FO tank was filled with approximately 91KL of FO, which isequivalent to 96% of tank capacity. However, the oil transfer amount from the barge was as
instructed.

⑦

Therefore, though the stripping work was cancelled, the 1/E, who was the person responsible on
scene during bunkering work and in charge of maintaining contact between the barge and thevessel, was delayed in taking measures to initiate an emergency stop when it stated to overflow.

－ 52 －JAPAN P& I CLUB

§4-3

Accident Analysis in Accordance with Error Chain

Not limited to marine accidents only, it is almost impossible for an accident to occur from a single error. A series oferrors cause an accident in the end. Regarding the three cases which were introduced in §4-2, we are going to analyseeach event from the perspective of error chains.

§4-3-1 Case ① Piston Seizing and Piston Skirt Broken Damage
The error chain of piston seizing and piston skirt broken damage accidents (Case ① ) was analysed according to timesequence.

Time-sequence ① Trusted entirely to the manufacturers
Time
In October 2010, main engine No.4 cylinder piston skirt sustained broken damage and-sequence
repair was carried out by the engine manufacturer.
①

Errors12

Related problems

The crew, ship owner and ship management company did not

Insufficient ship

understand why it was replaced with remodeled parts.

management

Relied on the manufacturer because it was a replaced with aremodeled one (over-trusted)

Assumptions

Measures

Methods＜＜ Establish guidelines and ensure compliance with crew on ship ＞＞

Thorough instruction

In the case of discovering something unusual, make an inquiry to the manufacturer

Thorough ship manage-

for advice promptly and take emergency measures.

ment and supervision

Regarding repair by engine manufacturer, in spite of having exchanged the part with a remodelled one, crew, ownerand ship management company were not aware of the reason why.

Time-sequence ②
Investigation as to the cause was insufficient, despite the fact that LO consumption had increased
Increase of LO consumption as the sign of an accident cause was a phenomenal fact. Although the crew realized theabnormality, both the crew and the ship management company neglected to take the appropriate action.
Timesequence②

Trunk piston type lubricating oil is consumed mainly for lubrication between cylinder andbearing and cooling the piston. Since around June, 2012, the lubricating oil in the main
engine had been excessively consumed and - it increased to approximately three times thenormal amount just prior to the accident.

Errors12

Related problems

The Vessel noticed the unusual increase of consumption, however, it did not

Insufficient daily duty

make inquiry to the manufacturer for further information.

management

There was no guideline for lubricating oil management.

－ 53 －

Insufficient ship
management

JAPAN P& I CLUBP&I Loss Prevention Bulletin
Measures

Methods＜＜ Establish guidelines and ensure compliance with crew on ship ＞＞

Thorough instruction

Prior to the manufacturer’s repair, 'confirmation and request for important
repair procedures, timing of watch on the ship's work site, the necessity of any
assistance, etc.' should be sought.

Time-sequence ③

Thorough ship
management andsupervision

Could not discover abnormal state when inspecting the crankcase

Time-sequence There was no abnormality discovered when inspecting inside the crankcase.

③

Errors12
3

Related problems

At the time of inspecting inside the crankcase, why was 'theobservance of the parts consisting of the piston, cylinder liner, etc.'
not carried out?
In the event of inspecting the cylinder liner, it is necessary 'to adjust
the piston location'.

Insufficient daily duty
management
Crew's insufficiency ofworking skills
Insufficient ship

There was no observation guidelinemanagement

Measures

Methods＜＜ Establish guidelines and ensure compliance with crew on ship ＞＞

Thorough instruction

In the event of inspecting the crankcase, it is also necessary 'to observe not only
for foreign substances (such as metalic pieces of bearings, combustion residue, etc.)
at the bottom of crankcase, but also inside of the piston skirt, the appearance ofthe connecting rod, the state of the cylinder liner and so on'. When inspecting thecylinder liner, it is necessary 'to adjust the piston location'.

A crankcase is, as shown in Fig. 42, a box shape room
which houses the crankshaft. As there is a door attached, it
is possible to inspect the inside. However, this door is too
small and it is not possible to observe the internal structure
without using a hand mirror or adjusting the positionof the crankshaft (See Fig. 42). There are three errorsthat occurred in the chain, when analysing as to why theabnormality was not detected at the time of inspecting the
crankcase.

Thorough ship
management andsupervision

CHECK!

Fig. 42 Appearance of Crankcase－ 54 －JAPAN P& I CLUBTime-sequence ④

Insufficient response to abnormal wear of piston rings

The crew presumed that the cause of unusual LO consumption (Time-sequence ② ) was a result of abnormal wear of
the piston rings, however, they did not report or making an inquiry to the ship manager or manufacturer.
Until the accident occurred, abnormal wear of the piston rings was assumed to be theTime-sequence cause (all of the cylinders were planned to be opened up and examined during the next④
dock repair work scheduled in June 2013).

Errors12

Related problems

Despite the fact that abnormal wear of the piston rings was assumed,

Insufficient ship

why was an overhaul of the pistons not carried out immediately?

management
Insufficient ship

There was no guideline.

management

Measures

Methods＜＜ Establish guidelines and ensure compliance with crew on ship ＞＞

Thorough instruction

When it is deemed necessary to carry out an overhaul because of an abnormality,

Thorough ship manage-

make a request to the administrator immediately.

ment and supervision

Time-sequence ⑤

Not realizing abnormality within the engine

The main reason for burnout was a lack of LO, but it was in fact caused by the dropping-off of a snap ring. A description of the mechanism that controls LO and how this causes the oil to not flow smoothly, as a result of a snap ring
dropping off, is as follows. (See Fig. 43)
The main engine No.4 cylinder on the 28th of March, 2013 was as follows.
(1) Piston Skirt
Time(2)
Piston Pin Boss-sequence⑤(3) Snap Ring
(4) Cylinder liner: s evere seizing and broken damage at the bottom of oil ring:b
 roken damage at the bottom in entire circumference. There was acontact mark from the piston pin on the fore side.
:breakage to the centre and dropped off. There was no contact markin the gutter insert.
: existence of vertical scratch damage (two lines).

The causes are presumed as follows.
(1) The cause of burnout was down to a lack of cooling oil in the piston.
(2) Strength deterioration by piston skirt overheat.
(3) The snap ring on the bow side was not set correctly.
(4) The snap ring had dropped-off and the piston pin moved to the same direction.
(5) B oth left and right sides of the piston pin made contact with the liner on the bow side
and caused vertical scratch damage.
As a result, the following were caused.
Due to the dropping-off of a snap ring, there was a shortage of piston pin cooling oil.
Furthermore, as a result of the shortage of piston pin cooling oil, it caused overheat, strength
reduction and broken damage to the liner.

－ 55 －JAPAN P& I CLUBP&I Loss Prevention Bulletin
ErrorsRelated problems

1

The insufficient awareness of the inportance of piston assembly by
the engineer in charge.

2

Lack of risk prediction of 'engine trouble may be caused if snap ring is
not correctly inserted'.

3

Regarding assembling equipment which may lead to an accident, why
did he not instruct the manufacturer to pay attention to assembly
work or inspect the work that was being carried on board at that time?

4

There were no opportunity for training and on-ship guidance.

Insufficient ship
management
Crew's insufficiency ofworking skills
Insufficient ship
management
Insufficient ship
management

Measures

Methods＜＜ Thorough crew training ＞＞
The essence of the accident is 'how to understand the basic structure of apiston and what kind of accident can be predicted in the case of insufficientmaintenance'.
＜＜ Thorough guideline creation ＞＞
Regarding the parts which may lead to an accident occuring because of failure ofmaintenance inspection/assembly, and 'working instructions to the shore worker orwatch on the ship's work site'

Crew training

Thorough ship
management andsupervision(a)	As described earlier, the piston pin(full floating type) is inserted into
the piston pin boss. The snap ringis inserted into the gutter of bothends of the boss.
(b)	Therefore, if the ring gets separated, the pin will move toward theaxial direction. Thus, the passage
of LO gets blocked by the shiftingof the positions between the oilhole of the connecting rod and thefilling hole of the piston pin.

Snap Ring Missing

Snap Ring
Piston Pin

Piston Pin Moved(c)	As a result, the filling oil to theupper part of the piston pin bossand piston cooling space will be
stopped.

(a)Snap ring at normal
Fig. 43(b)Snap ring when dropped-off

Prevention of LO Flow which Aids Piston Pin Movement－ 56 －JAPAN P& I CLUB

§4-3-2  Case ②

Crank Pin Bearing Damage Accident

The error chain of Case ② ‘crank pin bearing damage accident’ was analysed according to time-sequence.

Time-sequence ①
Timesequence①

Crew’s lack of awareness regarding the important points of piston assembly.

On the 4th of October, 2010 Main engine No.7 Cylinder piston draw-out by the crew
ErrorsRelated problems

1

The insufficient awareness of the inportance of piston assembly by
the engineer in charge.

Crew's insufficiencyof working skills

2

Lack of risk prediction which 'may develop to engine trouble, if
connecting rod was tightened incorrectly'.

Crew's lack ofknowledge

3

Why was there no opportunity to take internal training?

Insufficient crew
training

Measures

Methods＜＜ Reinforcement of crew training ＞＞

Crew training'Allow the crew to learn about the basic structure of the connecting rod andeducate them as to what kind of trouble may occur in the event of maintenance
failure’, which is at the root of the trouble.

Thorough ship
management andsupervision

All error chains derive from the crew’s insufficiency of knowledge and operational skills required for important
maintenance.

Time-sequence ②
Timesequence②

Lack of knowledge regarding how to tighten bolts

When the accident occurred on 28th October in 2011, the condition of main engine
No.7 cylinder was as follows:● Two connecting rod bolts broke at the large end of the stud bolt.
● The other two bolts were bent in the middle
ErrorsRelated problems

The crew was not familiar with both the tightening technique andthe inspection method.
●T echnique of tightening based on the manufacturer's

1

instruction manual (torque, angle, hydraulics)● Handling a torque wrench (precision, setting and correction)

Crew's insufficiency ofworking skills●C arry out correct assembly of each part, inspect nut andbolt surfaces and penetration test of crank pin bolt before
tightening.

2

Insufficient ship

No maintenance guidelinemanagement－ 57 －JAPAN P& I CLUBP&I Loss Prevention Bulletin3

Why was the senior engineer negligent to confirm the important

Insufficient work

points regarding connecting rod assembly?

instructions, etc.

Measures

Methods＜＜ Thorough guideline creation ＞＞

Thorough instruction●R egarding connecting rod assembly, 'tightening technique, handling ofa torque wrench, parts assembly and cleaning the surfaces of nuts, andpenetration test of tightening bolts etc.'●'Items that the senior engineer must confirm' when maintaining a vessel.

Thorough ship
management andsupervision

Although crew should have been familiar with the ‘technique of tightening and the inspection method of the crank pinbolt, which were referred to in the manufacturer’s instruction manual’. But they could not have done this.
The crew must assemble each part so as for them not to come loose with centrifugal force and vibration during engine
operation. That is why it is important to understand the following regarding the technique of tightening and the inspection of bolts.
（a）Technique of tightening based on manufacturer’s instruction manual(torque, angle and hydraulic jack)Technique and force of tightening are stipulated in the manufacturer’s instruction manual. The crew must tighten theblots evenly based on the instructions. At that time, it is necessary to pay attention to each tightening unit.
＜ Remarks on bolt tightening method ＞●

Not to make a mistake in the technique of tightening using several different methods.

●

Torque method (N・m or kgf・m), angle method(°), torque ＋ angle method (tightening in two stages),
hydraulic jack method (MPa or kg/cm2), etc.,＜ Having disassembled the connecting rod and having newly replaced crank pin bolt remarks ＞●

Carry out re-marking of the Set Mark when assembling.

●Check for bolts and nuts that may have worked loose following a certain operation hours after theassembly. (For example: inspect the position of the Set Mark and re-tighten to the specified torque)(b)

How to handle a torque wrench (precision, setting and calibration)

In torque method, a torque wrench is used for tightening bolts. The wrench has the following features. Crew must
understand how the wrench works and handle it appropriately.
● Set the control value correctly for the wrench.
The unit should be noted:（[N・m] value ＝ [kgf・m] value × 9.8, [kgf・m] value = [N・m] value × 0.102,
For example, 49N・m = 5kgf・m）●

Crew must treat the wrench carefully as a precision-tool in order to maintain precision.

Also, the following are required for safekeeping of the wrench.
●

The wrench is to be stored separately from other general tools.

●

The setting point should be set to the minimum level.

●

The wrench should be calibrated regularly or replaced with a new one.

－ 58 －JAPAN P& I CLUB（c）

Assemble correct parts, clean and inspect nut and bolt surfaces before tightening

Before tightening, it is a must that the surfaces of nuts and bolts are thoroughly inspected and cleaned, together withcorrect assembly. For example, crew must tighten after inspecting and cleaning of the seat surface of the large end
and the bolt head and nut. If crew neglect to clean, dust will gather. This will cause the nut to end up in a ‘loosened
state’, because such dust stuck in a specific area deteriorates the tightening force of the nut and bolt then exposed tocentrifugal force and vibration due to the rotational motion of the crankshaft during engine operation.
As a result, the large end will detach from the crankshaft which has a danger working free. In addition, roughness andscratches on the seat surface of the bearing will reduce bearing contact surface area. If nuts and bolts are unevenly
tightened, a similar problem will occur. Therefore, the inspection of the seat surface is also important.

（d）

Dye penetration inspection of the bolt (non-destructive inspection), etc.

As the bolt receives repeated stress during engine operation, the strength is reduced each year. Then, at the time ofdisassembly and maintenance, crew must inspect to see if there is any damage on the metallic surface by Dye Penetration Inspection. If any damage is found on the bolt, it has a danger of breaking.
Note: ye Penetration Inspection is also referred to as colour check. This is a non-destructive inspection method which detects
Dcracks that appear on the surface of the material, by using a red or fluorescent coloured penetrant; with the usage of thecapillary action principle.

（e）Handling precautions regarding the bolt

In this case, the bolt itself was broken. Thus, in addition to the tightening method, durability management requires
special care. The points are: dye penetration inspection (non-destructive inspection described above in (d)), dimension
measurement (evaluation of bolt extension), maximum hours of use (bolt life management), etc. The necessity ofdye penetration inspection is mentioned above. Moreover, crew must be able to recognise the extent to which thebolt extended by measuring and recording the length of the bolt. In this case, compare it with a spare new one. Also,
maximum hours of use of the bolt is described in the manufacturer’s instruction manual. It must be replaced basedon this. For example, 20,000 hours of maximum use, is roughly equivalent to 3 years when annual operation rate
is approximately 80% (equal to around 7,000 hours per year). Therefore, the bolt must be included in maintenanceschedule as an essential spare part.
＜＜ Reference Information ＞＞
Nippon Kaiji Kyokai‘Summary of Damage’Generator Engine's Connecting Rod Accident.
The previously mentioned ‘accident’ occurred in the main engine of a 4 cycle diesel engine. Class NK showsa ‘Summary of damage’ in their bulletin annually. In their bulletin, Class NK issued a detailed warning notice
regarding the above accidents which occurred in the generator of the same type of engine (4 cycle diesel engine).
(They posted in the bulletins No. 292, 296, 301, 304, 309 and 312 from fiscal year 2009 to 2014) . The pointsof the above accident are summarized below, with reference to their bulletin. The number of annual average for
accidents that were clearly caused by crank pin bolt breakage (including looseness and dropping-off) accounted formore than 60%.
Crank pin bolt breakage is mainly caused by incorrect tightening during assembly of piston by crew. The mechanism is as below:－ 59 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

When the engine is in operation, inertia force of the piston interacts with the large end of the connecting rod. Atthat time, if the bolt is insufficiently tightened, it will work loose. As a result, the bolt will break and the nut will
drop off respectively.
The causes of insufficient tightening of bolts are mainly as follows:①

It was tightened with an insufficient torque.
Although the bolt was tightened by a prescribed torque, this was insufficient for thefollowing reasons:②（a） Failure to notice a rough seat surface. However, it was tightened as it was.
（b）

Failure to notice cracking at the part of the serration on the large end of theconnecting rod. However, it was tightened as it was.

‘Angle tightening’ as opposed to ‘torque tightening’ is indicated by the engine manufacturer. The reason is
because it can be tightened with greater precision.
Moreover, there is another large reason for breakage of the crank pin bolt. It is deterioration in strength of the bolt
itself. It is caused by the continued excessive hours of use of a bolt beyond the limit recommended by the engine
manufacturer. A measure is to carry out maintenance based on the instruction manual and service news updates.

§4-3-3 Case ③   Oil Spill Accident
The error chain of an ‘Oil Spills Accident’ (Case ③ ) was analysed by time-sequence. Error chains were caused byboth breach of work in accordance with work instructions and crew’s lack of operational skills and knowledge.

Time-sequence ①
Timesequence①

Failed to check for remaining oil of final top-up tank

At previous port, 2/E was allocated to measuring work of the remaining oil in thetopping up tank (No.3 FO tank), but he did not do it.
Related problems

Errors1

Did the 1/E accurately explain to the 2/E the work plan timetable, work
allotment, procedure and the importance of the task at the meeting
before duty? Could the 2/E grasp it?

2

Did the 1/E not confirm with the 2/E in the meeting that the work had
been completed?
Was there not bad communication between the 1/E and 2/E?

Daily duty
management
Daily duty
management

Did not the 2/E have more important work which was a priority?

3

If he had, why did not the 2/E ask the 1/E for a change of assignment?
Did not the 1/E grasp the 2/E’s work responsibilities?
Could not the 1/E rearrange the 2/E’s work with other personnel?

－ 60 －

Daily duty
management

JAPAN P& I CLUB

4

Were not remarks regarding the danger, when there was an error ofmeasuring remaining oil, described in the work instructions?
Could the 2/E grasp it?

5

Could not the 2/E predict the risk of trouble through failing to measure
the remaining quantity?

Work instruction
relatedRecognition ofdangerMeasures

Methods＜＜ Reinforcement of crew training ＞＞

Crew training

Daily duty management (planning, assignment, communication regarding actual

Crew training

duties, and inappropriate responses towards more important work to be prioritized)
Work instruction related (remarks missing regarding the danger of making a mistake
when measuring remaining oil)

Crew training

Recognition of danger (insufficiency of risk prediction towards the trouble which
may be caused by failure in measuring the remaining oil in the tank)Time-sequence ②

Breach of procedure

Because items to be checked was not conducted, breach of procedure was raised as a problem.
Timesequence②

Made a plan assuming that there was no remaining oil in the topping up tank,despite not having carried out measuring of the actual remaining oil amount.
ErrorsRelated problems

Did the 1/E accurately explain to the 2/E the work plan timetable,

1

work allotment, procedure and the importance of the task at themeeting before duty?

Daily duty
management

Did the 2/E understand it?

2

3

The 2/E did not carry out remaining oil measurement.
However the 1/E made the bunkering arrangement plan document,
assuming no oil remained. What is the reason for this?
Was the 1/E competent for the duty allocated in the assignment ofroles?

Fig. 37 Work instructions
Lack of information of
A-aFig. 37 Work instructions
Lack of information of
A-a

Measures

Methods＜＜ Thorough guideline creation ＞＞

Thorough instruction● Daily duty management (confirmation)

Thorough ship

● Work instruction related（making a bunkering arrangement plan document

management andand an allotted list for bunkering arrangement work sharing)－ 61 －

supervision

JAPAN P& I CLUBP&I Loss Prevention Bulletin

Time-sequence ③

Breach of plan

Work instructions were not considered during making the plan.
Timesequence③

Make a plan at a target level which is equivalent to 66% of the tank capacity(approximately 62KL) (this is related to Time-sequence ⑤）
ErrorsRelated problems
Table 37

1

How reliable was the remote level gauge for the topping up tank?
(Did the 1/E confirm if it may be useful to grasp the liquid level bychecking normal operation and indicator prior to bunkering?

Work instructions

2

Were the crew able to acquire the method and an understanding of
the state of the topping up tank through measuring the tank regularly
during bunkering?
Did the 1/E understand the various calculation methods (inflow
quantity(㎥ /h）, estimated completion time, etc.)

Work instructions

3

Could the 1/E obtain the calculation method for predictive adjustment of the final liquid level of the topping up tank, having measured
the liquid level of the tank which completed receiving oil.

4

Did the 1/E make plans to double-check the system for measuring
the liquid level of all tanks?
(Appropriate personnel arrangements)

Table 38
Work instructions
D-a

Thorough ship
management andsupervision

Although the 3/E and two oilers measured the actual remaining oil quantity in thetank just before the start of bunkering, they did not realize the quantity.
Related problems

Why did the 3/E not notice the remaining oil before thecommencement of bunkering?

Table 38
Work instructions
D-a

Who was the person responsible for calculating the remaining oil

2

D-a

The remaining oil measured was not precise.

Errors1Work instructions

Thorough instruction

work allotment)④

Table 38＜＜ Thorough guideline creation ＞＞● Work instruction related (appropriate bunkering work sharing and list of

sequence

D-a

Methods

measurement: remote level gauge, actual measurement (sounding scale)Time-

Table 38

Measures● Work instruction related (grasp of bunkering progress and regular tank level

Time-sequence ④

A-cquantity? The chief engineer or the 1/E?
Did the engineer in charge of calculation of remaining oil quantity
understand the calculation method?

－ 62 －

Fig. 37
Work instructions
A-a, b, cJAPAN P& I CLUB3

４

Did they correctly obtain the necessary environmental information

Table 37 and 38(temperature, trim, etc.,) for calculating remaining oil quantity andWork instructions

data (specific gravity & volume conversion factor, etc.)?
Did the chief engineer check the statement of re-calculated planning
immediately before bunkering that was formulated by the 1/E?
Was a final meeting immediately before the start of bunkering held?

A-c, C-a, D-a
Table 37
Work instructions
A-a, b

Measures

Methods＜＜ Thorough guideline creation ＞＞

Thorough instruction● W ork instruction related（measurement of all tanks, work sharing,Thorough ship manage-

calculating the remaining oil and supervision by superintendent)

Time-sequence ⑤
Timesequence⑤

Did not stop oil transfer despite the occurrence of an overflow

The 3/E and two oilers (who measured the liquid level continuously) did not stop
oil transfer even when it exceeded the planned top-up level during bunkering,which caused overflow from the air vent.
Errors1ment and supervision

Related problems

Why did the 1/E not stop even when it was beyond the top-up liquid
level of the plan?
● ‌Did the 3/E and two oilers actually measure the tank regularly
during bunkering and report to the 1/E?
●D‌ id the 1/E check the difference with the liquid level, by confirming the tank during bunkering by remote level gauge regularly?
● ‌Did the chief engineer have a grasp of the final situation justbefore completion of topping up?

Table 37

Work

instructions
C-a, D-a

Did the 1/E correctly calculate the top-up liquid level of all receivingtanks in advance?
● ‌Safe work and action cannot be ensured, if top-up liquid level ofeach tank is fixed at the time of making a plan.

2● I‌f the liquid level of the tank after bunkering is different to the plan,
the finalized liquid level of the topping up tank must be adjusted.
Did the 1/E conduct the correction calculation method?（PDCA）

Table 37

Work

instructions
A-a● ‌If the liquid level of the previously completed tank is less thanthat of the plan, the liquid level of the topping up tank will behigh. Did they not consider this to be dangerous?

3

Did all workers understand the final liquid level to be topped up?
● ‌Anyone could notice something unusual and offer an opinion.

Table 38

Work

instructions D-a

Measures

Methods＜＜ Thorough guideline creation ＞＞

Thorough instruction● Work instruction related（bunkering arrangement, estimate the liquid levelof the receiving tank, inform those around and monitor the situation）－ 63 －

Through ship management and supervision

JAPAN P& I CLUBP&I Loss Prevention Bulletin

Time-sequence ⑥
Both chief engineer and the 1/E did not have a firm grasp of the amount of oil in the final topping up tank.
Timesequence⑥

Overflow: When the accident occurred, 96% of tank capacity (approximately 91KL)
had been pumped into the topping up tank. There was no problem regarding
bunkering work on the barge side (agendas in the pre-meeting, oil transfer quantity,
total amount of oil transfer, etc.)
Related problems

Errors1

2

Did the chief engineer and the 1/E recognize that the topping uptank had been filled to 96% when it began to overflow.
As to what percentage did the chief engineer and the 1/E recognize
the liquid level of the topping up tank to be at that time?

Table 38

Work

instructions
D-aTable 37 and 38
Work instructions
A-a, b, D-a

Measures

Methods＜＜ Thorough crew training ＞＞

Crew training● Work instruction related（grasp of the bunkering quantity before topping

Thorough ship manage-up, tank liquid level and quantity adjustment before completion of transfer）

ment and supervision

Time-sequence ⑦
Timesequence⑦

Delayed emergency stop

The 1/E (who is responsible for bunkering work and contact liaison with the barge)
delayed in emergency stop measures, following overflow.
ErrorsRelated problems

Is there an emergency procedure instruction manual on board?
１

Handling of it ? Recognition of it ?
●

Fundamental code of conduct that the vessel is to maintainunder SMS and safety management manual２
３

４

Did all crew recognise 'accident impact in the case of neglecting
emergency actions'?
Did all crew attend an emergency procedure instructions workshop
in advance?

Had all crew conducted emergency drills at the time of overspillage?

－ 64 －

Table 37 and 38
Work instructions
A-b, C-a, D-a

Recognition of danger
Safety training
Safety management codeandtraining in the case ofan emergency

JAPAN P& I CLUB●

Measures

Methods＜＜ Thorough guideline creation ＞＞

Thorough instruction

Work instruction related（emergency procedure instructions）＜＜ Reinforcement of crew training ＞＞

Thorough instruction
Crew training● R ecognition of danger (Accidents that escalate when emergency response isinappropriate)●

Safety training (enthusiasm towards emergency procedure instructions)

Crew training● Safety management code (Making a plan and implementation of emergency drills)§4-4

Analysis with an ETM (Engine-room Team Management) Overview

Just as with Bridge Team Management (BTM), Engine-room Team Management (ETM) is a functional organizedsystem that utilises mutual communication between not only those such as chief engineer, engineer and engine
department crew, but also between software (SMS manual and safety management code, etc.), hardware (equipment)
and environment (external information).
As indicated in each table under ‘§4-3 Accident analysis along with the error chain’, the problem is ‘Why wassomething unusual (‘foresight’), which caused trouble from daily monitoring situations of equipment allocated in theengine room, not discovered?’ Or, ‘Why was there not the effective function of the ‘human five senses’ in order toshed light on the problem?’
The cause was down to a lack of basics regarding engine watch. As was introduced in the ‘collision accident’ cases,
the most important aspect of operation in navigational watch is ‘look-out’. Although it is emphasized that it is important to taking a quick and dynamic approach towards a dangerous situation at sea, the same applies to engine watch.
In other words, the fundamentals of engine watch is for the crew to collect and analyse difficult to detect information
via remote monitoring sensors, and by ‘utilizing the superior human senses during engine room round watch’.
Furthermore, crew is required to take the necessary actions.
Engine-room Team Management (ETM) Analysis
Compliance Rules

Problems
Piston seizing, Piston skirt broken damage

Constant operation information and adjustment of main
engine and auxiliary machineryand equipment (temperature,pressure, consumption andthose changes)①

Main engine LO consumption increased from around June, 2012.
Although consumption increased by approximately three times
to that of normal condition just before the accident, there wereneither inquires made to the manufacturer nor particular actions
taken, regarding the abnormal consumption of LO.

②

Were signs of abnormality not noted until the day prior to when thetrouble occurred? How had the temperature of LO and the pressurechanged? Was there an abnormal noise, or an overheated casing?

－ 65 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

Appropriate Planned Maintenance System: maintaining
the state of equipment that
performs to the design specification.

①

Was the piston maintained in a planned manner?

②

Because the item was replaced with a remodeled part, they
trusted the overhauling and assembly entirely to the manufacturer.
Assembling work was not confirmed on the vessel side.

Education on the ship: establishment of common recognition regarding the engine system.

①

Regular study session
workshops about
engine operation andits procedure with theoperation management
system.

①

As LO consumption increased by approximately three times to thatof normal, the inside of the crankcase was inspected. However,there was no abnormality found and it was thought that the pistonrings were worn.

②

Information sharingof trouble cases andexperiences①

Risk prediction was not recognized. What kind of accident was
expected, in the event of insufficient maintenance of the basic
structure of the piston?

①

There was no guideline for points to be checked‘such as important
procedure for assembling, timing regarding watch on the ship's worksite and the necessity of asking for assistance from the vessel’ formanufacturer’s repair work.

②

There was no guideline‘for inquiring after the manufacturer foradvice and emergency measures to take’in the case of discovering
an abnormality on the ship.

③

Because some parts such as a snap ring may cause an accident due
to damage, a guideline and a checklist‘on issuing an instruction
to manufacturer worker or watching out for abnormalities in the
ship's working areas’for inspection maintenance and assembly are
required.

④

There was no guideline‘on making a request to the ship superintendent
immediately, if overhaul due to abnormal prediction was found to benecessary’.

⑤

Did they share information in more casual circumstances (i.e. during
recess)?

③

Workshop based on themaintenance procedureand its risk assessment

Crank pin bearing damage accident
Constant operation informationof main engine and auxiliarymachinery and equipment (temperature, pressure, consumption
and those changes)
Appropriate Planned Maintenance System: maintaining
the state of equipment that
performs to the design specification.

①

Were signs of abnormality not noted until the day prior to when
the trouble occurred? Was there abnormal noise, or an overheatedcasing?

①

Carry out overhaul inspection based on the planned maintenanceschedule.

②

There must have been a description regarding the technique oftightening in their instruction manual.

－ 66 －JAPAN P& I CLUB

Education on the ship: establishment of common recognition regarding the engine system①②③

Information sharingof trouble cases andexperiences

Workshop based on themaintenance procedureand its risk assessment①

There was no recognition of 'if the connecting rod is tightenedincorrectly, that it may develop to engine trouble'.

①

There is no maintenance guideline regarding 'tightening techniques,
handling of a torque wrench, parts assembly and nut surface
cleaning, penetration test when tightening bolts, etc.'②

There was no safety guideline for 'items that the senior engineer
must confirm' when maintaining a vessel.

①

Was the utilization of the five senses to detect something amiss at
the time of round inspection understood?

②

Did they share information in more casual circumstances (i.e. during
recess)?

To utilize five senses

Oil Spills Accident
Education on the ship:
establishment of common
recognition regarding
bunkering①

Breach of procedure②

Insufficient communication③

Lack of risk prediction
Table 44 ETM Analysis§4-5§4-5-1Preventive Measures

Relationship between Accidents and Causes

In the above described cause analysis, the common causes are emergent in ‘ETM’ respectively. Firstly, the relationship between cause and accident, though basic, is the main focus.
In Table 45, ❶ cause investigation flow, tracking back from the accident result, is shown. The accident causes can beroughly divided into ❸ a direct cause, which is directly connected with the accident and ❹ indirect cause, which isthe surrounding circumstances behind it. And, the causes in the background can consist of ❺ human indirect causesand ❻ root causes led by insufficient control of the organization. It will be difficult to prevent a similar accident, until
the indirect causes related to human error, which are shown in flowchart ❺ and ❻ , including root causes hidden in❻ , are eliminated.

－ 67 －JAPAN P& I CLUBP&I Loss Prevention Bulletin❶

Consequences：Impact caused by an accident
Number of concerned people (injury or death), compensation forproperty damage, spilt quantity, damaged areas, black-out hours,
business disruption, loss amount, etc.

❷

Accident/Trouble
Equipment damage, black-outs, oil (bilge) spillage, air pollution, falls, etc.

❸

Direct Cause：Clear reasons
Dangerous action (Disregard for safe working practices, not wearing safety
equipment), dangerous situations（dark, noisy and harmful or explosive situations)❹Indirect Cause： Reasons underlying backgroundinﬂuences of direct cause
It may be the case that this cannot be proved, even if it wasinvestigated.

❺

Human Indirect Cause：
Human error： Human factor（lack of experience, etc.) andWork factor（i.e., sleep deprivation and fatigue)❻

Root Cause：Insuﬃcient management
Lack of planning, insuﬃcient procedure, standard and guideline,
lack of compliance, etc., even equipment design error.

Fig. 45 “Relationship between Trouble and Cause, and Cause Investigation Flow”

Each of those accidents that apply to this flowchart will be shown in Tables 46, 47 and 48.

－ 68 －JAPAN P& I CLUBCase ①

Piston burnout and piston skirt broken damage accident

Items

Details❸ Direct cause

The route for supplying lubricating oil was blocked and the piston overheated.
Subsequently, the piston skirt sustained broken damaged due to the piston seizing in
the cylinder liner. As a result, the cylinder liner and crankcase door was damaged.

❺ Indirect cause①

There was no recognition of risk prediction, for example, that 'engine trouble
may have developed if the snap ring had not been correctly inserted'.

②

At the time of inspecting the inside of the crankcase 'not only should
contaminants at the bottom (metal pieces of bearings, combustion residue,etc.) be observed, but also the state of the piston and liner'.

③

Could not recognise the signs of an accident by round inspection?

The following guideline was not established.

❻ Root cause①

Guideline of points to be checked 'such as important procedure for assembling,timing regarding watch on the ship's work site and the necessity of asking forassistance from the vessel for manufacturer’s repair work.

②

Guideline 'for inquiring after the manufacturer for advice and emergency
measures to take' in the case of discovering an abnormality on the ship.
In the guideline, the necessity of being able to adjust the piston location in theevent of inspecting the liner should be added.
Because some parts such as a snap ring may cause an accident due to damage, a③

guideline and a checklist of 'working instructions to the shore worker or watch on
the ship's work site' for inspection maintenance and assembly are also required.

Table 46

Case ②

Cause Analysis (Piston Seizing, Broken Damage in Piston Skirt Cases)

Crank pin bearing damage accident

Items

Details❸ Direct cause

Due to breakage of the connecting rod bolt, the large end of the connecting rod was
released and the connecting rod passed through the crankcase door, which disabled
the main engine operation.
①

There was no recognition of risk prediction that 'if the connecting rod wastightened incorrectly, that it would develop to engine trouble'.

②

Could not recognise the signs of an accident by round inspection?

❺ Indirect cause

The following guideline was not established.

❻ Root cause①②

Regarding the assembly of the connecting rod, guideline for maintenanceof 'technique of tightening, handling of torque wrench, parts assembly andcleaning the surfaces of nuts, penetration test of the bolts, etc.'
Safety guideline of 'items that the chief engineer and the 1/E must confirm'
when maintaining a vessel
Table 47

Cause Analysis (Cause Analysis Cases)－ 69 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

Case ③

Oil Spills Accident

Items

Details❸ Direct cause

Delay in emergency stop measures by the 1/E following overflow. The 1/E is
responsible for bunkering work and contact liaison with the barge.
Technical knowledge insufficiency①●

Method of measuring the tank liquid level●

Calculation method of remaining oil in tank (bunkering quantity)(Implementation of trim heel correction by tank table)

Lack of safety and environment awareness❺ Indirect cause②●

Superintendent's awareness of safety and environment●

1/E, 2/E and 3/E’s recognition of danger (risk prediction)● An accident that is expected to occur when tank measurement is not sufficient●Accidents that are expected to escalate when emergency response is inappropriate●

Safety training related: enthusiasm about emergency procedure instructions.

● afety management code related: Making a plan and implementation ofS
emergency drills

The following were insufficient regarding work instructions for bunkering.
●

Remarks before bunkering plan: measurement of remaining oil●

Remarks when making bunkering plan:⒜ Bunkering‌plan (ensure more than 10% of tank space for topping up = plan
not to fill more than 90% of tank capacity)⒝ Work sharing (personnel arrangements) and estimation of receivable tank level⒞ Supervise by superintendent and double-check●

Remarks before bunkering work:⒜ Meeting for information sharing on bunkering plan①⒝ Reconfirmation of countermeasure in state of emergency❻ Root cause● emarks before receiving: measurement of all tanks, work sharing, calculationRof remaining oil and supervision by superintendent● emarks during bunkering: regular measurement of tank level (remote levelRgauge, actual measurement (sounding scale))● emarks at the time of topping up the tank: grasp of receivable quantity
R
and tank level●

Emergency procedure instructions( There is a high possibility that spillage into the sea could have been
suppressed, had the 1/E taken action immediately at the time of the overflow.)

Insufficient routine work②●

 ailure of, inadequacy and/or lack of information sharing regarding reportingF
and confirming of plan, manning and practice, and plan changes (if applicable).

Table 48

Cause Analysis (Oil Spills during Bunkering Cases)－ 70 －JAPAN P& I CLUBConsidering the analysis of events with a viewpoint from the PDCA cycle (Plan, Do, Check and Action), the key pointis that ‘Safety can be defined as the result that avoids risks’ as explained in Chapter 2. In the case of engine relatedtrouble, Plan is associated with work instructions and guidelines which were created based on the manufacturer’s
instruction manual, work analysis, experimental rule, past lessons, principles of natural science and various kinds oftechnological information, etc. This technology is not simply summarised into work instructions. Extracting the fundamental risks assumed in each duty in advance, manageable measures will be introduced following analysis in orderto reduce the risk level. In addition, the risk level will be reduced, if everyone clearly understands work instructions
and guidelines of risk management (human factors) and practices it accordingly. However, if there is a lack of humanexperience and fatigue, the risk cannot be reduced because it is not possible to ‘Do’ (or) follow work instructions or
guidelines accurately. No matter how bad the outcome, risk cannot be avoided. Elements of human behaviour standbetween the fundamental plan and the end result. Therefore, when thinking about cause categories, it is an indirectcause that a human cannot execute.
Let’s compare daily duties or services on the ship to a drama. We exemplified daily duties on a ship using role play(drama). Work instructions and guidelines can be replaced with scenario (Plan) and the crews’ behaviours with theactors’ performances on the stage respectively. Even if the scenario is poor, once splendid actors perform (Do) andovercome the poor situation, it in turns into a masterpiece. However, it is hard for the ship owner and ship manager
to allocate a superstar (a noted member of crew) to always perform. In order to encourage the actors to perform better
than a certain level, it is important to prepare a wonderful (attractive) scenario to support them.
Meanwhile, accident analysis is Check (evaluation) and preventive measures are Action (improvement). Moreover, it
will be ideal, if the Plan can be improved so as to better verify as to whether the preventive measures are functioning
effectively.
However, following accident occurrence, the person involved tends to focus on the direct cause, which is easy toactualize generally. Because of this, symptomatic measures are often taken. This can be applied to the ‘grave-post
type’ of safety measure which was explained in the ‘Loss Prevention Bulletin: Thinking Safety (Vol.35)’; and that thiskind of symptomatic measure can cause another similar accident.
It should be emphasized that preventive measures should be introduced following the digging up of the root cause(‘preventative type’ of safety measure). Therefore, first of all, events prior to the accident should be specified and,then, the cause can be extracted by analysing as to why each time-sequenced event occurred. And, finally, preventive
measures will be led by examining ways to eliminate the cause.
In ISM Code 2010 amendment, the following is specified: 1.2.2. It should assess all identified risks to its ships, personnel and the environment and establish appropriate safeguards; and 9.2 The Company should establish proceduresfor the implementation of corrective action, including measures intended to prevent recurrence. Because of this, it ispresumable that both risk evaluation and the scheme for preventive measures are established in the SMS manual at therespective companies. Please take a look at it.

－ 71 －JAPAN P& I CLUBP&I Loss Prevention Bulletin§4-5-2Preventive Measures

Summarizing the root causes of Cases ① , ② and ③ , an accident could be caused, because the following items wereinsufficient. In all stages, it is required that work instructions and guidelines be equipped, to perform thorough crew
training and to observe the prepared guidelines and work instructions strictly.
 onduct the maintenance and inspection based on the manufacturer’s① C
instruction manual②Replace parts in accordance with the standard③ onfirmation of critical points regarding the process of maintenance andCrepair assembly④Watch-keeping that utilizes the human five senses⑤

 nderstand the relationship between the basic structure of equipment andU
trouble⑥ Maintenance of work instructions and guidelines⑦ Thorough crew training

Regarding prevention for accidents related to the engine including Oil Spill Accidents, the following items areespecially important.

Maintenance

The systems and equipment on the vessel must operate normally as designed basedon the principles. Therefore, the crew is expected to maintain and inspect the above
in a planned manner everyday. The measure is for the ship manager to establish‘a system that has guidelines and a thorough method of instruction’ as a Plan. For
example, the guideline requires PMS (Planned Maintenance System), work instructions,guidelines for maintenance and a work check list.

Monitoring of
the condition

The system and equipment on the ship is operated under a variety of conditions.
Thus, the crew must clearly understand those different operating states on a daily
basis. If they can recognize an abnormality at an early stage, appropriate measures
can be timely taken. Therefore, the measure is for the ship manager to establish the‘basics of engine watch’ in order for the crew to be able to Do (practice). For example,
enforcement of daily inspection and safety education.

EducationsystemThe crew are expected to understand trouble related to the basic structure of theabove. Thus, in order for the crew to practice (Do) it, it is important for the ship
manager to establish a ‘maintain and improvement system of knowledge level = theeducation system’. For instance, regarding the system and equipment, it is to reeducate the fundamental items and structure and hold a case workshop. These weresummarised in the Table 49.

－ 72 －JAPAN P& I CLUBNo①

M easures

Key points of‘E TM’‘Planned Maintenance
System (PMS)/Work instructions/
Maintenance guideline/Work checklist’

MaintenanceMonitoring thesituations

Insufficient items
Performance of maintenance andinspection based on manufacturer’s
instruction manual②

Part replacement in accordance with thestandard③

Confirmation of important phase in theprocess of maintenance, recovery andassembly④

Round inspection utilizing five humansensesDaily inspection and safety
training⑤

Understanding the relationship between
basic structure of appliance and trouble

Re-education of basic items
and structure

Table 49

§4-6

Education system

Summary

Proposals for Vessels with a Tight Operation Schedule

It is also essential to try to ensure the quality maintenance of vessels with tight operation schedules such as coastal
vessels, ocean going container vessels and PCCs. In other words, operation management is the main issue here due tothe influence of operating time schedules for these vessels. In these circumstances, the crew can only carry out smallscale maintenance during the short staying hours. For example, replacing fuel injection valves on an engine. However,
it is impossible to carry out medium scale maintenance in a short and limited time frame. Therefore, there will
inevitably be more cases of medium scale maintenance by engine manufacturers or ship repairing companies duringberthing. Regarding large-scale maintenance, it is to be carried out by the above mentioned agents during the docking
period. As a result, crews are facing the reality that they cannot be expected to improve their technical skill levels forthese middle and large scale operations, because they have less opportunity and experience of maintenance and also
get less opportunity to earn practical experience.
Therefore, ship managers should pay attention to the above mentioned maintenance background/circumstances andcrew’s technical skill levels. In order to compensate for this, a checklist that includes a summary of remarks for maintenance, inspection and assembly points for each maintenance site will be useful. It is important to make a checklist
like this and perform thorough instruction on the vessel. It is most effective for the crew to make this kind of checklist,
however, it would be an option to outsource this to an engine manufacturer or technical consultant.

－ 73 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

Conclusion
Safety is only a result that avoids all dangers. Thus, it is natural to think ‘safety does not exist’ in the world. If the
precision of planning to avoid danger becomes greater, it will be closer to realizing safety. Because of that, it cannot
disregard the PDCA method.
Therefore, the method for measuring the Safety Management System and the SMS manual is very rational. However,in order to organize this system which is embedded within safety management performance, it requires a tremendous
amount human energy. It is essential that we think of this energy as safety culture. While thinking of this culture, itneeds to consider the pyramid consisting of three items of ‘Science’, ‘Technology/Skill’ and ‘Technician’ which support safety.
Keeping that in mind, in analysing these cases, if it does not analyse by stepping into the issue of ‘why such risky
action was taken?’ with the Human Characteristics and, further, by taking a preventive measure, questioning ‘what itshould do in order not to be involved’, a similar accident could reoccur.
It is important to precisely analyse the individual sequence of events before an accident occurs, to extract and examine
the insufficient management which lays hidden in the background and to lead effective preventive measures in order
to exclude those factors. The author hopes you now recognize the importance of ‘preventative type’ safety measures.
Last but not least, for safe navigation, the importance of condition monitoring such as basic watch ‘lookout’ and ‘roundwatch’ should always be at the forefront of ones mind.

List of References（1）‌Marine Accident and Incident Reports by Japan Transport Safety Board of Ministry of Land, Infrastructure, Transport
and Tourism
Report search site：http://jtsb.mlit.go.jp/jtsb/ship/index.php（2）Class NK
・Class NK bulletin ’Summary of damage’ from fiscal year 2009 to 2014
・No. 292, 296, 301, 304, 309 and 312（3）Nautical Charts published by the Japan Coast Guard and the Japan Hydrographic Association
・Fig. 30 The Kii Suido (Strait)
・Fig. 31 Tokyo Bay
List of Attachments
Attachment ①：The Kii Suido (Strait) Traffic System Chart (Enlarged Drawing of Fig. 30)
Attachment ②：Tokyo Bay Traffic System Chart (Enlarged Drawing of Fig. 31)
Attachment ③：4 Cycle Diesel Engine of Vessel
Attachment ④：Additional Engine Trouble (3 Cases)－ 74 －JAPAN P& I CLUBAttachments
Attachment ①：The Kii Suido (Strait)

Traffic System Chart (Enlarged Drawing of Fig. 30)

I Shima

17 to 19
nautical miles

Hino-Misaki－ 75 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

Attachment ②：Tokyo Bay  Traffic System Chart (Enlarged Drawing of Fig. 31)

Hazard zone

Tsurugi SakiNorth of Izu O-shima Route(Mainly Coaster Vessels)

Coaster vessels

South of Izu O-shima Route(Mainly Ocean going Vessels)
East ⇔ West route which does notenter Tokyo Bay (coaster vessels)－ 76 －

Ocean going vessels

JAPAN P& I CLUBAttachment ③：4 Cycle Diesel Engine of Vessel
The basic structure of a ship’s 4 cycle diesel engine is identical to that of a car engine. As shown in Fig. 50, it constitutes a power output section (upper part) and driving mechanism (lower part). The power output section is comprisedof a cylinder liner and piston. This section is where the supplied fuel combusts. The piston slides up and down within
the cylinder, which has a combustion chamber located at the top. Fuel is supplied to the combustion chamber, where
power is generated via the combustion of fuel. The driving mechanism constitutes a connecting rod and a crankshaft.
This section generates propulsion powered by the engine. The ‘power’ which the piston obtains in the combustion
chamber is transmitted to the crankshaft via the connecting rod. The reciprocating motion of the piston is transferred
into rotary motion via the crankshaft. This then becomes the vessel’s propulsion power, which is the driving power.
If the power output section or driving mechanism is damaged, propulsion power cannot be obtained. Therefore, thisaffects the ship’s navigation.
The characteristics of a crankcase will be described. The crankcase can be defined as a box-shaped housing where thecrankshaft is stored. Because the housing has a door, it is possible to conduct internal inspection. The door is small,
however, crew can monitor the state of the engine’s internal structure sufficiently by using a hand mirror and adjusting
the position of the crankshaft.

Valve Gear System

Exhaust Gas Manifold

Intake Manifold

Fuel Oil Injection Pump
PistonConnecting Rod
Crank Shaft

Inspection Door

Fig. 50

4 Cycle Diesel Engine of Vessel－ 77 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

Attachment ④ : Cases of Additional Engine Troubles (3 Cases)【Reference Information】

According to Marine Accident and Incident Reports by the Japan Transport Safety Board, three cases of operation
disability due to engine trouble, together with our accident analysis will be introduced.

【Case ④

Accident summary】

On starting up the main engine in preparation for entering port following anchorage, there was an abnormal noise.
As a result of the inspection of each of the parts carried out by the crew, it was acknowledged that water was gushingout from the No.6 cylinder indicator valve.
Due to the leakage of cooling water into the cylinder, caused by a broken hole in the turbo charger casing, following
main engine start-up, this led to the bending and consequent damage of the connecting rod.
Analysis by Japan Transport Safety Board
Items
Cause
Analysis

Details<Relationship with hull, engine, etc.> Yes

Analysis by our Club
Items

Details

DirectDue to a hole that appeared in the turbo

cause

charger casing of the main engine, cooling<Analysis of detected items>●

connecting rod sustained bending dam-in the turbo charger casing of theage.

main engine, cooling water leaked into
and tried starting the main engine inpreparation work for entering port, theIndirect

Although the following instruction existed,cause

it was not strictly adhered to.
● Instruction for maintenance of turbo

connecting rod had sustained bending● Main engine operation instruction

not operate, which presumably led toservice incapacity.

● R ecognition 'of development to engine （Assumption）

When measuring the thickness of thetrouble, when using a casing that isout approximately two months prior to

beyond the its usage thickness limit'

this incident, it was detected there was● T he recognition of 'why does the （Assumption）

a thin part. If the use limit value andthickness wear and tear of the casing

past history were confirmed and theprogress?'casing had been replaced on this occa-● T he recognition of 'whether bending （Assumption）

sion, the occurrence of such an incident

damage of the connecting rod will be

may have been prevented.

sustained by liquid compression whenthe main engine is suddenly started'It is presumable that the trouble can be● C ould not recognise the signs of an

prevented, if the blowing air operation

accident by round inspection?

is carried out by opening the indicatorvalve before staring the main engine.

（Report）

There was no recognition as per below:

turbo charger casing, which was carried●（Report）

chargerdamage and the main engine could●（Report）

engine could not operate because theanchoring, due to a hole that appeared

the cylinder, she heaved up anchor

water leaked into the cylinder. Whenstarting main engine operation, the mainR e g a r d i n g t h e v e s s e l , w h i c h w a s

Remarks

Root

There were no guidelines as per below:

cause● ‘Coolingwater treatment guidance （Assumption）
that may affect the thickness reduction of the turbo charger’－ 78 －JAPAN P& I CLUB

Analysis by Japan Transport Safety Board

Analysis by our Club

Items

Details

Items

Details

Preventive

The following are considered to be usefulPreventive

measuresitems for prevention of similar trouble inmeasures(1)‌A superintendent of the vessel is to issue
a safety notice as follows and calls forattention to compliance of work instructions regarding maintenance and engine
operation.
● ‘Strictlyutilize maintenance instructionsof the ship, in accordance with the maintenance instructions of the turbo charger
manufacturer instruction manual’.
● ‘Operatestrictly based on operation
instructions of the vessel which werecreated in accordance with the main
engine manufacturer instruction manual.’

the future.
●M easure the thickness of the turbo
charger casing and replace with a new
one in the event that a thin part beyond
use limit is detected.

● Before starting and after stopping themain engine, carry out air blowing operation by opening the indicator valve tocheck if there is no contamination inside(2)‌A superintendent of the vessel must callfor attention of the following. A safety
poster is available.
● ‘Importanceof round inspection utilizing
the five human senses’

the cylinder.
●

Appropriate water quality treatment ofcooling water by injecting anti corrosive
agent(3)‌A superintendent of the vessel is to create the guideline and establish a systemof corrosion inhibition.
water treatment guidance that● ‘Cooling
may affect the thickness reduction of theturbo charger’(4)‌A superintendent of the vessel is to traincrew thoroughly as per follows:● ‘Helpingthem understand the structureof a turbo charger, and ask what kindof accident could be predicted in thecase of using it beyond the thickness use
limit’● ‘Why
does the thickness of the casing
deteriorate through wear and tear?
What kind of attention and management is necessary in order to restrain it?’● ‘Helpthem understand the structure of
the main engine and ask as to what kindof accident could occur in the case of
suddenly starting the main engine whenliquid enters the cylinder.’● ‘Round
inspection utilizing the five humansenses’Table 51

《Point of cause》

Engine Trouble Case ④

Breach‌of maintenance instructions, breach of procedure, lack of
education and training, insufficient round inspection, etc.

－ 79 －

Remarks

EngineManagement

EngineManagement

Monitoring thesituations

EngineManagement

Education

Education

Education

Education

JAPAN P& I CLUBP&I Loss Prevention Bulletin【Case ⑤

Accident summary】

During navigation, the lubricant oil low pressure alarm for the main engine reverse and reduction gear was activated.
Although the electric lubricating oil pump for back-up automatically started, the lubricating oil pressure indicated
0kg/cm2. Once the pump was stopped and re-started, the pressure increased once again, however, it went down immediately following that. Following the result of the overhaul inspection of the LO strainer for reverse and reduction
gear by the crew, they abandoned main engine operation, because traces of metallic powder were detected.
Also, as a result of the inspection of the reverse and reduction gear conducted by the engine manufacturer, damage tothe needle bearing of the directly-connected LO pump drive gear shaft and in the inner race, in the bush of forward
and reverse clutch shaft and bearing metal was discovered.

Analysis by Japan Transport Safety Board

Analysis by our Club

Items

Details

Items

Details

Remarks

Cause
Analysis<Relationship with crew, etc.> Yes<Relationship with hull, engine, etc.> Yes

Directcause

Damage to needle bearing of LO pumpof reverse and reduction gear caused
the decrease in oil pressure. Then, because of the lack of LO supply quantity,
the main engine could not operate.

(Report）

Indirectcause(1)‌Although instructions existed formaintenance of LO pump directly
connected to driving shaft of reverse
and reduction gear of main engine,
there were not strictly adhered to.

（Report）<Analysis of detected items>● During its navigation, damage to needle bearing of LO pump of reverse andreduction gear caused the decreasein oil pressure. Due to the shortage ofLO supply quantity, the main engine
could not operate and it seemed that
her service became unavailable.
●(2)‌There was no recognition as per
below:● R ecognition 'of development toengine trouble, when using a needle
bearing of LO pump that is beyond
the time by when it should be
replaced.'● C ould not recognise the signs of an
accident by round inspection?

 he needle bearing of the LO pump inTthe main engine had been used since
her first voyage, and there would be apossibility that the bearing caused thedamage because of ageing.

Root
cause

－ 80 －

The following instructions for maintenance were not established.
● 'Check operation details such as
check valve in LO system'(Assumption)(Assumption)(Assumption)

JAPAN P& I CLUB

Analysis by Japan Transport Safety Board

Analysis by our Club

Items

Details

Items

Details

Preventive
measures

The following are considered to be useful
items for prevention of similar trouble in
the future.

Preventive
measures(1)‌A superintendent of the vessels
creates the following guideline ofmaintenance and instructs those on
the whole of the vessel thoroughly.
● 'Regarding the confirmation of smallpart operations such as check valve,specifically what and how should it
be carried out?'● o inspect the needle bearing byToverhauling the LO pump of reverse
and reduction gear regularly and to
exchange the bearing within the time
described in the instruction manual.

(2)‌A superintendent of the vessel is to
issue a safety notice as follows.
● 'Strictly utilize maintenance instructions of the ship, in accordance withthe maintenance instructions of theLO pump manufacturer instruction
manual.'(3)‌A superintendent of the vessel must
call for attention of the following:● 'Importance of round inspection
utilizing the five human senses'

Remarks

Understandingof structure

EngineManagement

Monitoring thesituations(4)‌A superintendent of the vessel is totrain crew thoroughly as per follows:● 'Help them understand the structureof the LO pump, and ascertain as
to whether they know what kind of
accident could occur in the eventof using it beyond its replacement
hours.'● 'Round inspection utilizing the fivehuman senses'

Table 52 Examples of Engine Trouble ⑤《Point of cause》 ‌B reach of maintenance instruction, poor control of check valve(backflow prevention) in LO system, lack of education andtraining, insufficient round inspection, etc.

－ 81 －

Education

Education

JAPAN P& I CLUBP&I Loss Prevention Bulletin【Case ⑥

Accident summary】

During navigation, there was an abnormal noise from the engine room, and the crew discovered the leakage of LO
in the vicinity of main engine No.3 cylinder. When the crew overhauled the cylinder head cover of No.3 cylinder,
following the main engine manufacturer's instruction, the crew discovered one of two missing intake valves.
As a result of overhauled work on the cylinder head conducted by the main engine manufacturer, it was detected that
one intake valve cotter passed through the top part of the piston by dropping into the cylinder, after the cotter became
disengaged from the mounting part due to wear and tear of a piece of cotter of the intake valve (two-piece fittings
which are fixed in order not to drop the valve by being settled in the artificial groove portion on the valve shaft part ofthe intake/exhaust valve). In addition, through further detailed inspection, damage to the turbine nozzle ring and rotorof the turbo charger was discovered.

Analysis by Japan Transport Safety Board

Analysis by our Club

Items

Details

Items

Details

Remarks

Cause
Analysis＜ Relationship with hull, engine, etc. ＞ Yes

Directcause● A piece of cotter which was used in
the intake valve of main engine No.3
cylinder dropped off through thewear and tear and the intake valve
fell into the cylinder.

（Report）

Indirectcause● N o recognition of 'when the cotter
and cotter contact surface of theintake and exhaust valve will chafe
leading to engine failure'● C ould not recognise the signs of an
accident by round inspection?

（Assumption）＜ Analysis of detected items ＞● D uring navigation, a piece of cotter
which was used in the intake valve ofmain engine No.3 cylinder dropped
off through wear and tear and theintake valve fell into the cylinder. Then,damage to the piston and so forth wascaused by it being sandwiched by bothflanks of the cylinder head and top partof the piston, which, presumably, meantthat the main engine could not operateproperly and hence the termination of
the shipping service on that occasion.

Root
cause

－ 82 －

The following guideline was notestablished.
● G uidelines for maintenance regarding'overhauling, measurement andrecording of each part, from theimportant equipment, should start
after vessel purchase'● G uidance of maintenance 'what
we do with which parts specifically,
regarding the detailed maintenanceof accessories and related parts'.
● G uideline of maintenance of 'measurement inspection in order to grasp
wear and tear at the part of thecotter, when carrying out overhaul
maintenance'.

（Assumption）（Assumption）（Report）(Assumption)

JAPAN P& I CLUB

Analysis by Japan Transport Safety Board

Analysis by our Club

Items

Details

Items

Details

Preventive
measures

The following are considered to be useful
items for prevention of similar trouble in the
future.

Preventive
measures(1)A superintendent of the vessel is tocreate the guideline and establish
a system of detailed inspection
maintenance.
● G uidelines for maintenance regarding 'overhauling, measurement andrecording of each part, from theimportant equipment, should start
after vessel purchase'● G uidance of maintenance 'what
we do with which parts specifically,
regarding the detailed maintenanceof accessories and related parts'.
● G uideline of maintenance of'measurement inspection in orderto grasp wear and tear at the partof cotter, when carrying out open
maintenance'.

● W hen maintaining by opening andclosing cylinder head of main engine,
thoroughly inspect the cotter andcotter contact surface of the intake andexhaust valves.

(2)A superintendent of the vessel must
call for attention of the following: A
safety poster is available.
● 'Importance of round inspection
utilizing the five human senses'(3)A superintendent of the vessel is totrain crew thoroughly as per follows:● 'Allow the crew to learn about thestructure around the cylinder coverand educate them as to what kindof trouble may occur in the event ofmaintenance failure'● 'Round inspection utilizing the fivehuman senses'

Table 53

《Point of cause》

Remarks

EngineManagement

EngineManagement
Understanding ofstructure

Monitoring
the situations

Education

Education

Examples of Engine Trouble ⑥No‌ overhaul of important equipment, insufficient time management
for maintenance, under-management of parts regarding accessories ofimportant equipment, lack of education and training, insufficient roundinspection, etc.

－ 83 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

MEMO－ 84 －

The author

Capt. Takuzo Okada
Master Mariner
General Manager
Loss Prevention and Ship Inspection Dept.
The Japan Ship Owners’ Mutual Protection & Indemnity Association

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Translated by: YUZEN Translation LLC

Illustrator: Ms. Makoto Kiryu