Maritime Accident Accident Cause (Unsafe Behaviour) Collision withŌshima Bridge

Attachment 18Man
Human factor (The vessel, shipowner and ship management company）
Cause (Unsafe behaviour)
1 Psychological3 Organizational⑧⑧⑧⑨⑨⑨⑨⑨⑨⑨⑨⑩⑪⑫①②③④⑤①②③④

Mental shortcuts

Cuts corners

Judgement based on speculation

Mistakes and perceptual illusion

Habituation phenomenon

Personality

FatigueLack of sleep

Alcohol, medicine or disease

Physical ability

AgeingDesire and willingness

Leadership and teamwork

Communication

Commitment (responsibleintervention)

Personal problems⑥⑥⑥⑥⑥⑥⑥⑥Habituation behaviour⑦④

Forgetful

Unconscious acts

③Sen
SeSensense of urgency and sensitive
sensitively
ely②

Impulsive action⑤①In ① , write down a direct cause
which was investigated basedon the facts After ② , write
down the root cause using theWhy Why Analysis. Then, circle
each applicable cause. Regarding items other than Man (Human factors), enter the sub-item
number of each item in the 4M
Classiﬁcation List.

2 Emotional

2/O E and Ship managementcompany E1

2/O E created the Passage
Plan between Onsan andEtajima without conﬁrming the height of the ŌshimaBridge〇〇

Why was the Passage Plan
② created using nautical chartordering software?

〇

〇〇〇

〇

〇

What was the data copied③over to the ECDIS?

〇〇〇

〇

〇

〇

Why was Draft and Air Draft④ data not input into the ECDIS?

〇

Regarding the Passage Plan,⑤ why did the managementcompany not intervene?

〇

Example
E
Exa
xa
xa
amm
mp
pllle
pe (1(1/3)
1//3
1/33)

Master E and 2/O E

2〇

Why did the Master E believe that the previous Master had signed the PassagePlan?
Why was the Master E un② able to take over effectively
from the previous Master?

〇Why did the 2/O E create
the Passage Plan between③ Onsan and Etajima withoutconﬁrming the height of theŌshima Bridge?

〇〇〇

〇

〇

〇

〇

Master E and 2/O E

4

Why did the Master E continue navigating even though
he felt uneasy about theheight of the bridge?

〇〇〇

〇

〇

〇

Why did the 2/O E not② re-conﬁrm the height of thebridge beam?
Master E

6

Why did he continue navigating regardless?
Why was an Abort Point not②arranged?
Total number of circled items〇31〇〇〇

485〇
32613127

MachineMan

Mechanical factors such asmachinery not working properly or being out of order

4 Individual skills
Cause (Unsafe behaviour)
4-2 Inadequate
4-1 Inadequate knowledge
4-3 Poor work ethic
skills

Mainly on the vessel①②③Tool box meeting was not
implemented

Design ﬂaw in the machinery

Defective protection against hazards

Lack of fundamental safety (designand ergonomic arrangement)〇〇〇

Why was the Passage Plan
② created using nautical chartordering software?

〇〇〇〇〇〇〇〇ied
What was the data copied③over to the ECDIS?

〇〇〇〇〇〇〇〇

Why was Draft and Air Draft④ data not input into the ECDIS?

〇〇〇〇〇〇〇〇

Regarding the Passage Plan,nt⑤ why did the managementcompany not intervene?
Master E and 2/O E

Why did the Master E believe that the previous Master had signed the PassagePlan?

2

Why was the Master E un② able to take over effectively
from the previous Master?
Why did the 2/O E create
the Passage Plan between③ Onsan and Etajima without
conﬁrming the height of theŌshima Bridge?

〇ExampleEExxam
xam
ampl
mple
plee (2(2/3)
2/33)

Master E and 2/O E

Why did the Master E conontinue navigating even thoughoughhe felt uneasy about theeheight of the bridge?

4

Why did the 2/O E not② re-conﬁrm the height of thebridge beam?

〇〇〇〇〇〇〇〇

Why was an Abort Point notarranged?

〇〇〇〇〇〇〇〇

Total number of circled items
ms

666

76666

Master E

Why did he continue navigatigating regardless?

6②128

Lack of machinery and facility
maintenance, etc.

②Health check not implemented prior
to working〇⑥①

Protective wear not worn〇

Lack of standardization④〇⑤③

Covers up or tolerates dishonest
work
Intentionally dishonest regarding
work, and breaks the rules〇

2/O E created the Passage
sage
Plan between Onsan anddEtajima without conﬁrmming the height of the Ōshima
himaBridge

1

Lack of consideration regarding
ergonomic factors②

Not “ready” to work〇

2/O E and Ship management
entcompany E④③①

Not enough training

UUn
Unaccustomed
naccustomed to work, inex
inexperixperi
peri-enced, inadequate skills
Lacks basic knowledge of thework
Mistakes regarding work procedure/ forgetfulness
Lack of a sense of urgency andawarenessWork content not understood ormisunderstood
Inadequate or inappropriate knowlIInwll
ledge aaboutbout the work to be carrie
carriedrrie
riedd outrieoouThe belief that the work done is satisfactory,
when objectively it is inadequate①①①①①①①①②⑤⑤⑤⑤⑤⑤④③②②②①①①①①①①①

ause
In ① , write down a direct causedwhich was investigated basedon the facts After ② , write
hedown the root cause using thecle
Why Why Analysis. Then, circle
rdeach applicable cause. Regarduing items other than Man (Huitem
man factors), enter the sub-item
number of each item in the 4M
Classiﬁcation List.

5 Managementof health andworking environment

MediaManagement

Media connecting Manwith Machinery

Management factors and organization

Cause (Unsafe behaviour)⑤①②③④⑤⑥①②③④⑤⑥

Inadequate management/organization

Inadequate/incomplete regulations
and procedure manual

Inadequate safety management
planning

Lack of education and training

Inadequate layout arrangement

Inadequate supervision of his/hersubordinates

Inadequate management/organization

Inadequate/incomplete regulations
and procedure manual

Inadequate safety management
planning

Lack of education and training

Inadequate layout arrangement

Inadequate supervision of his/hersubordinates

Inappropriate work method

Inadequate work space③

Work preparedness/inadequate
working conditions

Poor working environment conditions②

Lack of information regarding work
to be carried out④①

In ① , write down a direct cause
which was investigated basedon the facts After ② , write
down the root cause using theWhy Why Analysis. Then, circle
each applicable cause. Regarding items other than Man (Human factors), enter the sub-item
number of each item in the 4M
Classiﬁcation List.

Shipowner and Ship managementcompany

On the vessel

①③②

②

①

①

Necessity of re-investigation

The vessel, shipowner andship management company

2/O E and Ship managementcompany E

2/O E created the Passage
Plan between Onsan andEtajima without conﬁrming the height of the ŌshimaBridge

1

①

③〇

Why was the Passage Plan
② created using nautical chartordering software?
③

What was the data copied
over to the ECDIS?

Why was Draft and Air Draft④ data not input into the ECDIS?
Regarding the Passage Plan,⑤ why did the managementcompany not intervene?

②①①

Master E and 2/O E

Why did the Master E believe that the previous Master had signed the PassagePlan?

2

Why was the Master E un② able to take over effectively
from the previous Master?
Why did the 2/O E create
the Passage Plan between③ Onsan and Etajima without
conﬁrming the height of theŌshima Bridge?

ExampleExaE
xam
mpplee ((3/3)
3/3)

Master E and 2/O E

Why did the Master E continue navigating even though
he felt uneasy about theheight of the bridge?

4The number in the circle applies to thenumber in Attachment 2-2 (Maritime Accidents 4M Classification List)

Why did the 2/O E not② re-conﬁrm the height of thebridge beam?
Master E

Why did he continue navigating regardless?

6②

Why was an Abort Point notarranged?

Total number of circled items

111112221129

Attachment 19

Maritime Accident Analysis using 4M5E and Countermeasure List
(Unsafe behaviour) Collision with Ōshima BridgeManMachineMediaThe vessel,The vessel, shipowner andMainly
shipowner andship management company on the vessel ship managementcompany

Risk factors（Direct causeand indirect/rootcause）

ManagementOn the vessel

Shipowner andship managementcompany

1. 2/O E created thePassage Plan between
Onsan and Etajima
without conﬁrming thebridge beam height of
the Hakata-Oshima
Bridge（1- ③ and ⑤〜⑪）

1. Vague setting 3. Vague
7. No intervention
method ofprocedure forwas taken into
ECDIS (inputconﬁrming
account whatsoeverting basic daand approving regarding theta) (1- ③ , ⑤
the Passage
vesselʼs Passage〜⑧ and ⑪） Plan（1- ①Plan (Managementand ⑦〜⑨） 2- ②，3- ① and4- ①）
2. What the

2. Regarding the Passage
Plan between OnsanEtajima, Master E did
not receive details fromthe previous Master.（1① , ⑧ and ⑨）

Master did
receive fromthe previous
Master wasvague (1- ① ,⑧ and ⑨）

6. Continued navigating
while feeling uneasy
about the height of thebridge,（1- ① , ⑥ , ⑨and ⑩）
1. Abort Point: Was there aclear plan if the Passage
Plan got interrupted
or if there were nonreturnable points?（Reexamination necessary)（1- ① , ② and ⑥〜⑨）

Education
Education andtraining
Knowledge, skills,
consciousness,being giveninformation, etc.

・Re-training for thepersonnel in charge ofcreating the Passage Plan(2/O E)
・Re-training regarding
handling of Abort Point
procedure・Re-training on how tohandle feeling uneasinessregarding navigation
・Re-training for MasterE regarding Safety
Management CodeEngineering
Technology andengineering
Technologicalcountermeasures

130

・Formulation ofcontinued training
and education forCrew

ManMachineMedia

The vessel,
The vessel, shipowner andMainly
shipowner andship management company on the vessel ship managementcompany

・Re-training for taking
over from previous
Master・In particular, procedure
manual complianceThorough guidance
regarding the approvaland enforcement
procedure of Passage
Standardization,Plans.
proceduralization,
alerting, reward and ・Formulation of handling
method (procedure)
punishment KYT,
regarding the route checkcampagnes etc.
function of ECDISEnforcement

Management

On the vessel・Thorough・Creationcomplianceof Passage
with thePlans using
revisedECDIS andprocedure
a procedure
manualmanual on
how to utilize
the routefunction

Shipowner andship managementcompany

・Review of SMS
procedure manual
regarding creation,
conﬁrmation andapproval of Passage
Plans. (To include
basic setting methodof ECDIS)
・Guidance andcompleteness ofrevised procedure
manual for all ships
under management
・Enforcement ofinternal auditing

ExamplesCase studies,countermeasuresand rules
Lead by example,
experience ofsuccess, introduce
model cases,“Hiyari-Hatto” (nearmisses), etc.
Environment
Workingenvironment,ofﬁce internalmanagement, onboard organization,
etc.

131

Author (photograph):

Maritime Counselour/ Captain Takuzo Okada
Loss Prevention and Ship Inspection Dept., JAPAN P&I CLUBTranslated by:Mr.Geoff England
Co-founder and CEO YUZEN Translation LLC
Tel/Fax: 050-1407-1394 geoff@yuzentranslation.com

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