Hiroshima Pref.

Actual Sailing Route taken

Kure

Recommended Route

Edajima

Yamaguchi Pref.
Yanai City

Ohshima Bridge
Suoh Oshima Town
Yshiro Isl.

Heigun ISl.

Yamaguchi Pref.
Yanai City
Ohshima Bridge

Point Accident Occurs(22 October 2018, atapproximately 00:27.00 (JST))oetNo.3 Pier

S
ke

ta

ba

Oh

el

nn

a
Ch

No.4 Pier

Ohiso LH

Suoh Oshima Town
Yashiro Isl.
Fig. 3669

５−２ Summary and Damage Sustained to a Vessel(Cargo ship E）

Photograph 37

Gross tonnage： 25,431 G/T

L×B×D： 180m×30m×15m（Length）（Breadth）（Depth）

70

Port of origin： The port of Onsan (Korea)
on October 19, departed at 08:30

Port of destination： Etajima, Hiroshima Prefecture Private berth

Cargo

:

Draft

： Fore 5.95m

Crew arrangement： Total number of 21（12 Indonesian, 4 Filipino, 2 Russian,
1 Turkish, 1 Indian and 1 Ghanaian)

Ship's Bridge on duty
personnel at the time of
the accident.

： Master E, 2/O and AB E

Master E： Indonesian national at the age of 44 joined as crew in1998 and became Master in 2016 with a crew change
at Qingdao (port before last) on October 16. He had
a great deal of experience manoeuvring in the Seto
Inland Sea area as a Master, but it was his first time tomanoeuvre in the Obatake-Seto channel.

2/O E： Indonesian national at the age of 26 joined as crew in2012 and boarded Vessel E from July, 2018. It was his
first time to serve on board as 2/O.

Oxidized aluminium Approximately 6,300KT
Aft 6.97m

Air Draft（Fig. 38）and Damage（Photograph 39）

AirDraft
Aft. Mast

No.4

Abt. 35m

No.３

No.２

Abt. 34m
No.１

Abt. 42m(Fore 5.95m Aft 6.97m)

Fig. 38

No.1, No.2, No.3 cranes and the aft mast sustained damage. Air Draft（height from thewater surface) is as shown in Figure 38.

Figure 39 illustrates damage sustained.

Broken Aft Mast
⬅ Fore71No.1 Crane

No.3 Crane

No.2 Crane

No.4 Crane
Inspection passage debris dropped from Oshima bridge
Photograph 39

５−３ Summary of Ōshima Bridge（Figure 40）
and the Damage Sustained（Photograph 41）
Pasage Length 290ｍ

Damaged Location← Yanai City

Suoh Ohshima Town →TP+31.9m

24m

No.3 Pier

24m
Created from the generallayout provided by
Yamaguchi Prefecture

Height of General Drawing :TP（Ave. Sea Level in Tokyo Bay) + 31.90m
Estimated Tide Level : 22nd Oct., 2018 00:30 JST
TP-0.69m← Yanai City

No.4 Pier

Iwakuni City →Cross Section Drawing:
Prepared using General Drawing(Yamaguchi Pref., Japan)

約１ｍ
Water Pipe
Inspection Passage
Cross Section Drawings of Ohshima Ohashi(Image)Fig. 4072

Height from water
surface at the timeof accident :about 33.0m

Ōshima Bridge Damage
Bridge sustained cracks and depressions in the bridge girders, and an inspection corridor
which was situated under the girders dropped down damaging a water mains pipe,
power and communications cables etc.
In almost all parts of Suo-Oshima Town, 9,046 houses and 4,590 residents and local
industry suffered approximately 40 days without water. In addition, in a part of SuoOshima Town, there were problems such as a temporary power outage, interruption ofInternet connections and mobile phones, and electrical equipment such as bridge lights
and so on.

Photograph 4173

５− 4 Events and Sailing Routethat Led to the Accident
Timelines and sailing route that led to the accident are summarised in Figure 42 andTable 43.

▶

The passage plan was created just 1 week before the accident by the
2/O E.

▶

On the day of the accident, at around 22:00 on October 21, MasterE ascended the bridge in the vicinity of Figure 42 ① in preparation
for navigating the Obatake-Seto channel, and commenced shiphandling command.

▶

At 00:00 on October 22, the duty was taken over by 2/O E at the
point of 1 nautical mile south of Kasasa-jima.

▶

As Master E felt uneasy about the height of the Ōshima Bridge, heordered 2/O E to confirm it. But he continued navigating. 2/O E triedin vain to ascertain information, regarding the height of the bridge
beam using pilot directions and the ECDIS.

▶

10:27 (approx.) On Octorber 27, the Vessel collided with Ōshima
Bridge. Master E tried to make a call to the agency but no one
answered at all. Master E kept navigating because it seemed that
there was no appropriate point of anchor in the vicinity and at 04:00(approx.) he finally anchored off the Port of Kure.

74

Fig. 42

Date・TimeNo.

Occurrence of Events According to an Interview
and Questionnaire

9/24 〜 10/19―

9/24 Departed Kwinana Quay (Australia) and arrived at theport of Onsan (Korea)via Isabela (Philippines) and Qingdao(China) on 10/19.

10/13 Approx.

―

2/O E made the Voyage Plan for Onsan - Etajima.

10/21

10/16

Master E took over from previous Master at Qingdao.

10/20

Master E and 2/O E confirmed the Passage Plan between
Onsan and Etajima.

08：30

Departed the port of Onsan.

75

No.

Occurrence of Events According to an Interview
and Questionnaire❶

In preparation for navigating the narrow channel the Mastermanned the bridge (Master, 3/O E and A/B E).

00：00

❷

Duty Officer 3/O E was relieved by 2/O E.
As Master E felt uneasy about the height of the bridge, heordered 2/O E to confirm it.
2/O E tried in vain to ascertain information regarding theheight of the bridge beam using BA edition sailing directions.

00：09

❸

Although 2/O E tried to check the height of the bridge beam
operating the ECDIS, he did not notice how high the bridge
was.

Steered to
starboard to thewest of Kasasajima.

❹

Ship's Bridge on duty checked for bridge lights, but wereunable to see them due to it being too dark.
Master E worried about being pressed by the westerly
current.

00：26❺

2/O E instructed hard to starboard and A/B E responded tothe order.

Date・Time
10/21

10/22

22：00
Approx.

00：27

Shortly after Master E ordered midships, the No.1, No.2 andNo.3 cranes and the aft mast collided with the bridge insuccession.

00：36

❻

Although Master E made a call to the agency requesting themto report this to the Japan Coast Guard, the person in charge
at the agency could not hear what was being explained well,thus it did not get reported.
Master E kept navigating because it seemed that there was
no appropriate point of anchor in the vicinity and it would besafe to continue to the destination.

04：00

❼

Anchored off the Port of Kure.
Table 43

５− 5 Accident Causes
2/O E made the Voyage Plan with ECDIS and it was signed by the previous Masterand Master E. Excerpts from the Japan Transport Safety Board Report (MA2019-10-762), summarise statements in Table 44 (2/O E) and Table 45 (Master E), so that we may
compare their respective statements with the ship management company’s procedure
manual (SMS manual).

Passage Plan of 2/O E
Ship Management Co. E Procedures(SMS Manual: ISM Code)Actual Passage Plan made by 2/O E
2/O E did not confirm the information regarding
Obatake-Seto using Sailing Directions.
⇒ According to the Sailing Directions
published by the Japan Coast Guard, theheight of the bridge over the narrowest
point of the Obatake-Seto is said to be 24
to 30 meters.
⇒ It is shown as 24 meters in the Sailing
Directions of the BA edition.

Both the Master and duty officer(s) shallcarefully review Sailing Directions anytime
prior to and during the voyage, especiallywhen operating ocean-going vessels.

When making the route plan from Onsan toEtajima, 2/O of E used software installed in the
PC on board in order to operate the electronic
chart and to place orders. At this point the route,from Onsan to Etajima via Obatake-Seto, that thesoftware had automatically created was copied
to the ECDIS to be used.

For small, medium and large scale electronic
charts, the route is to be refined in stages.

2/O E used the route check function and noticed
that there were several warnings, including
shallows on this particular route, but, he missed
the warning for Ōshima Bridge.
⇒ The registered height in the ECDIS was
24 meters. As the vessel’s draft and air
draft had not been input, when using theroute check function, it showed up as“Unidentified”. Later on, when inputting thedraft and air draft, it had been verified as“Not Passed”.

The duty navigation officer and the Master are
to visually check the route that has been input
into the ECDIS and must very carefully checkthis during the entire sailing route on theelectronic chart using the appropriate scale.
This is to be then reconfirmed using the route
check function of the ECDIS.

Table 4477

2/O E created the Passage Plan one week before the accident occurred. However, thefollowing deviations from the procedure manual were identified:▶

2/O E did not confirm the information regarding Obatake-Seto using
pilot directions.

▶

According to the SMS procedure manual for creating Passage Plans,
it is specified that it be created by confirming each item of data before
inputting it into the electronic chart. However, he created the Passage
Plan using nautical chart ordering software and copied the data over tothe ECDIS.

▶

When creating a Passage Plan, it is necessary to input the draft, safety
isobaths and air draft information of the vessel to begin with, but heneglected to do this. As a result, he could not use the route check
function of ECDIS successfully.

Master E
Ship Management Co. E Procedures(SMS Manual: ISM Code)

Checks carried out by Master E
The previous Master had checked and signed
Passage Plan document for Qingdao. The
Master was relieved by another master at
Qingdao. (Checked only the summary anddid not sign for it)
Master E believed that the former Master had
confirmed this because the Passage Plan had
already been made when he boarded on 16
October.
Master E checked the Passage Plan to Etajima
with 2/O E using the ECDIS when staying
at the port of Onsan. However, this was not
carried out in detail.
Master E’s signature was found dated 20
October (one day before departure) on the
Voyage Plan for Onsan - Etajima.

The Master is to confirm the Passage Plan
first-hand by himself/herself in order toensure that there are no errors. When the
Master signs a Passage Plan document thismeans that it has been officially approved.

Table 45

78

The following deviations from the procedures are also found for both Master E andManagement Company E.
▶

Master E boarded at Qingdao on 16 October (which was 5 days before theaccident occurred). As the previous Master mentioned to Master E that
the Voyage Plan for Onsan - Etajima had been created, Master E assumed
that the previous Master had checked and confirmed the plan, meaningthat Master E did not check it himself.

▶

The Master checked the Voyage Plan to Etajima with 2/O E using the
ECDIS when mooring at the port of Onsan. However, this was not carriedout in detail.

▶

Master E and 2/O E were not used to using the check-bridge-heightfunction on the ECDIS.

▶

Ship Management Company E would not usually intervene during thecreation of a Passage Plan which are created on board each vessel. At thetime of the accident, they had no information about any of the Passage
Plans, including the Passage Plan from Onsan to Etajima, in advance.

79§6 4M4(5)E Analysis of
Bridge Collision ＝ Accident ＝

６−１ Human characteristics（Human error ）and
Psychological factors (See Attachment 16)
Before starting a specific 4M4(5)E Analysis, let’s look at the relationship between humancharacteristics (human error) andpsychological factors.

Attachment 16
Date
and
time

Movement

Who?

Vessel E Ōshima Bridge Collision Accident:
Human Characteristics, Human Error and Psychology
Behaviour

In the same manner as theprevious chapter, Attachment 16

・2/O E did not conﬁrm information
regarding Obatake-Seto (including
bridge beam height) using pilot
directions

was summarized with the results・Worked according to the following
procedure when creating a Passage Plan

used in “(2) Human characteristics

13 Oct.
approx.

Navigating
en route to
Qingdao.

Copied the data over to the ECDIS⑩ Human beings are sometimes
lazy: Knew the procedure, but cut
corners

As a result, although some warnings
were detected by the route check
function of ECDIS, as the vesselʼs Draft
and Air Draft had not been input, thewarning for Óshima Bridge showed
up as “Unconﬁrmed” and was thus
overlooked.

komado 18 (Safety Loopholes)
dated 30 June, 2002 (Provisional⑩ Human beings are sometimes
lazy: Knew the procedure, but cut
corners① Human beings sometimes makemistakes: The software was notfor creating Passage Plans

３）Did not input Draft and Air Draft
data into the ECDISCentre Co., Ltd from Anzen-no-② Human beings are sometimes
careless, ③ Human beings
sometimes forget

16 Oct.
approxWhen mooredat Qingdao

・The previous Master had checked andsigned the Passage Plan document for
Qingdao under his command. He only checked a summary of the Passage
Master E
Plan between Qingdao-Onsan, andOnsan-Etajima, and did not sign for it.

Error in “P.4 1-2 As a Mechanism

・Master E believed that the previous
Master had conﬁrmed this because
the Passage Plan had already beencreated.

behind Maritime Accidents
20
Oct.
approxWhen mooredat the port of
Onsan

Master E

The Master E checked the Passage Planbetween Onsan-Etajima with 2/O E
using the ECDIS. However, this was not
carried out in detail.

Psychological Factors”.

Normalcy bias
Human beings have thecharacteristic to underestimate
or ignore information regarding
him or herself.

Peer pressure
・Human beings are prone
to make a judgement or
decision inﬂuenced bysomebody elseʼs ideas andthoughts.

While it may be easy to use
・When normalcy bias andconvenient software for orderingpeer pressure are combined,
charts, if ECDIS is not used correctly
a deviation from what wasthen it will return incorrect results
the standard occurs. Then,
as a result, and in no timeat all, this then becomes the
new standard.

The next Master E took over from theprevious Mastertranslation）（Figure 5)” which

Caused by Human Error” and “(3)Psychology③ Human beings sometimes forget:
Forgot the procedures of the
Safety Management Code

１）Created using software forordering charts ｈ
2/O E（Nihon VM (Visual Motivation)

explains Causes behind Human

Human characteristics

Created Passage Plan: Onsan - Etajima⑩ Human beings are sometimes
lazy: Neglected to take overproperly

Normalcy bias
Human beings have thecharacteristic to underestimate
or ignore information regarding
him or herself.

⑨ Human beings sometimes makeassumptions: It was assumed thatthe previous Master had approved
the Passage Plan up until
completion of voyage discharge

Social loaﬁng
There is the psychologicaltendency to cut corners in the
belief that someone else willtake care of it⑨ Human beings sometimes makeassumptions: Based on theabove, he assumed that the
Passage Plan had been enteredinto the ECDIS correctly⑩ Human beings are sometimes lazy:Knew the procedure, but cut corners

21 Oct.
08:30

Departed theport of Onsan.

22:00

The west of
Heigun Island

Master E

Manned the bridge in preparation for
navigating the narrow channel

No speciﬁc problem

22 Oct.

Table 46 (Attachment P. 124)80

No speciﬁc problem

2/O E's Creation of the Passage Plan
While he may be versed in the Safety Management System (SMS)’s procedure manual,
he was unable demonstrate this. When applying this with human characteristics, thefollowing emerge. (Numbered Figure 5 on P. 6）
1

Human beings sometimes make mistakes and

10 Human beings are sometimes lazy

Created Passage Plan using nautical chart ordering software and copied the data over tothe ECDIS as is.
2

Human beings are sometimes careless and3

Human beings sometimes forget

Before inputting specific data of sailing route, it is a requirement that basic informationsuch as Draft, Air Draft、Safety isobaths of the vessel, be input. This was neglected.
In addition, as for psychological factors, overlaps of Normalcy Bias which is to ignore
information that is inconvenient（e.g. following the procedure manual in the Safety
Management System (SMS）is time consuming, etc.,) and Peer pressure such as the
copying of data into the ECDIS from the Passage Plan using software for ordering charts
by superiors and predecessors contributed to the above mentioned actions.

Master E
We can conclude that the following human characteristics invited human error.

9

Human beings sometimes make assumptions

The previous Master checked and signed the Passage Plan up until Qingdao Port where
the takeover Master boarded. The Master assumed that the Passage Plan created for
Qingdao-Onsan-Kure (Etajima) was complete and that the previous Master had checked
and signed it.
10 Human beings are sometimes lazy

The Safety Management System (SMS）specifies that the Master is to check the details

81

of the Passage Plan and sign for it. However, he neglected this duty because of hisassumption.

The following psychological factors underlay the root cause behind these humancharacteristics.
● Normalcy bias： Similarly for 2/O E, he conveniently interprets
the burdensome task at hand.
● Social loafing： Simply assuming that someone（in this case,the previous Master) was supposed to do it.

As Master E felt uneasy about the height of the bridge, he ordered 2/O E who justascended the bridge to confirm it. But, it must be said that this was in vain, because it
was too late. Let’s proceed to the following 4M4(5)E analysis, while considering theseunderlying root causes.

６−２ Summary of Related Facts (See Attachment 17）
It is possible to list up the following related facts from the main accident causessummarised in 5-5.

Creation of Passage Plan by 2/O E▶

Did not research the waterway enough.

▶

Did not input basic information such as draft, Air draft and safety
isobaths of the Vessel into the ECDIS.

▶

Saved to the ECDIS only by copying the Passage Plan data which
was created using nautical chart ordering software.

82

Attachment 17

Maritime Accident Summary of Related Facts（Collision with Ōshima Bridge)

Caused by

1

2/O E

〇

1

〇

Check facts and problem areas
Created Passage Plan: Onsan - Etajima
without checking the bridge beam heightof Ōshima Bridge. Abort Point procedure
was unclear

13 Oct.
approx.

Re-examination necessity

Time

Unsafe conditions

Date

Unsafe behaviour

Reference No.

Identiﬁed problems from survey ﬁndings

Accident cause evaluation

Direct cause

Did not input Draft, Air Draft and Safety
isobaths data into the ECDISCreated Passage Plan using nautical chartordering software and copied the dataover to the ECDIS as is2

16 Oct.

Master E

Believed that the previous Master had
checked and signed the Passage Plan
both between Qingdao-Onsan andbetween Onsan-Etajima.

〇

5

3

20 Oct.

Master E
and 2/O E

Passage Plan between Onsan-Etajima
were not conﬁrmed in detail on the
ECDIS.

〇

2

4

22 Oct.

Master E

As Master E felt uneasy about the heightof the Ōshima Bridge, he ordered his 2/O
E to conﬁrm it.

〇

4

2/O E

2/O E did not conﬁrm bridge beam heightusing pilot directions and the ECDIS〇

3Master E

Continued navigating without conﬁrming
the height of the bridge beam

〇

6

Ship
managementcompany E

No intervention was taken into accountwhatsoever, regarding the vesselʼs
Passage Plan

〇

6

5

6

22 Oct.
22 Oct.

7

00:00

00:00
00:11

Accident cause assessment: Prioritized according to the scale of the cause

Table 47 (Attachment P. 126）

Master E▶

Believed that the previous Master had checked and signed the
Passage Plan from Qingdao-Onsan-Kure (Etajima).

Passage Plan conﬁrmation between Master E and 2/O E▶

Both did not do a ﬁnal check of the passage plan before departing
the port of Onsan.

▶

Immediately before the accident, Master E ordered his 2/O E toconﬁrm the height of the Ōshima bridge, but 2/O E could not conﬁrm
this with pilot directions and the ECDIS.

▶

Continued navigating without conﬁrming the height of the Ōshima
Bridge.

We can understand that the accident occurred, because the chain of human errors was
not broken.
83

Ship Management Company E▶

No intervention was taken regarding the creation and conﬁrmation of
the management of the vessel's Passage Plan

６−３

Analysis Related to Unsafe Behaviour for
Master E and 2/O E (See Attachment 18)
Man

Human factor (The vessel, shipowner and ship management company）
4 Individual skills
Cause (Unsafe behaviour)
2 Emotional

3 Organizational
4-1 Inadequate knowledge

Management
Management factors and organization

Mainly on the vessel

The vessel, shipowner andship management company

Shipowner and Ship managementcompany

On the vessel

①

②

③

④

⑤

⑥

Inadequate layout arrangement

Inadequate supervision of his/her
subordinates

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/her
subordinates

Inappropriate work method

Lack of education and training

Work preparedness/inadequate
working conditions⑥

Lack of information regarding work
to be carried out⑤③

Lack of machinery and facility
maintenance, etc.

Inadequate safety management
planning②

Lack of standardization

Inadequate/incomplete regulations
and procedure manual①

Lack of consideration regarding
ergonomic factors④⑥

Lack of fundamental safety (designand ergonomic arrangement)

Inadequate management/
organization⑤

Defective protection against hazards③④

Design ﬂaw in the machinery②③

Tool box meeting was not
implemented

Inadequate work space

②

①

①

Health check not implemented prior
to working

Poor working environment conditions②

Protective wear not worn⑤①

Covers up or tolerates dishonest
work
Intentionally dishonest regarding
work, and breaks the rules④②

Desire and willingness④

Ageing③

Physical ability

Not enough training①

Alcohol, medicine or disease

The belief that the work done is satisfactory,
when objectively it is inadequate⑤

Lack of sleep

Not “ready” to work④

Fatigue③③

Personality①②

Habituation phenomenon①①

Mistakes and perceptual illusion

⑤

⑫

④

⑪

Judgement based on speculation②⑩

Mental shortcuts

Cuts corners

③

⑨

②

⑧

Unconscious acts

Communication⑦

Personal problems

Sense of urgency and sensitively①⑥

Habituation behaviour

Leadership and teamwork⑤

Forgetful

Unaccustomed to work, inexperienced, inadequate skills
Lacks basic knowledge of thework
Mistakes regarding work procedure/ forgetfulness
Lack of a sense of urgency andawareness
Work content not understood or
misunderstood
Inadequate or inappropriate knowledge about the work to be carried out
Commitment (responsible
intervention)④

Impulsive action

〇

④

③

〇

③

②

〇

②

①

〇

4-2 Inadequate
4-3 Poor work ethic
skillsMedia
Media connecting Manwith Machinery

①

③

②

②

①

①

Necessity of re-investigation

1 Psychological

In ① , write down a direct cause
which was investigated basedon the facts After ② , write
down the root cause using the
Why 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.

MachineMechanical factors such asmachinery not working properly or being out of order
5 Managementof health andworking environment

2/O E and Ship managementcompany E

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

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

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

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

What was the data copied
over to the ECDIS?

〇

〇

〇

〇

〇

〇

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

〇

1

③

〇

〇

①

③

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

②

①

①

2

2

2

〇

Master E and 2/O E

Why did the Master E believe that the previous Master had signed the Passage
Plan?

2

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 without
conﬁrming the height of theŌshima Bridge?

〇

〇

〇

〇

〇

〇

〇

〇

Master E and 2/O E

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

4

〇

〇

〇

〇

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

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

6

6

6

7

6

6

6

6

Master E

Why did he continue navigating regardless?

6②〇

Why was an Abort Point notarranged?

Total number of circled items

〇
〇

3

1

〇

〇

〇

〇
3

2

6

4

8

5

1

3

1

1

1

1

1

1

Table 48（Attachment P. 127）

There is a tendency that causes are from “1 Psychological factors” and “4 Individual
skill factors” in Human Factor (Man) of 4M.

Psychological Factors
Among the psychological factors, ⑥ Sense of urgency and sensitivity, ⑧ Cutting
corners and ⑨ Judgement based on speculation, are the main causes.
Created a Passage Plan using nautical chart ordering software andcopied the data over to the ECDIS as is. ⑧ Cutting corners is applicable.
Did not input Draft, Air Draft and Safety isobaths data into the ECDIS ⑧
Cutting corners is applicable.

84

Before departing the Port of Onsan, Master E and 2/O E conﬁrmed the ﬁnal
Passage Plan, but without checking the details. In addition, as a planned
Abort Point had not been identiﬁed, it was also not input into the ECDIS. ⑥
Sense of urgency and sensitivity and to ⑧ Cut corners are applicable.

Ship Management Company E
The Safety Management System (SMS) specifies the creation procedure manual of
the Passage Plan, and there was no problem with this in itself. However, regarding
management at the oﬃce on land, it is clear that they were not involved in the Vessel
including any other vessels. “2 Inadequate/incomplete regulations and procedure
manual”, “3 Inadequate safety management planning” and “4 Lack of education andtraining” are applicable. As the problem lies in that of the operational method, we havedesignated this as Re-examination necessary.

６−４ Countermeasures for Unsafe Behaviour for
Master E, 2/O E and Ship Management Company E（See Attachment 19）
Attachment 19

Maritime Accident Analysis using 4M5E and Countermeasure List
(Unsafe behaviour) Collision with Ōshima BridgeMan

The vessel, shipowner andship management company

Risk factors（Direct cause
and indirect/root
cause）

MachineMediaManagement

The vessel,
Mainlyshipowner andon the vessel ship managementcompany

On the vessel

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

7. No intervention
1. Vague setting 3. Vague
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- ①
Plan (Management
and ⑦〜⑨） 2- ②，3- ① and
4- 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 , ⑨
and ⑩）

・Re-training for the
personnel in charge ofcreating the Passage Plan
(2/O E)

Education andtraining
Knowledge, skills,
consciousness,being given
information, etc.

・Re-training on how tohandle feeling uneasinessregarding navigation

・Re-training regarding
handling of Abort Point
procedure

The vessel, shipowner andship management company

・Re-training for taking
over from previous
Master・In particular, procedure
manual compliance
Thorough guidance
regarding the approvaland enforcement
procedure of Passage
Standardization,
Plans.
proceduralization,
・Formulationof handlingalerting, reward andmethod (procedure)
punishment KYT,
regarding the route checkcampagnes etc.
function of ECDISEnforcement

MachineMedia

The vessel,
Mainlyshipowner andon the vessel ship managementcompany

Management

On the vessel

・Creation
・Thoroughof Passage
compliance
Plans usingwith theECDIS andreviseda procedure
procedure
manual on
manualhow 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 of
success, introduce
model cases,“Hiyari-Hatto” (nearmisses), etc.

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）

EducationMan

Shipowner andship managementcompany

Environment
・Formulation ofcontinued training
and education for
Crew

Workingenvironment,ofﬁce internalmanagement, onboard organization,
etc.

・Re-training for MasterE regarding Safety
Management CodeEngineering
Technology andengineering
Technologicalcountermeasures

Table 49 (Attachment P. 130)85

When listing risk factors derived from a direct cause and indirect/root cause,countermeasures for improvement will emerge.

Recurrence Prevention Countermeasures through
Education (education and training) for Master E and 2/O E
It is likely that there were no major deficiencies in the procedure manual on how tocreate the Passage Plan according to the Safety Management System (SMS). The root
cause shows that the creator(s) did not have the foundations necessary to plan the
Passage Plan according to the manual.
Therefore, it will be important for both Master E and 2/O E to receive re-training on
creating a Passage Plan including the utilization of ECDIS.
Also, Master E continued navigating even though he felt uneasy about the height ofŌshima Bridge. Re-training on how to handle feelings of uneasiness while navigating
will also be required.

Recurrence Prevention Countermeasures by Ship
Management Company E
Regarding the creation of the Passage Plan, the fact that the management company was
not directly involved poses a problem, since they relied on related parties only. Confirm
if there any problems with regards to the ISM Code or SMS Manual. If there are any
deficiencies, they need to be improved. This should include the following:● A review of the Passage Plans procedure using the ECDIS and procedure manual. This is
to include how to utilize the route function.
● This should not stop with work completion and an improved procedure manual, butthat ongoing verification be carried out if it is to be practised reliably at sea (PDCA
cycle). Namely, it is important to manage the following:▶

Thoroughly introduce accident summary and guidance and completeness ofrevised procedure manual for all ships under management.

▶

86

Until the management company can confirm that they reliably practice this witheach ship under management, the implementation frequency of internal audits
is to be increased.
▶

Moreover, it is important to evaluate these operation results and, if necessary,
review in order to not forget the lessons learned from the accident.

Specific prevention countermeasures will be summarized here by adding therecurrence prevention countermeasures compiled in Japan Transport Safety Board’s
report (MA2019-10-2).（As the (X) numbered items are recurrence prevention
countermeasures which are defined in the Japan Transport Safety Board Report, ourrecurrence prevention countermeasures with 4M4(5)E analysis are almost identical.)

1 When crew create the passage plan regarding a sea area where they areto navigate for the first time, it is a requirement that they carry out an indepth investigation throughout the entire route, using nautical charts, sailinginformation and other oceanographic information in particular.
1

Recurrence Prevention Countermeasures Specific to (1)When considering why they could not perform their duties, as mentioned
above, psychological factors and individual skill factors of Master E and 2/
O E underlay the root cause. Another direct cause, which is a result of
insufficient knowledge and experience regarding Passage Plan creation by 2/
O E（who firstly conducted the duty as 2/O on this vessel）can be identified.
Thus, the following two points can be regarded as recurrence prevention
countermeasures:▶

Re-training for Master E and 2/O E regarding the creation procedure of the
Passage Plan.

▶

Ship Management Company E to systematize crew education and training.

2 When creating the Passage Plan using the ECDIS, crew must not overlook thepotential hazards en route. They must (1) confirm the electronic charts and (2)employ the ECDIS function. The contents of any cautions displayed should bethoroughly inspected.
3 It is sometimes the case that crew are not fully aware of the potential hazards

87

en route when using computer generated voyage plans. When using computer
software for navigation, crew should pay attention to the aforementioned two
points.
4 In order to prevent oversight of any aerial obstacles, crew should make full useof the ECDIS height check function, if so equipped. It is hoped that the shipowner will actively encourage implementation of this function.
One factor is the fact that both Master E and 2/O E had insufficient skill andknowledge to operate the ECDIS route check function. According to the Japan
Transport Safety Board Inquiry, vessel E’s ECDIS displayed the height above sealevel of the Oshima Bridge as 24m. However, neither vessel draft or air draft had been
input and so cautions regarding the bridge were displayed as “Undefined”.

When the route was rechecked following input of the vessel draft, air draft andsafety isobath data, the display changed to “Not passed”. Before departing Onsan
Port, it appears that both Master E and 2/ Ｏ

E did check the route with the

ECDIS, but failed to notice the “Undefined” display.
From this author’s history of being on board vessels, it can be said that although
the route check function is useful, too many alerts are shown on screen (this could
be related to the settings of basic information), and there is a tendency to get
desensitized to the meaning of the alerts. Regarding this area, we hope to discuss
how to improve this aspect via Machine (out of 4M) in the future. Considering
this background information, the following have been identified as recurrence
prevention countermeasures:
2 〜 4 Recurrence Prevention Countermeasures Speciﬁc to (2) - (4)▶

Re-training for obtaining safe isobaths and vessel information via ECDIS for
not only the parties involved but also all Masters and navigation officers ofcontracted ships（including how to deal with draft, Air Draft and so on.）▶

It is important to carry out not only temporary re-training, but ongoing andperiodic training, also. It is necessary that Ship Management Company E
create and review the education and training programme for crew.

88

5 When crewmembers feel uneasy during navigation, navigation should continue

only after confirming satisfactory safety by the taking of necessary steps tochange course, reduce speed, stop manoeuvring and so on asap, depending
the circumstances.
Master E’s continuing to navigate, even while feeling uneasy could be a direct cause.
Because of the inadequate planning for an abort point, the information was not
displayed on screen. At that time when checking the lights at the Ōshima Bridge, it
might be possible to judge if she could keep manoeuvring by stopping navigation atthat point, and take into consideration the manoeuvrability of the vessel (minimum
stop distance, turning etc.).

5 Recurrence Prevention Countermeasures Specific to (5)▶

When approaching port entry and passing narrow channels, it is necessary to
clarify the location of an Abort Point and determine whether or not to continue
navigation at that point.

▶

Ship Management Company E is to prepare the procedure manual and set
up the Abort Point, and systematise further education and training for Masters
and officers.

The ship’s Sea Trial Results and the Turning and Stopping performance displayed on thebridge are as follows:891. Turning performance

Right (Starboard) Turn

Left (Port) Turn

(Initial Spd 12.9kts
Rudder Angle 35deg.)(Initial Spd 13.5kts
Rudder Angle 35deg.)

90° Turn (Advance)

about 543m

about 559m

(Req. Time)(2 min. 10 sec.)(2 min. 02 sec.)

180° Turn Tactical
Diameter(Req. Time)

about 441m

about 463m

(4 min. 22 sec.)(3 min. 52 sec.)

Table 50

Turnig Circle
Original Course
Tactical DiameterTransfer

90° Turn

180° Turn
Advance

90

er
et
iam
lD
na
Fi

Kick

2. Stopping performance
When operating full speed sternway during employing full speed ahead (14.3 knots),
the distance forward until stopping the vessel was 2,116 meters and its time taken was 9
minutes and 53 seconds.
At approximately 00:00 (27 miniutes before the accident occurs) on October 21 when
Master E felt uneasy about the height of the Ōshima Bridge, he ordered his 2/O E toconfirm it; the vessel was at the point of 1 nautical mile south of Kasasa Island (Kasasajima). Considering this sea area, it would have been possible both to return by turning or
stopping the vessel itself.
In addition, in the case of heading for Kure（Etajima) passing Kanmon Straits, as it is
not suitable to navigate Obatake-Seto channel for large ships, for example, those that are
more than 180 meters in length, i.e. Vessel E, it is common to pass via Kudako Suido（See Figure 42）instead. In the event of being unfamiliar with this sea area, it would benecessary to have a pilot on board.

91

§7

Conclusion

As explained in the Chapter 1, almost 90% of the root causes of all maritime accidents
are said to be caused by a chain of human errors. In terms of accidents such as
collisions, bridge damage and groundings, which were closely examined this time, it is
no exaggeration to say that the root causes were down to human errors (100%). BTM/
ETM and the 4M4(5)E analysis can break the error chain and prevent future accidents.
By utilising the PDCA cycle and by analysing why the parties involved caused theaccident and using lessons learned from past accidents to reflect and prevent the same
type of accident occurring, it is our hope that these methods may serve to prevent similar
accidents from happening in the future.
References•

Transport Safety Board Reports•

A collection of tribunals by the Marine Accident Inquiry Agency (MAIA) (Provisional translation)•

Cultural lectures held by the Japan Captains’ Association：
75th Human Error from a psychological perspective (Provisional translation）
77th What is BRM? (Provisional translation）
80th Cultural lecture：Ensuring safety in a proud profession ＝ Why BRM is required(Provisional translation）＝
81st Accident elimination caused by human factors (Provisional translation）•

The Maritime Human Resource Institute, Japan: Engine room resource management (Provisionaltranslation）•

Bridge team management published by Seizando•

P&P Network: Meaning and object of OJT (Provisional translation）•

Japan Industrial Safety & Health Association Training materials from a Cause analysis andprevention seminar through lessons learned from disaster cases (Provisional translation）

JISHA

92

Attachment 1

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Percentage of accidents that occur when the two overlap

1 Site investigation
・Carry out investigation in as much detail as possible, ideally by a third party (such as asurveyor or marine consultant etc.)
2 Analysis of site investigation report・ Clarify accident cause/s (4M) using a classification table and so on.
・ Organize these into a matrix to examine the facts.
・ Furthermore, clarify which items need to be inspected/investigated again.
3 Once the above have been established, compile this information into an accident
cause/s matrix (unsafe behaviour and unsafe conditions).
・Refine relevant items.
・Carry out a Why Why Analysis.
4 Once the above 3 has been completed
・Classify the direct cause, indirect cause and root cause of the accident referring to the
4M5E table.
・Devise a countermeasure for every 5E item.
5 Carry out and verify countermeasure based on the above⇒ Brush up with PDCA cycle.

93