4

Case Studies
4-1. Crew Claims

1 Incident Overview
During vessel at dockyard the second engineer (a 58 year old Filipino) had a sudden attack, characterized bysymptoms such as vision clouding. He was immediately transported to a clinic at the dock and given a medical
examination. He was then transported to a medical facility in town. The examination at this medical facility foundthat he had cerebral vascular disturbance, high blood pressure, diabetes, and latent hyperthyroidism. He was taken toanother medical facility and underwent surgery. He remained at that location and was cared for by his family.
After eight months, he was given permission by his doctor to return to his home country. He was escorted by a nurse
and taken back to the Philippines, where he was hospitalized for additional treatment.

2

Cause of Incident

There were remarks on his pre-boarding medical examination that he had high blood pressure and diabetes, but that hewas being treated with medicine, and that therefore he was "fit for employment".
The employment period in this case was 10 months, but 14 months had already passed when the symptoms of theabove illnesses became evident on-board. His medication situation after the 10 month period is unclear (for example,
it is not known how much medication he brought with him, or whether he replenished his supply of medication), but
it is possible that because he was on-board for a longer period than contracted, he ran out of medication for his preexisting conditions, causing them to worsen.

3

Reoccurrence Prevention Measures

Even if an examination comes back as "fit for employment", whenever possible the employment of persons requiring
medication to control pre-existing conditions should be avoided, though this depends on the specific pre-existing
conditions in question. When employing a person with pre-existing conditions, management of their medication isimportant. When pre-existing conditions are being controlled with medication, it is likely that the crew member inquestion will bring medication with them, but the vessel managers (the captain and the employing department on land)
must also confirm that the crew member is bringing the medication when they board the vessel, must avoid employing
the person for a period of time longer than that for which they have medication, and must not rush to extend theemployment period even if the crew member requests an extension.
As part of overall on-board health management, medical examinations which can be performed on-board, such as
weight measurement, blood pressure measurement, and diabetes testing, should be performed on a regular basis. Thereare even some examples of having doctors board vessels to carry out basic medical examinations.
－ 65 －

4

Insurance Compensation

Residual disability allowanceUS$66,000

Medical costsUS$133,000

Repatriation expenses, etc

US$

66,000

Correspondence expenses

US$

7,000

Total

Approx.US$

272,000$

This incident involved over $100 thousand in medical costs, as well as over $60 thousand to replace the crew member.

1

Incident Overview

During cargo loading, ship rope shift work was being performed on the vessel due to land cargo equipment considerations, and a fore spring mooring line snapped. The severed mooring line struck a chief officer who was working on
deck in the legs. The chief officer was immediately taken to a hospital, but both legs suffered multiple fractures, andultimately the right leg had to be amputated at the knee.

2

Cause of Incident

The rope shift work was using one fore spring line to move the vessel back. There was a 2.9 knot current in the opposite direction of the movement of the vessel. This increased load on the rope is believed to be the cause of the springline breakage.
The injured chief officer was moving from the stern of the vessel to the bow of the vessel to check the status of theshift work when he was struck by the broken mooring line.
・ Mooring line maintenance condition
As instructed by the vessel ship management company, inspections were performed every 3 months, and mooring lines were rotated or replaced appropriately, as instructed by the shipmanagement company. The conditionsof all mooring lines, including the mooring line which broke, had been inspected and found problem-free.
・ Personnel placement when performing rope shift work
There were no problems with personnel station on the vessel when the accident occurred. The mooring line justhappened to snap at the same location as the chief officer as he was moving from the aft of the vessel to its fore.

－ 67 －

・The bow spring line was not connected as indicated in the shipyard's guidelines, but it is not clear if thisresulted in abnormal tension being placed on the spring line (see Figure 1 below).

Mooring line placement recommended
by shipyard
Head line ×4

Mooring line conditions at time of
accident
Head line ×3
Estimated site of line cut

Breast line×1

Breast line×1

Injured chief oﬃcer
No.1 C/H

No.1 C/H

Spring line ×1

Spring line ×1

Figure 1. Mooring Line Placement Recommended by Shipyard and Mooring Line Conditions at Time of Accident

3

Reoccurrence Prevention Measures



Although it was not an issue in this particular case, mooring line inspections shouldbe performed at appropriate intervals. Rope manufacturers do not have standards forwhen ropes should be replaced, but break testing on 75mm diameter double-braided
hawsers used for six years found that the break load was reduced to 65% of that of
new ropes. Ropes replacement, like inspection, should be performed at appropriate
intervals.

When performing ship rope shift work, provide detailed explanations of theprocedures, etc. to all deck crew, and if any situations arise which differ from planned
procedures, work must be immediately halted and the situation re-assessed.



Situations in which rope shift loads are placed on a single mooring line should always
be avoided. It is also important to consider using tugboat support when necessary.



Inform crew of snap back danger zone
Notifying and educating crew members about snap back danger zones are also
important. The snap back danger zone encompasses a 22 degree cone (11 degrees leftof center to 11 degrees right of center), with the point of the point of break, pointing
in the direction of the point of restraint. It is also important that crew understand thatwhen mooring lines pass through a fairlead, the snap back danger zone covers a muchgreater area. (See Figure 2 on the right) For regular shipping routes with identical
berth piers at each port, snap back danger zones must be indicated on-deck, but basic
training must be provided to crew members to not stand within a 60 degree angle inthe direction of the mooring line when reeling the mooring line in.

Projected snap back danger zone fora system where a line is secured directly
Point of break

Point of restraint

Snap backdanger zone

Projected snap back danger zone fora system where a line is secured directly
Point of break

Point of restraint

Stand roller
Snap backdanger zone

Figure 2. Snap Back Danger Zone

－ 69 －

4

Insurance Compensation
Residual disability allowanceUS$137,500

Medical costs

US$477,500

Repatriation expenses, etc.

US$27,500

Correspondence / surveyor expenses US$

66,500Total

Approx. US$ 709,000$

In addition to residual disability allowance and medical costs, this accident also involved significant expenses to pay
for a surveyor to investigate the conditions at the time of the accident and correspondence expenses to assist withmedical treatment, etc., in the country where the accident happened and in the crew member's country.

4-2. Cargo Damages

1

Incident Overview

While the vessel (bulk carrier / 25,000G/T ) was at sea off the south coastof Australia, it encountered stormy weather (8 on the Beaufort scale).
Seawater leaked into the No. 1 cargo hold and damaged the coal inside.
At discharging port, the extent of the damage was investigated, and it
was determined that roughly 250MT of seawater had entered the hold.
The vessel sailed through stormy weather for one week. During thewinter, there is always a high possibility of stormy weather to the south ofAustralia.
The vessel had folding hatch covers (which opened towards the fore and aft). Evidence was found that sea waterleaked in from multiple points on the hatch cover center joint and cover stern and bow areas. There were also several
areas of damage on the compression bar, and the drain holes of drain channel were clogged with cargo residue,
preventing them from functioning as intended.

2

Cause of Incident

The cause of the leakage of sea water appears to have been problems in the mechanisms used to ensure the watertightness of the hatch cover. This appears to have been exacerbated by the fact that the vessel was at sea in stormy
weather for an entire week.

－ 71 －

3

Reoccurrence Prevention Measures The seals of hatch covers, access hatches, ventilators, and the like must be regularly inspected and maintained
to prevent water from leaking into cargo holds.
 When there are forecasts for stormy weather while at sea, shipping routes must be selected based on detailed
analysis of weather forecast data obtained in advance (including the possibility of taking shelter from stormy
weather). Optimally, shipping route selection should not be left entirely up the vessel, but ground operations
should also provide support and guidance.

4

1

Insurance Compensation

Settlement amount of cargo claim

US$470,000

Correspondence expenses

US$180,000

Total

Approx. US$ 650,000

Incident Overview

The vessel (bulk carrier / 18,600G/T) was discharging cargo from six of its eight holds. The hatch covers were open
during the discharging work. It began raining, so the crew began closing the hatch covers. However, the hatch covers
of four of the holds could not be closed, resulting to water damage to bagged rice in those holds. The rain continued
intermittently thereafter, and some holds remained unclosed, extending the scope of damage. Ultimately, 90,000 bags
(4,500MT, approximately 20% of the cargo) were lost to water damage.

2

Cause of Incident

A fault in the vessel's hatch cover operation hydraulicsystem made it impossible to close the hatch covers,
allowing rainwater to enter the holds. For two of theholds which hatch covers could not be closed, highpressure flexible hose was used as a stopgap replacement for the hydraulic hoses, but it was not possible
to close the hatch covers in time.

－ 73 －

3

Reoccurrence Prevention Measures

Insufficient day-to-day inspections and repairs to the hatch cover operation system led to the cargo damage incident.
This equipment needs to be recognized as important equipment with a direct impact on potential cargo damage.
・ Day-to-day inspections
Hydraulic piping is exposed to the elements on deck, and is prone to rusting. It may also be difficult to inspect,with sections covered by grating. In-depth inspections, therefore, must be performed. Sections of pipes withproblems should be replaced as soon as possible.
・ Rust prevention measures
Unlike other pipes, hydraulic equipment pipes are high pressure pipes, making it especially important toprevent external corrosion. Generally, external corrosion is prevented by wrapping the pipes with rustproofing(corrosion-proofing) tape.
・ Maintain system functionality
In addition to piping, control components must also be regularly inspected and maintained.

3

Insurance Compensation

Settlement amount of cargo claim US$

1

1,160,000

Correspondence expenses

US$

Total

Approx. US$ 1,248,000

Incident Overview

The vessel (chemical tanker / 18,400G/T) dischargedof part of its cargo of ethyl acetate to a smaller vessel.
However, a cargo sample taken from the smaller vessels
tanks showed that the water content of the cargo was
4,800ppm instead of the correct amount of 100ppm.
The off-spec cargo (500MT) was discharged to a separate
shore tank and resold.

－ 75 －

88,000During the discharging to the smaller vessel, the cargo tank next to the tank which was supplying the ethyl acetate (theNo. 6S tank) was being cleaned.

2

Cause of Incident

Investigation found that during the cleaning of the cargo tank next to the tank supplying the ethyl acetate (the No. 6Stank), a vessel crew member accidentally connected the cleaning hose to the No. 6S tank, and therefore water for tankcleaning was being pumped into the tank containing the ethyl acetate.
The vessel used flexible hose to connect the end of the fixed cleaning water pipe with the cleaning machine. The sea
water/fresh water tank cleaning valves were color coded, but the labels for the cleaning machine were not clearly
legible, which is believed to be why the crew misconnected the hose.

3

Reoccurrence Prevention Measures Always perform in-depth tank cleaning plan briefings in advance.
 Color code cleaning tube labels and sea water / fresh water valves.
eg.) Sea water: Green Fresh water: Blue, etc.
 When using fixed cleaning machines, place labels near the cleaning machine dome. When using movablecleaning machines, place labels near the fixed manholes. Labels must include tank names (as well as clearly
indicating if they are port/center/starboard).
 It is also important to lock valves and cocks near cleaning domes for tanks which contain cargo.

4

Insurance Compensation

Settlement amount of cargo claim

US$95,000

Correspondence expenses

US$

12,800Total

Approx. US$ 107,800

4-3. Collisions(Note: Sections 1. Incident Review and 2. Cause of Incident are excerpts from the Marine Accident
Investigation Report dated November 25, 2011 by the Japan Transport Safety Board)

1

Incident Overview

An insured vessel ("Vessel A", a 10,833G/T Pure Car Carrier, with a Thai captain and 18 crew members fromThailand, Myanmar, and Indonesia) left Mikawa Port in Aichi Prefecture, headed to Yokohama Port. To adjust its
arrival time, it passed north of Izu Oshima Island, and then speed at 17 knots on course <147> towards the relatively
uncrowded sea to the east of Izu Oshima Island.
Opponent vessel ("Vessel B", a 4,255G/T Multipurpose Carrier, with a Korean captain and 16 crew members from
Korea and Indonesia) was loaded with steel coil from Kashima Port, and was speed at 11 knots on course <240> to theeast of Izu Oshima Island, headed to Yosu Port in Korea.
At approximately 02:13 JST the two vessels collided approximately 9 nautical miles to the east of the Izu Oshima
Ryuozaki lighthouse. Vessel A's bow was pierced, but fortunately there were no injuries or deaths, and the vessel wasable to enter Yokohama Port under its own command. However, Vessel B sank two minutes after the collision, withall 16 crew members going missing. Furthermore, fuel oil leaked from Vessel B, causing pollution damage to nearby
aquaculture facilities.

2

Cause of Incident

Both vessels approached on intersecting approaches, but Vessel A was to the starboard of Vessel B, and the bearing
change was slightly to the left, so Vessel A attempted to cross in front of Vessel B, from its starboard side to its portside. Vessel B had been slowly turning to the right since 02:03, 10 minutes before the collision, but when Vessel A
was approximately 1.3 nautical miles from Vessel B it began turning left, and was turning hard port immediately
before the collision. Attempts to avoid collision were unsuccessful, and while attempting to turn in front of Vessel B,
the bow of Vessel A struck the middle port side of Vessel B at an almost perpendicular angle. 5 minutes before thecollision Vessel B hailed Vessel A by VHF, using its vessel name, determined from AIS, but it has been confirmedthat Vessel A did not respond.
The cause of the accident is detailed below.
・ Insuﬃcient lookout by oﬃcer on duty on Vessel A
The Automatic Radar Plotting Aids (ARPA) alarm rang twice, but Vessel A was not constantly monitoring Vessel B's movements. At approximately 02:00, Vessel A spotted Vessel B at a distance of 5 nautical
miles, both visually and by radar, but did not maintain a lookout to constantly confirm any bearing changes.
Article 17 of the Act for Preventing Collisions at Sea states that when vessels are on intersecting paths, the holding
vessel must not turn left unless it is otherwise unavoidable, and Vessel A violated this stipulation.

・ Insuﬃcient lookout by oﬃcer on duty on Vessel B
Because it was impossible to hear accounts from crew members, few details are known, but based on AIS records it
has been ascertained that Vessel B began slowly turning right from approximately 10 minutes before the collision(at a distance of approximately 4 nautical miles), so it can be said that Vessel B was aware of Vessel A. According
to Article 16 of the Act for Preventing Collisions at Sea, the avoiding vessel must maneuver promptly and in apronounced manner in order to distance themselves sufficiently from the vessel to be avoided. The slow turn to theright appears to be a violation of this stipulation.

Based on the above, collision liability was determined to be shared 50:50, and resolution negotiations began.
－ 79 －

Vessel A Route

Izu Oshima Lighthouse

OshimaIsland,Tokyo

Approx. 270 °
0150

55
0200

. 45
°

10

05

rox

10

App

05

Ryuozaki Lighthouse

45
ox
.
pr

Vessel B(4.255t)

55
0200

Ap

Oshima Island°[Estimated Collision Conditions]
0150

Vessel A(10.833t)

Vessel B Route

Accident Site

Keihin Port
(Yokohama Area)

Accident Site

Boso Peninsula
ute

Ro

lB

e
ess

V

e

lin

Izu Oshima Lighthouse
Approx. 01:00

Oshima Island
Approx. 01:24

ect

Dir

se
Ba

Approx. 01:45

e

ss

Ve

lA

Ro

Approx. 01:00

ig
ere

rri

(Te

Bo

v

So

Kashima Port

Approx. 01:47

Approx. 00:00
e
ut

nty

Approx. 00:00

r
rde

)

ine

lL

ia
tor

Ryuozaki Lighthouse

Accident Site
(March 10, 2009,
Approx. 02:13)

Mikawa Port

(Source： Japan Transport Safety Board)

3

Reoccurrence Prevention Measures

As discussed earlier, almost 100% of collisions are due to human error. This case required officers on duty on bothships to use radar, visual contact, ARPA, etc., to constantly monitor the movements of the opponent vessel, andrequired the avoiding vessel (in this case, Vessel B) to take early and pronounced avoidance measures. If the holding
vessel had doubts about the actions being taken by the opponent vessel, it needed to use whatever means at its disposal(VHF / whistle / cooperative action to prevent the risk of collision before it becomes critical, etc.) to avoid the collision.

－ 81 －

4

Insurance Compensation[Vessel A Insurance Compensation]
Compensation for deaths of crew members on opponent vessel

US$

Cost of repairs to opponent vessel (1/4 of repair cost)

US$

Cost of cleaning oil spilled by opponent vessel

US$

Settlement amount of ﬁshing facility damage

US$Lawyer, surveyor expenses

US$

Total:

Approx. US$$

313,000
119
119,000

1,115
1
1,115,000
112
112,000
574
574,000

2
2,233,000[Vessel B Insurance Compensation]
Compensation for deaths of crew members on own vessel

US$

Cost of cleaning oil spilled by own vessel

US$

Settlement amount of ﬁshing facility damage

US$$Lawyer expenses

US$

Total

Approx. US$

1,219,000
653,000
6
63,0001
104,0002
2,039,000

4-4. Groundings
1

Incident Overview

The vessel (a 14,663G/T Pure Car Carrier, with a Korean captain and 21 crew members from the Philippines andIndonesia) was in ballast passage from the Port of Singapore to the Port of Busan when it encountered stormy weather
and took refuge (anchored) off the coast of Keelung (Taiwan). It began dragging anchor, so it weighed anchor andbegan navigating to Busan to take refuge from the stormy weather. Approximately 2 hours after resuming navigation,
at roughly 22:00, the vessel was struck by large waves and strong winds from the northeast, grounding it on a rock reef
approximately 200m from the shore. This caused a crack in the fuel tank, which resulted in an approximately 300M/T
fuel oil spill. Luckily, none of the crew members were harmed, but unfortunately the entire vessel had to be total loss.

2

Cause of Incident

As indicated above, the vessel encountered stormy weather off the east coast of Taiwan, and anchored near Keelungto take refuge, but strong winds resulted in anchor dragging. The vessel determined that it would not be possible toremain at anchor, so, taking ship swaying into consideration, the decision was made to set course for the west coastof Taiwan. Approximately 2 hours after setting off, extremely strong winds and large waves from the northeast (wind－ 83 －

speeds of 20m to 25m/sec, wave heights of 3.5 to 4.0m) suddenly pushed the vessel. In the darkness the captain saw
white waves, indicating the presence of shallows, to the port side. Recognizing the danger this posed, the captainturned hard starboard, but the pressure of the strong winds and large waves grounded the vessel on the reef.
The direct causes of the accident appear to have been that the captain did not sufficiently confirm the vessel's position,
and was insufficiently knowledgeable about the angle with which to receive strong winds, the pressure exerted bystrong winds, and potential ship maneuvering when faced with strong winds. Another cause of the accident appears tobe that the captain did not make corrective maneuvers until the vessel was already very close to the shore.

3

Reoccurrence Prevention Measures

When faced by stormy weather, the strength of the hull places limitations on the course a vessel can keep and themaneuvers it can take while limiting vessel swaying. Strong winds and large waves can be expected to sweep vessels,
so when navigating near coast, special care needs to be taken to avoid drawing near shore. When the ratio of windspeed to vessel speed exceeds 3.7, depending on the angle with which the wind hits the vessel, there will be regions inwhich vessels cannot maintain course. When the ratio exceeds 6, there will be regions in which vessels cannot change
course. It is important, in these conditions, to give sufficient consideration to wind speed, wind direction, and stormy
weather avoidance courses, and to establish avoidance plans which do not produce regions in which course cannot be
maintained or changed. (For details see Loss Prevention Bulletin Vol. 25: Preventing an Anchor from Dragging and
Loss Prevention Bulletin Vol. 32: Preventing Damage to Harbor Facilities and Ship Handling in Harbors PART 2.)
It is also important to frequently check the vessel's actual position, always being aware of the vessel's current position and the leeward pressure exerted on the vessel, and to maneuver the vessel to avoid dangerous conditions. In
particular, when navigating near coasts, steps need to be taken in advance to prevent the vessel from being put indanger, such as using sea charts to choose danger avoidance routes and "No Go Areas", based on water depths and thepositions of reefs, and to carefully formulate navigation plans.

4

Insurance Compensation
Cost of recovering and cleaning spilled oil

US$Settlement of ﬁshing facility damage

US$

Cost of wreck removal

US$

Crew repatriation expenses, etc.

US$

$

Other

US$

Lawyer, correspondence, and surveyor expenses

US$

Total

Approx.US$－ 85 －

5,577,000
23,0002

21,877,000
2
211,877,
170,
170,000
58
58,0001,365,000
1,3

29,070,000

4-5. Damage to Harbor Facilities and Fishing Facilities
1

Incident Overview (see attached ﬁ gure)The vessel (woodchip carrier / 38,844G/T ) planned to dock at a port in Indonesia to discharge cargo. A pilot boarded
when the vessel was anchored and navigated outside the port through a 375m wide channel at D. Slow Ahead (approx.
4 knots) with a 2,000HP tugboat at the vessel's starboard bow, and another at its starboard stern. However, there were
two other vessels berthed on the port side pier of the channel, so the effective channel width was approximately 350m
or less. A barge was preparing to leave port, facing the port side of the vessel, so the pilot hailed the barge via VHF
and requested that it stand by until the vessel had completed its turn round work in the area it planned to turn in (aroughly 420m diameter turn area, approximately twice the length of the vessel). However, there was no response fromthe barge, which continued on its course to leave the port. The pilot was therefore forced to start its starboard turn,driven by the tugboats, near the exit of the channel, but the vessel lost control when starting rotational maneuvers
without slowing, and the bow struck the starboard berth, damaging the fender and its support.
When the accident occurred there was a 3 to 5m/sec northerly wind and almost no current, so external force wasdeemed to have almost no impact on vessel handling.

2

Cause of Incident= Pilot handling error =・・The pilot was so concerned with the departing barge that he changed the initial turning
maneuver plan and began turning within the channel.
The pilot should have stopped the vessel before turning.
Generally speaking, even when a vessel is stopped, the diameter of the turning basin, the area needed for tugboats
to turn the vessel, must be twice the length of the vessel (in this case, 400m). The vessel should have avoided thedeparting barge and then stopped and performed its turn within the 420m turning basin, according to its original
maneuvering plan.

・Control failure.
The actual vessel displacement is unknown, but assuming a displacement of 37,500MT (based on its 8m of draft),
if the tug line angle of action were 20 degrees, and it pulled straight back with 2200HP (22tons) of force, given theinitial vessel speed of 4 knots, it would take 420m to bring the vessel to a complete stop.
The thrust of the tugboat, when pulling on a vessel moving at 4 knots, would have an apparent decrease of 60% to70%, and would be dragged by the vessel, so the tugboat could not be depended on to control the attitude of thevessel (supplement its rotation).

・The tugboats which were being used did not have enough horsepower (additional
tugboats were requested, but did not arrive in time).
General guidelines state that vessels in the class of the vessel in question would require two 3000HP tugboats. The
amount of tugboat power required can be calculated using the following formula, based on displacement. This also
makes it clear that the two 2200HP tugboats used provided insufficient power.

Total required horsepower ＝ 7.4 ×（ DWT ） 0.6
If the displacement were 37,500MT, then according to the above formula the total power required would be 4,108HP.
－ 87 －

= Vessel captain error =・The captain did not suﬃciently discuss the berth handling approach with the pilot.

・The captain realized that the vessel was moving too quickly when the turn maneuverstarted at a point which diﬀered from the turn plan, but did not provide advice to the pilot.

Based on the above, there was insufficient BRM between the vessel captain and the pilot.

3

Reoccurrence Prevention Measures

4

Wind
North 3~ 5/sec

Start right turn

375m
Contacted pier420m

Initial berthing plan When a pilot boards where a vessel
is anchored before anchor up, it ispossible to take time to discuss berthing maneuver plans in depth, so it isimportant to recognize the importanceof BRM and engage in in-depth
discussions. It is especially important
to closely confirm how much tugboat
horsepower will be required.
 It is important not to leave handlingentirely to the pilot, but create detailed
berthing preparation plans, including
calculating how much space and what
speeds will be required before entering the port, instead of relying purely
on past experience and gut instinct. In
particular, it is important to stop thevessel entirely before beginning turning work when turning in confinedareas such as narrow channels. (Fordetails see Loss Prevention Bulletins
Vol. 31/32: Preventing Damage toHarbor Facilities and Ship Handlingin Harbors.)

Planned berthing pierInsurance Compensation

Repair cost of Fender and harbor facilityUS$330,000

Correspondence / surveyor expenses

US$

28,000Total

Approx. US$ 358,000－ 89 －