JAPAN P& I CLUBVol.50 February 2021

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

4M4(5)E
4
M4(5 ) E
AnalysisAnalysis of Accident Cases

Contents§1 Introduction: Safety and Casualty Mechanism & Maritime Accident Prevention
1-1

What Is Safety? ………………………………………………………………………………… 2

1-2

As a Mechanism behind Maritime Accidents Caused by Human Error …………… 4

1-3

Prevention of Maritime Accidents ………………………………………………………… 11§2 4M4(5)E Analysis
2-1Errors Made by an Involved Party and Organizational Errors ……………………… 17

2-2

4M4(5)E Analysis ……………………………………………………………………………… 20

2-3

4M4(5)E Analysis Plus Why Why Analysis: Investigation, Analysis andCountermeasures…………………………………………………………………………… 22§3 Case Study = Collision Accident =3-1

Accident Summary (See Attachment 8）………………………………………………… 32

3-2

Events that Led to the Accident（See Attachments 8 and 9) ……………………… 39

3-3

Causes behind Maritime Accidents ……………………………………………………… 41

3-4

Accident Causes ……………………………………………………………………………… 44

3-5

Transport Safety Board Report ＝ Recurrence Preventive Measures ＝ ………… 45§4 4M4(5)E Analysis of a Case Study = Collision Accident =4-1

Summary of Related Facts（See Attachment 10）……………………………………… 47

4-2

Analysis of Unsafe Behaviour for Pilot A（See Attachment 11) ………………… 48

4-3

Analysis on Unsafe Behaviour for Master A and Master B (See Attachment 12) … 49

4-4

Countermeasures for Unsafe Behaviour for Pilot A（See Attachment 13) …… 51

4-5

Countermeasures for Unsafe Behaviour for Masters A and B（See Attachment 14) … 56

4-6

Accident Analysis from the Perspective of Human Factors and Human Error(See Attachment 15) ………………………………………………………………………… 64§5 = Case Study = Bridge Collision Accident
5-1

Accident Summary (See Figure 36） ……………………………………………………… 68

5-2

Summary and Damage Sustained to a Vessel (Cargo ship E）……………………… 70

5-3

Summary of Ōshima Bridge（Figure 40）and the Damage Sustained（Photograph 41）……………………………………………………………………………… 72

5-4

Events and Sailing Route that Led to the Accident …………………………………… 74

5-5

Accident Causes ……………………………………………………………………………… 76§6 4M4(5)E Analysis of Bridge Collision = Accident =6-1

Human Characteristics (Human Error) and Psychological Factors（See Attachment 16） ……………………………………………………………………… 80

6-2
6-3

Summary of Related Facts（See Attachment 17) ……………………………………… 82
Analysis Related to Unsafe Behaviour for Master E and 2/O E（See Attachment 18） ……………………………………………………………………… 84

6-4

Countermeasures Related to Unsafe Behaviour for Master E, 2/O E and Ship
Management Company E（See Attachment 19）……………………………………… 85§7 Conclusion ………………………………………………………………………………………… 92
References……………………………………………………………………………………………… 92

Attachments
Please use the following attachments and blank form of the 4M4(5)E Analysis List using
the QR code below or by downloading them from the follow URL:

https://piclub.box.com/s/qkc4c4w88m9izvmkegymyunpe7m93yd6
Please note that the attached documents and data are provided by an external service andthat publication may be suspended without prior notice.

ExamplesAttachment 1

4M4(5)E Analysis ……………………………………………………………… 93

Attachment 2-1

Causes behind Maritime Accidents 4M Classiﬁcation List …………… 94

Attachment 2-2

Maritime Accidents 4M Classiﬁcation List ……………………………… 95

Attachment 3

Maritime Accident Summary of Related Facts ………………………… 98

Attachment 4

Maritime Accident Accident Causes (Unsafe Behaviour) …………… 99

Attachment 5

Maritime Accident Accident Causes (Unsafe Conditions)

Attachment 6

Maritime Accident Analysis using 4M5E and……… 102

the Countermeasure List (Unsafe behaviour) ………………………… 105
Attachment 7

Maritime Accident Analysis using 4M5E andthe Countermeasure List (Unsafe Conditions)……………………… 106

Vessel A and Vessel B: Collision accident oﬀ the port of Kobe
Attachment 8

Movements of Vessel A and Vessel B with Map for Reference … 107

Attachment 9

Table of Events Leading up to the Accident ………………………… 109

Attachment 10

Vessel A and Vessel B Collision Accident Summary of Related Facts … 112

Attachment 11

Vessel A and B Collision Accident Maritime Accident Cause(Unsafe Behaviour): Pilot A ………………………………………………… 113

Attachment 12

Vessel A and B Collision Accident Accident Cause(Unsafe Behaviour): Master A and Master B ………………………… 116

Attachment 13

Vessel A and Vessel B Collision Accident Analysis using 4M5E andCountermeasure List (Unsafe behaviour): Pilot A …………………… 119

Attachment 14

Vessel A and B Collision Accident Analysis using 4M5E andCountermeasure List (Unsafe Behaviour): Master A and Master B ……120

Attachment 15

Vessel A and B Collision Accident Human Behavioural Traits andHuman Error (Psychological Analysis) …………………………………… 122

Vessel E: Collision Accident with Bridge
Attachment 16

Vessel E Ōshima Bridge Collision Accident: Human Characteristics,
Human Error and Psychology …………………………………………… 124

Attachment 17

Maritime Accident Summary of Related Facts(Collision with Ōshima Bridge) …………………………………………… 126

Attachment 18

Maritime Accident Accident Cause (Unsafe Behaviour)
Collision with Ōshima Bridge……………………………………………… 127

Attachment 19

Maritime Accident Analysis using 4M5E and Countermeasure List
(Unsafe Behaviour) Collision with Ōshima Bridge …………………… 130

1§1 Introduction:
Safety and Casualty Mechanism& Maritime Accident Prevention

In our previous Loss Prevention seminars and Loss Prevention Bulletins, we introduced
the definition of “safety”, mechanisms behind maritime accidents, how to prevent
maritime accidents and so on. (Please see our Loss Prevention Guides “Thinking Safety(Vol.35)” published in 2015 and “A Psychological Approach to Safety Behaviour” (Vols.
46 and 47) published in 2020.

１−１

What Is Safety?

In the world, absolute safety does not exist, and we are always exposed to all hazards.
According to the International Basic Safety Standards 1st Edition (ISO/IEC GUIDE 51:
1990）published in 1990, safety is defined as:
Quality is not a synonym for safety and consequently the respectiveroles of quality and safety should not be confused.

There can be no

absolute safety. and There is no freedom from unacceptable risk.
Also, thinking of “Safety” has been discussed in various diﬀerent fields, but, in summingthem up, “Safety can be defined as the result or evaluation of all danger being avoided.”

Although each related person, not only those on the vessel but those also working in
the oﬃces on land, is always in pursuit of safe operation, unfortunately, “zero marine
accidents” have not been achieved yet. Looking at the statistics of P&I accidents
reported to us, the accident rate which was calculated by dividing the total numberof accidents that occurred over the last 10 years by the number of entered ship2

underwriting at the beginning of the term was 171.7% for oceangoing vessels and 9.5%
for coaster vessels. This means that, with regards to some P&I accidents, oceangoingvessels caused 1.8 accidents per vessel per year, while this amounted to less than one inten coaster vessels per year.（See Graphs 1 and 2）
Ocean going vessels

The number of insurance accidents and accident rate ﬂuctuation
Number of
Accidents

7,000

197.5%

10 Years Total：
41,393 Cases Accident rate (%) 177.2

195.6%

187.0%
175.6%

Harbour & Fishery Facilities：2,335

173.1%

182.2%

6,000

156.3%

153.6%
144.1%

5,046
5,000

4,736

4,492

4,454

329

226

4,000

209

180.0%
160.0%

120.0%

3,647
202

3,000

200.0%

140.0%

4,107

213

257

284

147.4%

4,609

Accident
rate %

3,411
201

3,567
205

3,324

100.0%

209

80.0%
60.0%

2,000

40.0%
1,000
20.0%
0.0%

0
2010PY

2011PY

2012PY

Cargo Damage

Crew

2013PY

2014PY

2015PY

2016PY

Harbour & Fishery Facilities

2017PY

Others2018PY

2019PY

Accident Rate(%)

Graph 1
Domestic vessels

The number of insurance accidents and accident rate ﬂuctuation
Number of
Accidents

Accident
rate %

10 Years Total：2,200 / Cases Accidents rate(%)：9.5%

300

Harbour & Fishery Facilities：1,267

16.0%

269
246
224
210

14.0%

219
200

202

200

13.2%

198

163
9.3%

131

128
10.7%

9.3%

8.3%

12.0%

12.6%

180

137

252

133

10.0%

112
8.6%

100

8.6%

8.0%

122

8.0%

8.6%

105

107

129

6.0%
⁝
0.0%

0
2010PY

Crew

2011PY

2012PY

Cargo Damage

2013PY

2014PY

2015PY

2016PY

Harbour & Fishery Facilities

2017PY

Others2018PY

2019PY

Accident Rate(%)

Graph 2

3

It is concerning that the number of accidents have been increasing since 2017/18 Policy
Year for oceangoing vessels and 2016/17 Policy Year for for coaster vessels.

１−２

As a Mechanism behind Maritime Accidents
Caused by Human Error

Why then do marine accidents still occur, even though we are aiming to eradicate
them every day by taking all possible safety measures? It is necessary to consider themechanisms that trigger marine accidents.
According to a guidebook called “Facts and countermeasure against maritime accidents
in 2017 (provisional translation)” issued by the Japan Coast Guard, the ratio by types ofcauses as accumulated over the last five years of total maritime accidents reported to theJapan Coast Guard shows that approximately 74% of the causes were those of Human
factors. (See Graph 3)

The ratio by type of cause of total accidents
as accumulated over the last ﬁve years
Insuﬃcient lookout
Irresistible forces etc.

Irresistible forces etc.

Materials and structure

20 %

20 %

2,173

2,148

6%

26 %
2,766

Human
factors

593

74 %

16 %

Inappropriate
ship operation

11%

Other human factors

6%
590

8%
883

1,123
Engine handling error
Insuﬃcient maintenance ofhull and equipment

Graph 3

4

1,378

7,826

1,704

Insuﬃcient monitoring of weather
and sea conditions

13 %In addition, those which are caused by Force Majeure (unforeseeable circumstances)
are also almost all related to human errors. Then, it may be presumed that 94% of all
maritime accidents are caused by human factors.
Therefore, it follows that if there were no human errors, most maritime accidents should
not occur. However, unfortunately, it is not possible to realize zero human errors, as thefollowing four aspects are behind the main root cause.

Causes behind Human Error
1 Common characteristics among the people who have acquired

advanced skills such as Master, Navigation Officer, aeroplanepilot, medical doctor and so on.

（80th Cultural lecture held by the Japan Captains’ Association: Ensuring safety in aproud profession - Why BRM is paramount - from a person with a proud profession(provisional translation.）

These common characteristics of technicians, which are shown in Figure 4, sometimes
cause human error.

1.

Pride and confidence in one’s work and skills.

2.

When hearing of an accident, they have astrong sense of conviction that they would
never cause such an accident.

3.

Behind this there is the assumption that safety
comes naturally if one has a high level of skill.

4.

Feel offended by imposition of Safety Management Regulations and SMS manuals etc.
from the management division.

5.

Cover-up: Protect each other, particularly inthe case of an accident.

6.

Mistakes are matters of acute embarrassment,
and are concealed.
Fig. 45

2 Human characteristics（Nihon VM (Visual Motivation) Centre Co., Ltdfrom Anzen-no-komado 18 (Safty Loopholes) dated 30 June, 2002
(Provisional translation）

Figure. 5 shows the “human characteristics that everyone has” which are likely to cause
human error.

Twelve human characteristics
Human beings sometimes makemistakes
2
Human beings are sometimes careless3
Human beings sometimes forget4
Human beings sometimes do not notice5
Human beings have moments ofinattention
6 ㅤHuman beings sometimes are able to seeor think about only one thing at a time

1

7
8

9

10
11
12

Human beings are sometimes in a hurry
Human beings sometimes become
emotional
Human beings sometimes makeassumptions
Human beings are sometimes lazy
Human beings sometimes panic
Human beings sometimes transgress
when no one is looking

Fig. 5

3 Psychological Factors

The following psychological factors mainly induce human error.
① Psychological reactance（self-eﬃcacy）
This is when people do not wish to do something that is not of their own
volition. They may be inclined to say, “I won’t do what you tell me.”②

Entrainment, Peer Pressure and Normalcy Bias (justification and cognitive
dissonance）
Anyone else would do the same and the psychology of, “What will theneighbours think?” and “I’m special, nothing can hurt me!”③

Confirmation bias
People are unconsciously prone to believe only “what they want to believe” and“information that supports what they believe” rather than purposefully seeking
information to the contrary. They may say something like, “Stop exaggerating!”

6④Social loafing
This is when someone does not choose to take the initiative. They may say,“Someone will do it for me.”4 Human Brain Capacity

The reason why we can say that the human brain is a very ineﬃcient organ is because
it occupies only 2% body weight, yet consumes 20% of all the energy. Our brains areprogrammed to save as much energy as possible, while aiming to achieve maximum
energy eﬃciency. The following are examples of its energy-saving mode, and it is thesethat are responsible for optical illusions and perceptual errors.
Since Neoanthropic man (Cro-Magnon man) was born 70,000 years ago, human beings
have been making a living from hunting, pasturage and farming. In 1769, which is just
250 years ago, a Scottish mathematician and engineer, James Watt invented the steam
engine, which was epoch making for humanity. In other words, problems in the era offarming and pasturage were mainly only floods, fires, and natural disasters, but now,
new disasters can be added to this. It is said that human beings inhabited the earth
approximately 40,000 years ago. If this were compressed into 1 year, and human beings
started to inhabit the earth from 00:00 on January 1, the industrial revolution would
have begun at 17:15 on December 29. Meaning that only 2 days and 6 hours and 45
minutes have passed since human beings came into contact with machines. It is true thattechnological advances in machinery and equipment are becoming more upgradable
and complex, however, we should still think of our DNA and brain capacity as “firstgeneration processes that cannot keep up with these changes”.
■

Avoids thinking deeply (it gets tired)■

Is not good at thinking logically■

Forgets and does not remember easily■

Not able to reject our assumptions■

Tends to believe that our choice is correct■

Tends to make choice based on first impression etc.
Fig. 6

7

Optical illusions
Human beings sometimes make assumptions

Fig. 7

When looking at the illusion in Figure. 7, we recognize that there are two different
women: one is a young lady who is facing away from us, and the other a profile of anelderly lady. If you can only see a young lady, try focussing on her ear to then see an eye, andher chin to then notice a nose, and then her necklace to see a mouth. On the other hand,
if you can only see an elderly lady, try focussing her eye and you will notice an ear, her nose
to reveal a chin and her mouth to reveal her necklace. Now it is possible to recognize bothladies, but isn't it hard to switch to seeing the other lady, once your mind is set on either ofthem at one time?

Interestingly, there is a strong tendency that someone of a younger generation willrecognize the young lady at first and that someone of a senior generation will rather
recognize the older woman first.
It is an old painting from the 19th century, and as of 2016, it is the oldest confirmed
drawing on a German postcard from 1888. The author is unknown, but what is
known is that this postcard’s illustration was used for a US automobile manufacturer
advertisement for the Anchor Buggy Company at around that time in 1890.
Source from Wikipedia: Trompe l'oeil (deceive the eye) My Wife and My Mother-in-Law

8

Optical illusions
Observe the black and white tiles
that are separated by grey lines. The
grey lines appear as though they arecrooked. This is an optical illusion.
Really, each of these grey lines are infact straight and not crooked. This is
one example of a geometric illusion.
The straight lines between the rows ofalternating black and white “bricks”

Fig. ８: Café Wall illusion

appear to be tilting, when they are in fact parallel.
This illusion was first described under the name of Kindergarten illusion in 1898, andwas re-discovered in 1973 by Richard Gregory. According to Gregory, this eﬀect wasobserved by Steve Simpson, a member of his laboratory, on the wall tiles of a cafe at thefoot of St. Michael’s Hill in Bristol. This is a variant of the “shifted-chessboard illusion”
originated by Hugo Münsterberg.
Source from Wikipedia: Cafe wall illusion

As a Mechanism behind Maritime Accidents
Unlike traffic accidents that may be caused by a single driver, casualties at sea are
seldom caused by one single human error. In most cases, there is a chain of humanerrors that leads to an accident, and unless the error chain is broken, as a result, an
accident is likely to occur.
An example of a collision accident is shown in Figure 9. It is understood that an accident
occurs when several errors overlap.

9Collision could have been avoided
by breaking the error chain
Lack of proper look-out

Delay observing the other vessel

Delay taking action to avoid collision

Expects other vessel to take action

Lack of close communication

Collision
Fig. 910１−３Prevention of Maritime Accidents

Basic approach
Herbert William Heinrich (1886-1692). When working as an assistant superintendent of
the engineering and inspection division of a non-life insurance company in America, hislaw Heinrich’s Law was derived from his thesis which was published on 19 November,
1929.(Heinrich’s Law: Figure 10)
Behind every serious accident or disaster, it is said that there are 29 minor ones and that
there are 300 near misses that fortunately do not lead to any accidents. Hazardous “unsafe
acts” referred to as “unsafe situations” number in their thousands, meaning that evenmore dangers lurk in the background.
Thus, if we are able to decrease the several thousands of unsafe conditions and 300 nearmisses, maritime accidents either minor or major, could definitely be reduced.

                     Fig. 1011

There can be no “absolute safety” and “Safety can be defined as the result or evaluationof all danger being avoided”, as explained above in 1-1. Then, how can we achieve
the safe operation of vessels which are always exposed to a variety of dangers? Byunderstanding the Johari Window (see Figure 11）in the field of psychology, we can seethat it is possible to “heighten the level of safety”.
Considering the scope of activities in vessel operation, there are many dangers lurking in
the Johari Window. This consists of four window-panes: ① Known to self (Open area),② Not known to self (Blind spot), ③ Known to others (Hidden area) and ④ Not known
to others (Unknown area). The most dangerous area is the “Unknown area”. Namely,
the unknown area is an area that no one knows about (or a danger that no one notices)where safety measures are yet to be taken.
A requirement that would heighten the level of safety would be to enlarge the Open area.
In other words, the Open area specifies that all members within the range of activity,
including the vessel and its land management department, are equally aware of thedanger, thus proactive measures can be taken.
The “Blind spot” can be narrowed by learning from each other’s knowledge andexperience, thus expanding the “Open area” of the team. Also, by opening our Hidden
areas (what we know that others don’t) and by being aware of others’ blind spots, theOpen area will be expanded, which will in turn bring about improved safety, eventually.
If we remain unaware of the “Unknown” area and its inherent dangers, this will renderus defenceless.
However, if we enlarge the Open area, the Unknown area will reduce. At the same time,
the Blind spot and Hidden area will also reduce. This means that the level of safety will
improve.

12

Johari Window

to Self  

to Other  

  




  

 

              Open Self

Blind Self   

             

Hidden Self             

Unknown Self

to Self 

 

 

to Others 


 

              Open Self

Blind Self

  

             

Hidden Self 






           
 

Unknown Self

Fig. 11

13

BTM and ETM
Bridge/Engine Room Team Management

BTM and ETM have been introduced as methods to prevent maritime accidents fromoccurring by breaking the chain of human errors (error chain). This method seeks to
acknowledge that it is a) impossible not to generate human error, b) that the team unite
and work together so that one person’s mistake does not create a dangerous situation, c)that mistakes be noticed and corrected in a timely manner, and d) that everyone find away to support each other and break the error chain.
The concept of BTM and ETM is based on communication with the resources
surrounding the subject.（See Figure 12）

Fig. 12The person at the centre（: Person responsible for the accident）is surrounded bythose resources such as:（: Hardware ）, (and（

: Software）,（: Environment）,: Persons other than the person responsible for the accident）. Each resourceis always in a state of change. This situation can be shown in terms of quivering
rectangles.

14