JAPAN P& I CLUBCoastal vessels No. 4 March 2018

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

Coastal vessels
Prevention of damage
to harbour facilities andrelated cases

JAPAN P& I CLUBP&I Loss Prevention Bulletin
Contents§1

Introduction････････････････････････････････････････････････････････････････････ 1§2

P&I Insurance accident statistics:
Statistics of claims between 2008PY and 2016PY§２－１

Fluctuation of the number of accidents･ ･･････････････････････････････････････････････1§２－２

Fluctuation of insurance money････････････････････････････････････････････････････････4§２－３

P&I Insurance accident statistics:
Statistics of claims between 2008 PY and 2016 PY･･･････････････････････････････････8§3Damage statistics regarding harbour and fishery facilities§３－１

Trends concerning damage to harbour and fishery facilities causedby coastal and ocean going vessels･･･････････････････････････････････････････････････ 10§３－２

Statistics on the number of accidents by accident occurrence area in Japan ･････ 14§３－３ S tatistics on the number of accidents by accident occurrence month in Japan ･･････ 17

§4

§5

§３－４

Statistics on the number of accidents by damaged facility･･････････････････････････ 18§３－５

Statistics on the number of accidents by ship type･･････････････････････････････････ 23§３－６

Statistics on the number of accidents by size of ship (G/T)･････････････････････････ 25

Accidents regarding harbour and fishery facility causes§ ４－１

Statistics on accident causes ･････････････････････････････････････････････････････････ 28§ ４－２

Human Error Concept･･････････････････････････････････････････････････････････････････ 29§ ４－３

BTM (Bridge Team Management)/ETM (Engine Room Team Management)･･････････ 31

Case study§５－１

Case ① Quay contact･･････････････････････････････････････････････････････････････････ 34§５－１－１

Chain of events leading up to the accident･ ････････････････････････････････････ 35§５－１－２

Judgement and cause analysis by Marine Accident Tribunal････････････････････ 35§５－１－３

Analysis according to Human characteristics and Preventive Measures･･･････ 36§５－２Case ② Oyster raft accident that sustained damage･････････････････････････････････ 38§５－２－１

Chain of events leading up to the accident･････････････････････････････････････ 40§５－２－２ A nalysis by Japan Transport Safety Board and Marine Accident Tribunal
and Preventive Measures･････････････････････････････････････････････････････････ 41§５－２－３§５－３Analysis according to Human characteristics and Preventive Measures･･･････ 41

Case ③ Fair way buoy damage･････････････････････････････････････････････････････････ 43§５－３－１

Chain of events leading up to the accident･････････････････････････････････････ 45§５－３－２

Analysis by Japan Transport Safety Board and Marine Accident Tribunal
and Preventive Measures･････････････････････････････････････････････････････････ 46§５－３－３§6

Analysis according to Human characteristics and Preventive Measures･･･････ 47

Conclusion･･･････････････････････････････････････････････････････････････････････････････････ 49
References･･･････････････････････････････････････････････････････････････････････････････････････ 50

JAPAN P& I CLUB

§1

Introduction

In November 2013, a Loss & Prevention Seminar under the theme of “Prevention of damage to harbour facilities”
was held at the following five areas: Tokyo, Kobe, Imabari, Fukuoka and Saeki. Following these, Loss Prevention
Bulletins Vol. 31 and 32 covering these themes were issued.
This time, the outline of the Loss & Prevention Seminar “Prevention of damage to harbour facilities caused by coastal
vessels and related cases”, which was held from September to December in 2017, will be included.

§2

P&I Insurance accident statistics:

Claims in 2008PY to 2016PY Statistics

Note : Policy Year (PY) : the insurance period shall be one year from 20th February to the following 20th February§２－１
Number ofaccidents

350
300

Fluctuation of the number of accidents

Coastal vessels
328

9.1%

250

The number of insurance accidents and accident rate fluctuation

Number of damage reports regarding harbour and ﬁshery facilities：1,291

271

7.9%

8.4%

8.0%
224

203

10.6%

11.1%

9.7%

270

200
150

Accident rate %Total number of cases over last nine years：2,178

8.6%
210

10.0

8.8%
205

227

211

232

8.0
6.0

157

163
137

100

131

129

117

127

127
4.0
2.0

50
0

12.0

2008 PY

2009 PY
Crew

Graph 1

2010 PY

2011 PY

Cargo damage

2012 PY

2013 PY

Damage reports regarding
harbour and ﬁshery facilities

2014 PY

2015 PY

Others2016 PY

Accident rate

Coastal vessels The number of insurance accidents and accident rate fluctuation

－1－

0.0

JAPAN P& I CLUBP&I Loss Prevention Bulletin

By accident type

2008PY 2009PY 2010PY 2011PY 2012PY 2013PY 2014PY 2015PY 2016PY

Total

%

41
29

28
27

29
30

15
25

26
21

18
17

22
30

14
51

18
56

211
286

10%
13%

203

157

163

137

131

129

127

117

127

1,291

59%

1
11
14
2
27
55
328

1
12
22
5
19
59
271

2
13
10
3
20
48
270

2
7
12
5
21
47
224

0
7
11
1
13
32
210

1
4
9
2
25
41
205

3
8
8
4
9
32
211

2
10
9
3
21
45
227

1
2
9
3
16
31
232

13
74
104
28
171
390
2,178

1%
3%
5%
1%
8%
18%
100%

Number of entered vessels at the
beginning of the policy year

3,609

3,428

3,225

2,799

2,436

2,319

2,176

2,134

2,098

24,224

Accident rate (Number of accidents
divided by Number of entered vessels)

9.1

7.9

8.4

8.0

8.6

8.8

9.7

10.6

11.1

9.0

Crew
Cargo damage
Damage reports regarding harbour andfishery facilities
Other people except crew
OthersCollision
Oil spilt
Groundings, sinkings and fire
OthersOther · Subtotal
Total

Table 2The total number of P&I insurance accidents concerning coastal vessels reported between 2008PY to 2016PY was
2,178. Of this figure, the number of damage accidents to harbour facilities and fishery facilities were 1,291, which
occupied 59% of the total. Along with this, cargo damage accidents and crew injury / death related accidents accountfor approximately 80% of the total.
The number of accidents showed a tendency of decreasing at a peak of 328 cases in 2008PY, however, this number
has slightly increased following 2014PY.
Although this trend shows a decrease in the number of accidents, it is influenced by a decrease in the number ofentered ships. Thus, we compared this with an accident rate using a calculation that divides the number of accidents
by the number of entered vessels at the beginning of the policy year.
Although the accident rate was 8% in 2011PY, it has increased very slightly since then.
In 2016PY, the accident rate was 11.1%, which, on close examination, tells us that 11 out of 100 ships caused some P&I
accidents. We believe that urgent action should be taken to stop this increasing trend in order to decrease the call rate.
Number ofaccidents

4500
4000
3500
3000

Ocean going vessels

The number of insurance accidents and accident rate ﬂuctuation

3,848

Number of damage reports regarding harbour and ﬁshery facilities: 2,481 Cases

140.2%

3,751

130.9%

342

324

138.6%
328

Total number of cases over last nine years:：29,836 Cases

3,992
3,365

122.1%

121.1%

3,119

123.8%
3,096

283

2500

257

250

121.3%

123.1%

3,002

2,962

252

115.8%

120

2,701

100

239

80
60

1500

40

1000

20

500
0

160
140

248

2000

Accident
rate %

2008 PY

2009 PY
Crew

Graph 32010 PY
Cargo damage

2011 PY

2012 PY

2013 PY

Damage reports regarding
harbour and ﬁshery facilities

2014 PY
Others2015 PY

2016 PY

Accident rate

Ocean going vessels Number of accidents and accident rate fluctuation－2－

0

JAPAN P& I CLUBBy accident type

2008PY 2009PY 2010PY 2011PY 2012PY 2013PY 2014PY 2015PY 2016PY

Total

%

1,880

1,904

1,833

1,491

1,321

1,326

1,173

1,182

1,075

13,185

44%

1,135

1,078

1,321

1,161

1,157

1,201

1,248

1,193

989

10,48335%

Damage reports regarding harbour andfishery facilities

342

324

328

283

257

230

232

246

239

2,481

8%

Other people except crew

93

95

99

106

73

76

67

67

74

750

3%

Collision

72

60

64

45

32

32

42

32

42

421

1%

Oil spill

55

34

34

47

35

40

26

30

34

335

1%

Groundings, sinking and fire

18

9

12

19

7

11

10

11

11

108

1%

Others

253

247

301

213

237

180

204

201

237

2,073

7%

OthersCrew
Cargo damage

Other · Subtotal

491

445

510

430

384

339

349

341

398

3,687

12%

Total

3,848

3,751

3,992

3,365

3,119

3,096

3,002

2,962

2,701

29,836100%

Number of entered vessels at the
beginning of the policy year

2,745

2,866

2,880

2,757

2,576

2,500

2,475

2,406

2,333

23,538

Accident rate (Number of accidents divided
by Number of entered vessels × 100%)

140.2

130.9

138.6

122.1

121.1

123.8

121.3

123.1

115.8

126.8

Table 4

Ocean going vessels

Number of accidents and accident rate fluctuation

On the other hand, the total number of P&I accidents concerning ocean going vessels, which were reported between
2008PY to 2016PY, was 29,836. Of this figure, the number of damage accidents to harbour facilities and fisheryfacilities were 2,481, which occupied 8% of the total. The largest P&I accidents concerning ocean going vessels arecrew injury / death related accidents, which occupy 44% of the total (13,185 cases). Cargo damage accidents came
second place occupying 35% (10,483 cases) and in third place, damage accidents regarding harbour and fisheryfacilities occupying 8% of the total.
The differences between accident trends regarding coastal and ocean going vessels will vary depending on thecontents of the insurance contract. The cost of medical treatment etc. for crew injury related accidents on board
coastal vessels is covered by the seaman’s insurance. If you contracted with P&I insurance which covers a seaman’s
accident compensation, you will be liable for any costs not covered by the seaman’s insurance. Also, regarding coastal
vessels, because shipowner as a business practice was not compensated for loss as a result of cargo damage accidents
in the past, cargo related accidents concerning coastal vessels were not subject P&I insurance either. However, in
recent years, cargo owners or cargo insurance companies that have been claiming for cargo accidents due to mistakes
made by shipowners and crew have been increasing. In order to address this, there has been an increase in shipownersof coastal vessels also taking supplementary cargo related cover (Cargo Indemnity). In proportion to this, the numberof cargo damage accidents for coastal vessels reported to P&I has shown a tendency to increase.
For coastal vessels also, we considered the accident rate using a calculation that divides the number of accidents
of ocean going vessels by the number of entered vessels at the beginning of the policy year. Although there was adifference in the contents of insurance contract as described above, the accident rate was between 115.8% to 140.2%,
which, on close examination, tells us that there were between 116 to 140 cases per 100 ships.
It is not appropriate to simply make a comparison, as there is a difference concerning insurance contracts. In addition,for ocean going vessels, crew injury / death related accidents occupy nearly half of the total number of accidents.
However, comparing accident rates shows that the number of coastal vessel cases is only one tenth of that of ocean
going vessels.

－3－

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

Insurance money Fluctuation
Coastal vessels

Total amount:
JPY one million

Insurance money ﬂuctuation
Average insurance money:

Total insurance amount over last nine years: JPY 18,701 million

6000

JPY ten thousand

1800

1670

1600

5000

4,525

1400

1162

4000

3,138
3000

691

1200

1036

1000

744

2,266

557

544

2000

800

2,351

656

1,562

1,345

1,218

1,175

483

600

1,120

400

1000
0

200
2008 PY

2009 PY

2010 PY

2011 PY

2013 PY

2014 PY

Coastal vessels

2015 PY

0

2016 PY

Simple average insurance money(JPY ten thousand)Less than JPY ten million

More than JPY ten million

Graph 52012 PY

Insurance money fluctuation
Unit of insurance money: JPY one million

2008PY

2009PY

2010PY

2011PY

2012PY

2013PY

2014PY

2015PY

2016PY

Insurance money

Number of accidents

Insurance money

Number of accidents

Insurance money

Number of accidents

Insurance money

Number of accidents

Insurance money

Number of accidents

Insurance money

0

0

0

0

0

0

0

0

0

0

0

0

0

1

2,605 0% 14%

784

3

623

5 1,573 2

244

5

758

2

532

1

101

2 1,276 2468

27

6,359 1% 34%

More than JPY 50 million but
2less than JPY 100 million

118

2

138

9

265

2

148

3

243

3

236

4

0

29

2,127 1% 11%

662

4

316

0

Insurance money

Number of accidents

1 2,605 0

Number of accidents

Insurance money

Number of accidents

Number of accidents

Number of accidents

Insurance money

Insurance money
0

Insurance money

Number of accidents
More than JPY one billion 0
More than JPY 100 million but
5less than JPY one billion

％

Total

More than JPY ten million but
42 964 33
less than JPY 50 million

808 28 649 19 442 17 381 15 317 27 613 22 544 19 425

222 5,142 10% 27%

More than JPY five million but
20 145 19
less than JPY ten million

133

121

More than JPY one million but
80 191 65
less than JPY five million

167 60 144 49 108 54 131 59 139 50 114 54 122 48 103

Less than JPY one million 179
TOTAL

8

54

15 108 16 106 11

75

11

80

8

56

13

91

849

6%

5%

519 1,218 24% 7%

64 148 50 160 56 135 52 116 38 115 39 119 31 137 37 150 33 1,259 399 58% 2%

328 2,266 271 4,525 270 3,138 224 1,218 210 1,562 205 1,345 211 1,175 227 2,351 232 1,120 2,178 18,701 100% 100%

Table 6

Coastal vessels

Insurance money fluctuation－4－

JAPAN P& I CLUBRegarding insurance money for coastal vessels, the insurance money has largely fluctuated every Policy Year.
Compared to the number of accidents, it is conspicuous that there has been great change, recently. The total amount of
insurance money over the last nine years is JPY 18,701 million. Although the largest amount was recorded in 2009PY(JPY 4,525 million), 2016PY came to only a quarter of the 2009PY (JPY 1,120 million).
The reason as to why there is a significant difference according to each individual Policy Year is because insurancemoney was greater for the PY when large P&I insurance accidents occurred, and, on the contrary, when there wereno large P&I insurance accidents, the insurance money was small by comparison. Particularly, in 2009PY, only one
accident occurred but the insurance amount was JPY 2,605 million, which was 57% of the total insurance money of
the Policy Year (JPY 4,525 million). This came to 14% of the total insurance amount over the last nine years.
It is conspicuous that the ratio of insurance accident money comes to more than JPY ten million, which is significant,no matter which policy year it is.
The following two pie charts compare the total number of accidents and insurance money over the last nine years.
Coastalvessels
Coastalvessels

Coastalvessels
Coastalvessels

insurancemoney(numberof accidents
ratio)
ByBy
insurancemoney(numberof accidents
by byratio)

Bandof insurance
amountratio
Bandof insurance
amount
by by
ratio

Total
numberof cases
over
nine
years
: 2,178
Total
numberof casesoverlastlast
nine
years: 2,178

Total
insurance
amountovernine
years:
Total
insurance
amountoverlastlastnine
years:

Cases
279279
Cases
13％
13％

18,701
millionJPYJPY
18,701
million2,467
millionJPYJPY
2,467
million13%
13%

16,234
million
16,234
million
87%
87%

1899
1899
87％
87％

More
than
millionMorethan
JPYJPYtentenmillionMore
thanmillionMorethan
JPYJPYtentenmillionLess
thanmillionLess
than
JPYJPYtentenmillionLess
thanmillionLess
than
JPYJPYtentenmillionGraph 7
Coastal vessels

Graph 8

By insurance money (number of accidents by ratio)

Coastal vessels

Band of insurance amount by ratio

When it comes to the number of accidents, the insurance amount that was less than JPY ten million equated to 87% of
the total. However, as for insurance money that was less than JPY ten million, it only equated to 13%.
Whereas, the number of accidents that came to more than JPY ten million were 13%, however, as for the insurancemoney, it accounts for 87%. Thus, we learn that large accidents greatly influence the total loss record.

－5－

JAPAN P& I CLUBP&I Loss Prevention Bulletin
Ocean going vessels

Total amount:

Average insurance money:

JPY one million

JPY ten thousand

Total insurance amount over last nine years: JPY 117,386 million

25000

20,331
20000

15000

Insurance money ﬂuctuation

15,253
16,37015,512

700

657

600

13,400

453

500

430

410

10,264

403

400

346
10,162

10000

8,140

271

295

271

300

7,955

200
5000

0

100

2008 PY

2009 PY

2010 PY

2011 PY

More than JPY ten million

Graph 92012 PY

2013 PY

2014 PY

0

2016 PY

Simple average insurance money(JPY ten thousand)Less than JPY ten million

Ocean going vessels

2015 PY

Insurance money fluctuation
Unit of insurance money: JPY one million

2008 PY

2009 PY

2010 PY

2011 PY

2012 PY

2013 PY

2014 PY

2015 PY

2016 PY

Total%

Number of accidents

Insurance money

Number of accidents

Insurance money

Number of accidents

Insurance money

Number of accidents

Insurance money

Number of accidents

Insurance money

Number of accidents

Insurance money

Number of accidents

Insurance money

Number of accidents

Insurance money

Number of accidents

Insurance money

Number of accidents

Insurance money

Number of accidents

Insurance money

3

5,108

1

1,096

4

6,401

2

2,413

1

4,366

3

11,695

0

0

1

2,282

1

1,108

16

34,4680%29%More than JPY 100 million
14 3,472
but less than JPY one billion

92,787 10 3,302 20 6,687

9

3,158 12 2,687

7

1,645

4

2,109

7

2,288

92

28,136

0%

24%

750

11

763

14

990

13

906

10

682

110

7,787

1%

7%

More than JPY ten million
147 2,791 134 2,433 136 2,494 134 2,633 131 2,366 139 2,564 152 2,865 144 2,599
but less than JPY 50 million

89 1,721 1,206 22,468

4%

19%

More than JPY five million
147 1,043 177 1,239 147 1,036 172 1,249 146 1,090 130
but less than JPY ten million

98

674

1,250 8,953

4%

8%More than JPY one million
543 1,161 490 1,100 517 1,182 466 1,044 460 1,032 447 1,039 467 1,045 467 1,028 411
but less than JPY five million

880

4,268 9,512 14%8%805 2,930 757 3,162 791 2,563 631 2,361 625 2,353 613 2,227 622 2,235 619 2,085 601 22,894 6,062 77%

5%More than JPY one billion

More than JPY 50 million but
16less than JPY 100 million

Less than JPY one million 2,978
Total

1,131 10

16 1,165

8

596

12

803

930 135

973

98

721

3,848 15,512 3,751 10,162 3,992 16,370 3,365 15,253 3,119 13,400 3,096 20,331 3,002 8,140 2,962 10,264 2,701 7,954 29,836 117,386 100% 100%

Table 10

Ocean going vessels

Insurance money fluctuation－6－

JAPAN P& I CLUB

Although not as steep as coastal vessels, the insurance money for ocean going vessels also fluctuates every PY. The
amount JPY 20,332 million in 2013PY is prominent. However, of these three cases the insurance money of morethan JPY one billion in accidents among them was JPY 11,695 million, which occupied 57% of the total amount of
insurance money in 2013 PY.
As shown in the following charts which compare the number of accidents over the last nine years and the total of
insurance money, similar to coastal vessels, the number of accidents of more than JPY ten million came to 1,424 (5%of the total), however, as for the insurance money, it came to 79% of the total.
Ocean
Ocean going
going vessels
vessels
Ratio
Ratio ofof thethe number
number ofof accidents
accidents

Ocean
Ocean going
going vessels
vessels
Band
Band ofof insurance
insurance amountamount by
by ratio
ratio

Total
Total number
number ofof cases
cases over
over last
last nine
nine years:
years:

Total
Total insurance
insurance amountamount over
over last
last nine
nine years:
years:

29,836
29,836JPY
JPY 117,386
117,386 million
million

1,424
1,424 Cases
Cases
5％
5％

JPY
JPY 24,527
24,527 million
million
21%
21%

JPY
JPY 92,859
92,859 million
million28,412
28,412 Cases
Cases
95％
95％

79%
79%

More
More than
than JPY
JPY tenten million
millionMore
More than
than JPY
JPY tenten million
millionLess
Less than
than JPY
JPY tenten million
millionLess
Less than
than JPY
JPY tenten million
millionGraph 11
Ocean going vessels

Graph 12

Ratio of the number of accidents－7－

Ocean going vessels

Band of insurance amount by ratio

JAPAN P& I CLUBP&I Loss Prevention Bulletin§２－３ P&I Insurance accident statistics:
Statistics of claims between 2008 PY and 2016 PY
We evaluated the insurance accident statistics which were described above, by comparing the number of accidents andinsurance money by accident type and present them in the bar graph below.

Insurance money

Number of accidents

0%

20%

40%

60%

80%

100%
1%

10%

14%

59%

13%

42%

1%

3%

0% 12%

3%

5% 1%

24%

8%

4%

Crew

Cargo damage

Damage reports regarding harbour
and ﬁshery facilities

People except crew

Collision

Oil spill

Groundings, sinking and ﬁreOthersGraph 13

Coastal vessels

Accident classification

Number ofaccidents

The number of accidents and insurance money evaluation

Evaluation
Average insurance money
Insurance
per case (JPY)(JPY one million)
Number of accidents Insurance money

Crew

211

2,541

12,043,589

MediumLarge

Cargo damage

286

217

759,784

Fewer

Fewer

Damage reports regarding
harbour and fishery facilities

1,291

7,784

6,029,316

Greater

Large

Other people except crew

13

70

5,403,762

Fewer

MediumCollision

74

2,307

31,173,935

Fewer

Large

Oil spill

104

500

4,812,400

MediumMediumGroundings, sinking and fire

28

4,579

163,538,058

Fewer

Large

Others171702

4,103,671

Fewer

Small

Total

2,178

18,7018,586,201

Table 14

Coastal vessels

The number of accidents and insurance money evaluation

Regarding coastal vessels, loss records will be greatly improved if damage to harbour and fishery facilities can beprevented. Of course, it is important to reduce the number of large accidents such as collisions, groundings, sinkings
and fire. Regarding crew accidents, the insurance money per case by simple average is significant. This is thereason as to why most take out supplementary insurance to cover "seamen’s accident compensation" to cover in partcompensation of death accidents and residual disability that were not covered by the seamen’s insurance.
－8－

JAPAN P& I CLUB

0%

20%

40%

60%

80%

Number of accidents

1%

Insurance money

44%

25%

24%

2%

1%

8% 3%

35%

14%

100%

1%

13%

1%

7%

18%

3%

Crew

Cargo damage

Damage reports regarding harbour
and ﬁshery facilities

People except crew

Collision

Oil spill

Groundings, sinking and ﬁreOthersGraph 15

Ocean going vessels

Classification by accident

Number ofaccidents

The number of accidents and insurance money evaluation

Insurance (JPY
one million)

Average insurance money
per case (JPY)

Evaluation
Number of accidents

Insurance money

Crew

13,18529,1782,212,945

Greater

Fewer

Cargo damage

10,483

16,473

1,571,383

Greater

Fewer

Damage reports regarding
harbour and fishery facilities

2,481

27,805

11,207,095

Greater

Large

Other people except crew

750

1,982

2,642,474

Fewer

Small

Collision

421

15,55336,942,304

Fewer

Large

Oil spill

335

1,693

5,055,088

Fewer

MediumGroundings, sinking and fire108

21,049194,896,468

Fewer

Large

Others

2,073

3,654

1,762,564

Fewer

Small

Total

29,836

117,386

3,934,372

Table 16

Ocean going vessels

The number of accidents and insurance money evaluation

Because the insurance and supplementary content for ocean going vessels is different from those of coastal vessels,
we compared the number of accidents and the insurance money in a bar graph, similar to those of coastal vessels, andevaluated it as follows.
▶▶ It is a necessary to reduce them, because the number of crew accidents is significant. However, the simple
average of insurance money for one case is approximately one sixth of that of a coastal vessel.
▶▶ The simple average insurance money per damaged accident regarding harbour and fishery facilities is large
only after huge accidents such as collision, groundings, sinkings and fire. It is necessary to reduce this.

Naturally, the goal is for an accident never to occur, however, it is becoming evident that loss records will be greatly
improved if the number of accidents regarding harbour and fishery facilities are reduced for both coastal and ocean goingvessels.
－9－

JAPAN P& I CLUBP&I Loss Prevention Bulletin
Damage statistics regarding
harbour and fishery facilities

§3
§３－１

Trends concerning damage to harbour and fishery facilities
caused by coastal and ocean going vessels

Trends concerning all accidents in our Club were referred to in the previous chapter. Here, damage sustained byharbour and fishery facilities will be analysed.
Damage reports regarding harbour and ﬁshery facility Fluctuation in the number of accidents
600

Total Number of cases over last nine years

545

500

Coastal vessels: 1,291 cases

491

481

420
400

388

Coastal vessels

Ocean going vessels

359

257

230

232

246

137

131

129

127

117

127

2011 PY

2012 PY

2013 PY

2014 PY

2015 PY

2016 PY

328

324

283

200

203

100
0

2008 PY

Graph 17

157

163

2009 PY

2010 PY

Damage reports regarding harbour and ﬁshery facility insurance money ﬂuctuation

JPY one million

7000

Coastal vessels

Total Number of cases over last nine years

5,561

5,402

Coastal vessels:

JPY 7,784 million

Ocean going vessels:

5000

4,609

4000

4,365

3,418

3000

3,572

Sum total:

5,863

4,855

3,632

2,211

0

6,411

Ocean going vessels

6000

1000

239

Damage reports regarding harbour and fishery facility Fluctuation in the number of accidents

Total amount:

2000

366

359

363

342

300

Ocean going vessels: 2,481 cases

Sum total: 3,772 cases

1,424

1,984
1,037

2008 PY

2009 PY

2010 PY

JPY 35,589 million

2,508

2,477

1,968

1,851

2,044

1,222
989

JPY 27,805 million

733

548

706

620

540

626

2011 PY

2012 PY

2013 PY

2014 PY

2015 PY

2016 PY

Graph 18 Damage reports regarding harbour and fishery facility insurance money fluctuation－ 10 －JAPAN P& I CLUBThe total number of accidents over nine years concerning coastal and ocean going vessels was 3,772 cases: thenumber of accidents for ocean going vessels accounts for 2,481 cases, which is approximately double that of coastal
vessels. In addition, the total number of accidents for both coastal and ocean going vessels came to approximately 360
cases. This figure has remained constant since 2013PY.
On the other hand, insurance money greatly fluctuates depending on the scale of the accident. Further, accidents that
occurred on ocean going vessels accounted for approximately 3.6 times that of accidents that occurred on coastal vessels. 67 cases regarding large accidents of more than JPY 50 million occurred between 2009 PY to 2013 PY (coastal
vessels: 22 cases and ocean going vessels: 45 cases, average 13.4 cases per year). Meanwhile, the number of large
accidents after 2014 PY increased up to 20 cases (coastal vessels: 5 cases and ocean going vessels: 15 cases, average
6.7 cases per year). This is also shown in the simple average insurance amount per case.
JPY ten thousand
2500

2281

Damage report simple average (JPY ten thousand)per case regarding harbour and ﬁshery facilities
2111

2000

1500

1103
1000

Ocean going vessels

1217
1283

487
500

660

535

357
0

Graph 192008 PY

2010 PY774

2011 PY

547

488

462

493

418
2012 PY

2013 PY

2014 PY

2015 PY

1121

603

Coastal vessels
2016 PY

Average overnine years

Damage report simple average (JPY ten thousand) per case regarding harbour and fishery facilities

Unit：％

Damage reports regarding harbour and ﬁshery facilities
accident rate (Number of accidents divided by Number of entered vessels at the beginning of the policy year）

14
13

2009 PY

800

614

1042

12.5%

12
11

11.3%

11.4%

10

10.2%
10.3%

10.0%

9

9.2%

9.4%

5.6%

5.8%

10.2%

10.5%

Ocean going vessels

8
7
6

5.6%
4.6%

5
4

2008 PY

2009 PY

5.1%

4.9%

5.4%

5.5%

6.1%
5.3%
Coastal vessels

2010 PY

2011 PY

2012 PY

2013 PY

2014 PY

2015 PY

2016 PY

Average overnine years

Graph 20 Damage reports regarding harbour and fishery facilities
accident rate (Number of accidents divided by Number of entered vessels at the beginning of the policy year）－ 11 －JAPAN P& I CLUBP&I Loss Prevention Bulletin
Unit of insurance money: JPY one million

Ocean going vessels
Amount band (insurance)

Coastal vessels

Total

Number of accidents

Insurance money Number of accidents Insurance money Number of accidents Insurance money

Number ofaccidents%

Insurancemoney%

Number ofaccidents%

Insurancemoney%

Number ofaccidents%

Insurancemoney%

More than JPY one billion

5

0.2%

11,739 42.2%

0

0.0%

0

0.0%

5

0.1%

11,739 32.9%

More than JPY 100 million
but less than JPY one billion

27

1.1%

9,022

32.4%

13

1.0%

2,882

37.0%

40

1.1%

11,905 33.5%

More than JPY 50 million
but less than JPY 100 million

28

1.1%

1,992

7.2%

17

1.3%

1,275

16.4%

45

1.2%

3,267

9.2%

More than JPY ten million
but less than JPY 50 million

133

5.4%

2,727

9.8%

96

7.4%

1,961

25.2%

229

6.1%

4,688

13.2%

Large accident (More than JPY ten million) subtotal

193

7.8%

25,481 91.6%

126

9.8%

6,118

78.6%

319

8.5%

31,598 88.8%

More than JPY five million
but less than JPY ten million

121

4.8%

851

3.1%

82

6.4%

580

7.4%

203

5.4%

1,431

4.0%

More than JPY one million
but less than JPY five million

431

17.4%

1,005

3.6%

354

27.4%

825

10.6%

785

20.8%

1,830

5.1%

Less than JPY one million

1,736

70.0%

468

1.7%

729

56.5%

261

3.4%

2,465

65.3%

730

2.1%

2,288

92.2%

2,324

8.4%

1,165

90.2%

1,666

21.4%

3,453

91.5%

3,990

11.2%

Less than JPY ten million subtotal

Table 21

Total

2,481 100.0% 27,805 100.0% 1,291 100.0% 7,784 100.0% 3,772 100.0% 35,589 100.0%

Coastal vessels

Harbour and fishery facilities by insurance amount Number of accidents and ratio

Coastal vessels

Ocean going vessels

Band of insurance amount (ratio of the number of accidents)

Band of insurance amount (ratio of the number of accidents)

126 Cases
10％

193 Cases
8%

Total:
1,291 cases

Total:
2,481 cases
1,165 Cases

2,288 Cases

90％

92%

Large accident (More than JPY ten million)

Large accident (More than JPY ten million)

Less than JPY ten million

Less than JPY ten million

Graph 22Graph 23

Coastal vessels

Ocean going vessels

Band of insurance amount (ratio of insurance money)

Band of insurance amount (ratio of insurance money)
JPY 2,324 million
8%

JPY 1,666 million
21％

Total: JPY 27, 805 million

Total: JPY 7,784 million
JPY 6,118 million

JPY 25,481 million

79％

92%

Large accident (More than JPY ten million)

Large accident (More than JPY ten million)

Less than JPY ten million

Less than JPY ten million

Graph 24

Graph 25

－ 12 －JAPAN P& I CLUBIn addition, large accident claims accounted for more than JPY 10 million: 10% for coastal vessels and 8% for ocean
going vessels, however, when it comes to insurance money, it is 79% for coastal vessels and 92% for ocean goingvessels respectively, which means that large accidents make for worse loss records.
Meanwhile, looking at the accident rate which was divided by the number of accidents by the number of entered
vessels at the beginning of the policy year, it is possible to see that ocean going vessels is approximately double thatof coastal vessels.
Also, compared to the year when accident rates were at their lowest (coastal vessels: 2009PY(4.6%) and ocean goingvessels: 2013PY (9.2%)), it is notable that the accident rates for both coastal and ocean going vessels have been
increasing slightly since then.
Looking closely at the total number of accidents and insurance money over the past nine years by band of insurance
amount, the sum total number of accidents for coastal and ocean vessels was 319 cases, which occupied 8.5% of
the total. The insurance money was JPY 31,598 million (88.8% in total). Also, the number of accidents that came tomore than JPY one million were 45 cases, which occupied only 1.2% of the total, however, as for insurance money, it
accounts for JPY 23,644 million, which is 66.5% of the total.
Cases that claimed more than JPY 500 million will be introduced in the following.
In addition to damaging the quay, accidents involving damage to the on shore cargo work facilities and leakage of oil
will significantly increase the magnitude of the accident.

Cases that claimed more than JPY 500 million
Ocean-going container vessel

1

Ocean-going container vessel

2

Coastal tanker

3

Ocean-going container vessel

4

In April 2009, at the time of ship departure from a quay of Port Said in Egypt,when turning round with the assistance of two tug boats, she closed to thequay on her port side stern due to drifting caused by wind pressure. As she
made contact with a gantry crane which was consequently damaged, therepair fee and loss of time insurance for the gantry crane was claimed for. Thiswas caused by the pilot’s miss-maneuvering.
In December, 2009, at the time of departure on ballast condition from Osaka
Nanko, she was flown under during strong wind in the sea route after having
left the wharf while using two tug boats, and came into contact with abreakwater causing damage to it. Also, a broken hole was made in the shell
plating of the hull and approximately 0.8KL of fuel oil was spilt. Because spilt
oil appeared inside the tetrapod, it took two years to remove it. The cause
was the pilot’s miss-maneuvering.
In October 2010, during a berthing operation using two tug boats at the
petroleum station in Okinawa, ship posture control was lost and she madecontact with the mooring dolphin on her port side stern. A broken hole wasmade in the fuel tank and approximately 46KL of fuel oil was spilt. A huge
expense was incurred on the dolphin’s repair cost, fuel oil washing operation andfishery compensation. The cause was down to the Master’s miss-maneuvering.

In January, 2010, during the berthing operation at Tokyo Oi Container Terminal
using one tug boat, it made contact with a gantry crane due to excessive
speed. Crane repair and inactivity incurred a huge cost. This was caused by
the pilot’s miss-maneuvering.

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

Most damage to harbour facilities is caused by miss-maneuvering by the ship commander such as the Master or pilot.
Particularly, the risk increases in the event of sudden weather change at the time of leaving the wharf and duringberthing operation. It will be difficult to ensure that the number of damaged accidents be zero, however, through
BTM, it will be possible to reduce the amount of damage caused to harbour facilities. For example, after a pilot
comes on board at both the time of entering and departing port, to not rely solely on his maneuvering, but to have abriefing regarding the ship maneuvering procedure with the Master and exchange necessary information with eachother. Further, when it comes to coastal vessels where the pilot is not required to board, it should be seen to it that solemaneuvering is not carried out by the Master, but that his intentions of ship maneuvering are shared with the othercrew on the bridge, fore/after stations and the Chief engineer.
In addition, ship bottom contact accidents have occurred frequently because of a lack of investigation concerning
harbour facilities in advance. Needless to say, it is important to regularly check harbour facilities in advance, even if
the vessel has been navigating the line frequently.

§３－２ Statistics on the number of accidents
by accident occurrence area in Japan
Accidents regarding harbour and fishery facilities in Japan were compiled by accident occurrence area.
Coastal vessels Number of accidents according to accident occurrence area
Seto Inland Sea

325

Tokyo Bay

266

The Paciﬁc Coast

175

Kyushu150

Osaka Bay125

Ise Bay102

Hokkaido

62

Japan Sea

40

Kanmon Straits

40

Okinawa

Total: 1,291 cases

60Graph 2650

100

Coastal vessels

150

200

250

300

350

(number of accidents according to accident occurrence area)

Ocean going vessels Number of accidents according to accident occurrence area in Japan
Seto Inland Sea

170

Tokyo Bay110

Osaka Bay

93

Ise Bay81

The Paciﬁc Coast

79

Kyushu62

Kanmon Straits

28

Hokkaido

28

Japan Sea
Okinawa

40Graph 27

Total: 674 cases

1930

Ocean going vessels

60

90

120

150

180

(number of accidents according to accident occurrence area in Japan)－ 14 －JAPAN P& I CLUBCoastal vessels

Ratio and Number of accidents
according to accident occurrence area

Kanmon Straits 40 Cases
Japan Sea 40 Cases

Hokkaido 62 Cases
Ise Bay
102 Cases
Osaka Bay125 Cases

Kyushu150 Cases

5%

Ocean going vessels

Japan Sea 19 Cases

Okinawa 6 Cases

3% 3% 0%8%

Hokkaido 28 Cases

Kanmon Straits
28 Cases

Seto Inland Sea
325 Cases

25%

Ratio and Number of accidents
according to accident occurrence area in Japan

Kyushu62 Cases

4%

4%

Okinawa 4 Cases
3% 1%

25%

9%

10%

12%

12%

21%

13%

The Paciﬁc Coast
79 Cases

Tokyo Bay
266 Cases

16%
14%

12%

Ise Bay 81 Cases

The Paciﬁc Coast 175 Cases

Seto Inland Sea
170 Cases

Tokyo Bay110 Cases

Osaka Bay93 Cases

Graph 28Graph 29

For a more accurate analysis, it was necessary to compare the number of entered and departed ports of our Club’s
members’ ships by area over the past nine years, using the number of entered and departed ports by region, andcomparing this with the accident occurrence rate as a denominator. However, unfortunately, because data of such
numbers of entered and departed ports was not available, we only compared this with the number of accidents.
It should only be natural to imagine that a large number of accidents occur at Tokyo Bay, Ise Bay and Osaka Bay
where main ports are concentrated, and Inland sea where both coastal and ocean going vessels frequent. Coastal andocean going vessels account for about 70% of accidents in these top four areas. However, both coastal and ocean
going vessels that continue to use these major ports, continue to experience accidents at Pacific Ocean coastal ports,
also. (Coastal vessels occupy third place and ocean going vessels occupy fifth place)
As a matter of fact, the number of accidents by country for ocean going vessels is shown in the pie chart below. The
number of accidents that occurred in Japan occupied 27% of the total number of accidents.
Ocean going vessels (accident and ratio occurrence by country)
Total: 2,481 cases
Other 102 countries

823 Cases

VietnamEgypt

33%

49 Cases

49 CasesBrazil57 Cases

U.K.

66 Cases

India

Graph 30

2%
2%
2%

Japan

27%

674 Cases

9%
3%

3%

63 Cases
Australia 80 Cases

Ocean going vessels

3%

3%

6%

7%

China 235 Cases

South Korea 162 Cases

U.S. 139 Cases

Belgium 84 Cases(accident and ratio occurrence by country)－ 15 －JAPAN P& I CLUBP&I Loss Prevention Bulletin
Coastal vessels (number of accidents according to the port where the accident occurred)

100
90
80

Total: 1,291 cases

795

87
80

70

72

60
50

51

40

39

30

38

35

34

32

20

28

10
0

Chiba

Graph 31

Osaka

Yokohama

Coastal vessels

Nagoya Mizushima Kanmon Strait Kawasaki

Kobe

Tokyo

Tomakomai

Others(number of accidents according to the port where the accident occurred)

Ocean going vessels (number of accidents according to the port where the accident occurred)
100

Total: 674 cases

90

335

80
70
60
50

55

51

40

47
40

30

32

20

27

25

24

20

10
0

NagoyaGraph 32

Kobe

Chiba

Ocean going vessels

Osaka

Mizushima Kanmon Strait Yokohama Fukuyama Kawasaki

18

Kashima

Others(number of accidents according to the port where the accident occurred)

Moreover, we summarised the number of accidents by port.
A large number of accidents occurred at main ports for both types of vessels. One of the causes among the main portsof Nagoya, Osaka and Kobe and Chiba appears to be down to their similar quay structure.

－ 16 －JAPAN P& I CLUBPort of Chiba

Ports of Osaka and Kobe

Slit

PCC BerthPort of Nagoya

Fig. 33

Picture of Slits

Regarding the way that these ports are configured, there are a large number of slit type quays where larger vessels arealso to dock, which presumably could be causing the accidents. At the port of Nagoya, there are a large number ofPure Car Carriers (PCC) entering the port and the accident rate for this type of ship, which will be mentioned below, ishigh. Moreover, the frequency of docking on this slit type quay adds to increase the risk of accidents occurring.

§３－３ Statistics on the number of accidents
by accident occurrence month in Japan
There is the tendency that the number of accidents at the end of the year, beginning of the new year and at the beginning of the Japanese fiscal year (April) is larger for coastal and ocean going vessels, compared with other months
throughout a year. Regarding ocean going vessels, there were no trends like this in other countries but Japan. Thus,
this is characteristic of harbour and fishery facility accidents in Japan.
So as to eliminate such accidents, it will be necessary to remind vessels of these time periods.

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

Cases

160

Total Number of cases over last nine years

Coastal vessels: 1,291

140

Ocean going vessels: 674

Inland Japan Number of accidents
by month of occurrence (2008-2016 PY)

Sum total: 1,965

Coastal vessels

120

Ocean going vessels

100
80
60
40
20
0

January February

March

April

May

June

July

August September OctoberNovember

DecemberCoastalvessels

114

104

106

116

110

99

102

101

92

102

108

137

Ocean
going
vessels

63

59

44

63

59

57

52

59

59

49

41

69

Graph 34

Inland Japan

Number of accidents by month of occurrence (2008-2016 PY)§３－４ Statistics on the number of accidents by damaged facility
Coastal vessels

Cases

250

5.6
203

200

5.1
4.6
157

5.4
4.9

45

38

19

77

2008 PY
Quay

Graph 35

131

129

19

66

71

69

2009 PY

2010 PY

2011 PY

127

16

14

70

50
2012 PY

Facility and structure located on quay

Coastal vessels

6

%

5
4

18

50

5.5

6.1

Accident rate

137

100

5.8

5.6

163

150

0

Fluctuation of the number of accidents (by damaged facility)

2013 PY

Fender62
2014 PY
Buoy

117

34

117

49

3
2
1

43

39

2015 PY

2016 PY

Others0

Fishery facility

Harbour and fishery facilities Fluctuation of the number of accidents (by damaged facility)－ 18 －JAPAN P& I CLUB2008 PY 2009 PY 2010 PY 2011 PY 2012 PY 2013 PY 2014 PY 2015 PY 2016 PY

Total

%

Quay

77

66

71

69

50

70

62

43

39

547

42%

Facility and structure located on quay

45

38

19

19

18

16

14

34

49

252

20%

Fender

13

13

16

14

15

9

4

15

16

115

9%

Buoy

30

11

22

6

12

6

6

7

7

107

8%

Others

10

9

9

9

11

6

9

3

2

68

5%

Fishery facility

28

20

26

20

25

22

32

15

14

202

16%

203

157

163

137

131

129

127

117

127

1,291

100%

Number of entered vessels at the
beginning of the policy year

3,609

3,428

3,225

2,799

2,436

2,319

2,176

2,134

2,091

24,217

Accident rate (Number of accidents divided
by Number of entered vessels ×100%)

5.6

4.6

5.1

4.9

5.4

5.6

5.8

5.5

6.1

5.3

Total

Table 36

Coastal vessels

Fluctuation of the number of accidents (by damaged facility)

Coastal vessels
Ratio of the number of accidents (damaged facility)

Fishery facility

202

Others

68

Buoy

107

Fender115

Total: 1,291 cases

16%
5%

42%

8%

9%

Quay 547

20%
Facility and structure located on quay 252

Graph 37 Coastal vessels

Ratio of the number of accidents (damaged facility)

Examining the number of accidents of coastal vessels by damaged facility, the sum total of quay damage accidents(42%) and structure damage accidents including quay facilities (20%) occupy more than half of the total number ofaccidents.

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

Unit: JPY one million

Coastal vessels
Insurance money ﬂuctuation (by damaged facility)

2200
1,984

2000
1800
1600
1400
1200

1,037

989

1000
800

733

706

620

548

600

626

540

400
200
0

2008 PY

2009 PY

2010 PY

2011 PY

2012 PY

Facility and structure located on quay

Quay

Graph 38

Coastal vessels

2013 PY

Fender2014 PY

2015 PY

OthersBuoy

2016 PY
Fishery facility

Insurance money fluctuation (by damaged facility)
Unit of insurance money: JPY one million

2008 PY 2009 PY 2010 PY 2011 PY 2012 PY 2013 PY 2014 PY 2015 PY 2016 PY Total

%

Quay

482

316

677

383

222

250

278

249

343

3,200

41%

Facility and structure located on quay

126

534

980

56

34

193

74

128

95

2,220

28%

Fender

34

34

33

32

30

11

6

24

83

289

4%

Buoy

235

24

73

60

45

72

23

60

16

608

8%

Others

8

8

9

80

7

3

16

9

0

141

2%

Fishery facility

104

121

211

122

210

176

223

70

89

1,326

17%

Total

989

1,037

1,984

733

548

706

620

540

626

7,784 100%

Accident rate

13%

13%

26%

9%

7%

9%

8%

7%

8%

100%

Table 39

Coastal vessels

Fishery facility
1326

141

Buoy
608

Fender289

Graph 40

Coastal vessels
Insurance money ratio
by damaged facility

17%

OthersInsurance money fluctuation (by damaged facility)

Unit: JPY one million

2%

41%

8%
4%

28%

Coastal vessels

Quay
3,200
Facility andstructure locatedon quay
2,220

Insurance money ratio (by damaged facility)－ 20 －On the other hand, regarding insurancemoney, 2010 PY is prominent comparedto other insurance years due to one large
accident (929 million yen: 47% of 2010
PY overall) that occurred.
Also, regarding damaged facilities,
insurance money regarding quay damage, quay facilities and structure damage
occupy 70% of the total.

JAPAN P& I CLUB

Cases

450

Ocean going vessels
Fluctuation of the number of accidents
by damaged facility

12.5%

400

11.4%

324

328

10.3%

342

350

11.3%

300

Accident Rate

10.0%

9.4%

9.2%

257
232

230

10.2%

10.2%

246

239

10
9
8
7
6

200

5

150

4

209

100

196

180

160

2008 PY

2009 PY

2010 PY

2011 PY

Graph 41

Ocean going vessels

1322012 PY

Facility and structure located on quay

Quay

3

132

50
0

12
11

283

250

%
13

122

2013 PY
Fender2014 PY

69

2015 PY

2016 PY

Others

Buoy

2

76

1
0

Fishery facility

Fluctuation of the number of accidents (by damaged facility)

Unit of insurance money: JPY one million

2008 PY 2009 PY 2010 PY 2011 PY 2012 PY 2013 PY 2014 PY 2015 PY 2016 PY

Total

%

Quay

209

180

196

160

132

132

122

76

69

1,276

51%

Facility and structure located on quay

17

25

20

15

22

20

18

59

76

272

11%

Fender

53

61

60

63

50

45

48

65

52

497

20%

Buoy

20

19

23

23

16

12

17

18

12

160

6%

Others

2

2

1

3

2

1

1

0

0

12

1%

Fishery facility

41

37

28

19

35

20

26

28

30

264

11%
100%

342

324

328

283

257

230

232

246

239

2,481

Number of entered vessels at the
beginning of the policy year

2,745

2,866

2,880

2,757

2,576

2,500

2,475

2,406

2,333

23,538

Accident rate (Number of accidents divided
by number of entered vessels ×100%)

12.5

11.3

11.4

10.3

10.0

9.2

9.4

10.2

10.2

10.5

Total

Table 42
Fishery facility 264
Others 12
Buoy
160

1%
6%

Ocean going vessels

Ocean going vessels
Damaged facility
Ratio of number ofaccidents by facility

11%

51%
Fender
497

20%

11%

Fluctuation of the number of accidents (by damaged facility)

Unit: JPY one million

Quay
1,276

Facility andstructure locatedon quay272

Graph 43 Ocean going vessels Damage facility Ratio of number of accidents (by facility)－ 21 －

Similar to coastal vessels, regarding thenumber of accidents by damaged facility
in ocean going vessels including accidents
that occurred outside of Japan also, the sum
total of quay damaged accidents (51%) andstructure damage accidents including quay
facilities (11%) occupy more than half of thetotal number of accidents. However, fenderdamage accidents account for a large percentage (20%) which is different to that of coastal
vessels.

JAPAN P& I CLUBP&I Loss Prevention Bulletin

Regarding fender damage accidents, it includes fender accidents which occur as a result of wear and tear. It is notfair to include all of these causes with vessel miss-maneuvering. Especially, if the aged fender is damaged at a public
quay, then renewal by repair may be all that is needed. This kind of work is troublesome.
Ocean going vessels
Insurance money ﬂuctuation
by damaged facility

5,863

6000

4,855

5000

Unit: JPY one million

4000

3,572

3,632

3,418

3000
1,968

2000

1,851

1,424

1,222
1000
0

2008 PY

2009 PY

2010 PY

2011 PY

2012 PY

Facility and structure located on quay

Quay

Graph 44

Ocean going vessels

2013 PY

Fender2014 PY

2015 PY

2016 PY

OthersBuoy

Fishery facility

Insurance money fluctuation (by damaged facility)

2008 PY 2009 PY 2010 PY 2011 PY 2012 PY 2013 PY 2014 PY 2015 PY 2016 PY

Total

%

Quay

692

2,686

3,004

3,219

5,444

4,464

961

285

179

20,93475%

Facility and structure located on quay

95

114

70

98

92

35

132

1,045

1,160

2,840

10%

Fender

59

633

83

223

73

184

123

533

95

2,007

7%

Buoy

151

44

102

59

40

47

101

62

326

933

3%

Others

1

0

0

3

1

1

0

0

0

5

1%

Fishery facility

224

95

159

29

213

124

107

44

91

1,086

4%

Total

1,222

3,572

3,418

3,632

5,863

4,855

1,424

1,968

1,851

27,805

100%

%

4%

13%

12%

13%

21%

17%

5%

7%

7%

100%

Table 45 Ocean going vessel

Insurance money fluctuation (by damaged facility)

Ocean going vessels
Insurance money ratio
By damaged facility

Fishery facility 1,086
Others5

Buoy 933
Fender 2,007

7%

0% 4%

Unit: JPY one million

10%

75%

Facility andstructure locatedon quay

Quay
20,9342,840

Graph 46

Graph 46

Ocean going vessels

Insurance money ratio (by damaged facility)－ 22 －JAPAN P& I CLUB

§３－５

Statistics on the number of accidents by ship type
Coastal vessels By type of ship Accident rate
（Number of accidents ÷ number of entered vessels at the beginning of the policy year）

30%

25%

RO/RO・PCC
21.72%

20%

15%

Passenger ship
and ferry

10.11%

10%

General cargo ship
8.5%

Overall
5.33%

Tanker5%

2.95%

Tugboat

3.29%

Others0%1.56%

2008 PY

2009 PY

2010 PY

2011 PY

2012 PY

2013 PY

2014 PY

2015 PY

2016 PY

Average overnine years

Graph 47 Coastal vessels
By type of ship
accident rate（Number of accidents ÷ number of entered vessels at the beginning of the policy year）

Looking closely at the accidents regarding harbour and fishery facilities of coastal vessels by ship type along withaccident rate, the following characteristics are found.
• The accident rate for all ship types over the last nine years is 5.33% and, as for simple average, one out of twenty
vessels caused an accident.
• However, ship types above this average value are Ro-Ro ships, passenger ships and general cargo ships. In
particular, the accident rate of Ro-Ro ships is four times that of the mean value.

－ 23 －JAPAN P& I CLUBP&I Loss Prevention Bulletin
Ocean Going vessels Accident rate (by type of ship)（Number of accidents ÷ number of entered vessels at the beginning of the policy year）

40

％

35

30

25

RO/RO・PCC
24.29%
Ferry andpassenger ship20

12.94%
Generalcargo ship

12.12%Overall

15

10.54%

Tanker
9.79%

Container

10

8.90%

Bulker
8.06%

5

Others4.88%

02008 PY

2009 PY

2010 PY

2011 PY

2012 PY

2013 PY

2014 PY

2015 PY

2016 PY

Average overnine years

Graph 48 Ocean going vessels
By type of ship
accident rate（Number of accidents ÷ number of entered vessels at the beginning of the policy year）

On the other hand, the total accident rate for ocean going vessels is 10.54% over an average of nine years. The shiptypes above this average value are, similar to those of coastal vessels, Ro-Ro ships and PCCs, which are prominent at
2.3 times (24.29%) that of the mean value.
There is a trend that general cargo ships, ferries and passenger ships are higher than the average value, however, thedifference is not so dramatic when compared to coastal vessels.

－ 24 －JAPAN P& I CLUB＝ Reason as to why accident rates for PCCs and Ro-Ro ships are higher than other ship types ＝R ＝ 1/2（LーPB）× sin1°

The wind pressure area of PCCs and Ro-Ro ships
is larger than other ships of the same length (lengthof hull), which require maneuvering with caution.
Above all, they tend to be affected by the wind at
the time of leaving the wharf and docking.

R ＝ 1/2（LーPB）× sin1°
Ｌ
PB

Also, the ship’s hull construction is, as shown in
Fig. 49, the Parallel Body (PB: the part contacting
to quay) and it is short. And, if the mooring lines
at fore and aft station were not rolled up evenly,
the fore and aft parts may run aground on thequay (Over Hang) if the PB part loses balance
during docking at this point. Consequently, it cancause damage to the edge of the quay, mooring
bit, car stopper etc. According to the ship’s hullconstruction shown below in Fig. 49-2, we cansee that Over Hung (R) is approximately 1 m 38
cm. This was caused by shifting towards the quayby only one degree.

Ｒ

L＝ 210m

PB＝ 52m

Fig. 49-1

R ＝ 1/2（LーPB）× sin1°≒1.3ｍ
Ｌ
PB

Ｒ

L＝ 210m

PB＝ 52m

Fig. 49-2

In the event that this part isover hung on the quay,

this causes damage to the quayedge, car stopper, bit and hull.

Fig. 49-3§３－６ Statistics on the number of accidents by size of ship (G/T)
Accidents regarding harbour and fishery facilities of coastal vessels were compared according to the insurance
amount.
Because most entered coastal vessels are mainly less than 1,000 G/T, this size of ship occupies the largest number ofaccidents. Ideally, we should have carried out a more detailed evaluation, by comparing the accident rate that indicatesas to how many times each vessel entered and departed the port and how many damaged accidents were caused oneach occasion. Also, it is unfortunate that only the comparison of number of accidents and insurance money weremainly discussed in this section, and that there was a lack of data regarding numbers of those entering / leaving ports,
similar to “§3-2 Statistics on the number of accidents by accident occurrence area in Japan”－ 25 －JAPAN P& I CLUBP&I Loss Prevention Bulletin
Unit of insurance money : JPY one million

Amount band (insurance)

More than 3,000 tons but More than 1,000 tons More than 500 tons but
Less than 500 tons
More than 10,000 tons
less than 10,000 tons but less than 3,000 tons less than 1,000 tons

Total

Number ofaccidents

Insurancemoney

Number ofaccidents

Insurancemoney

Number ofaccidents

Insurancemoney

Number ofaccidents

Insurancemoney

Number ofaccidents

Insurancemoney

Number ofaccidents

Insurance
money

1

929

1

101

1

154

2

409

8

1,288

13

2,882

1

94

0

0

3

251

3

211

10

719

17

1,275

6

100

10

219

7

162

17

383

56

1,097

96

1,961

More than JPY ten million

8

1,123

11

320

11

568

22

1,003

74

3,104

126

6,118

% of total amount

1%

14%

1%

4%

1%

7%

2%

13%

6%

40%

10%

79%

4

28

13

102

7

46

8

59

50

344

82

580

16

45

48

108

35

85

53

128

202

459

354

825

Less than JPY one million

40

14

101

34

62

24

90

33

436

156

729

261

Less than JPY ten million

60

87

162

245

104

156

151

220

688

959

1,165

1,666

Ratio of total amount

3%

0%

8%

0%

5%

0%

7%

0%

34%

2%

56%

3%

Total

68

1,211

173

565

115

723

173

1,223

762

4,062

1,291

7,784

Ratio of total amount

6%

16%

13%

7%

9%

9%

13%

16%

59%

52%

100%

100%

More than JPY 100 million
but less than JPY one billion
More than JPY 50 million
but less than JPY 100 million
More than JPY ten million
but less than JPY 50 million

More than JPY five million
but less than JPY ten million
More than JPY one million
but less than JPY five million

Table 50

Coastal vessels

By band of insurance amount and G/T Number of accidents and insurance money

Coastal vessels
30

Accident rate by G/T（Number of accidents ÷ Number of entered vessels at the beginning of the policy year）

%

25

20

More than 10,000 tons
13.99%

More than 3,000 tons but
less than 10,000 tons
8.89%

15

More than 500 tons but
less than 1,000 tons

10

6.76%

More than 1,000 tons but
less than 3,000 tons
5.88%

5

Overall
5.33%
Less than 500 tons

0

4.41%

2008 PY

2009 PY

2010 PY

2011 PY

2012 PY

Graph 51

2013 PY

Coastal vessels

2014 PY

2015 PY

over2016 PY Averagenine years

Accident rate by G/TWhen comparing this with accident rate and the number of entered vessels denominator at the beginning of the policy
year, coastal vessels of more than 10,000 G/T greatly fluctuated every Policy Year. And, we can understand that there
is a tendency for the accident rate to be higher than for ships less than 10,000 G/T over a nine year average.

－ 26 －JAPAN P& I CLUB

Unit of insurance money : JPY one million
More than 30,000
tons but less than
50,000 tons

More than
50,000 tons

Amount band (insurance)

More than 10,000
tons but less than
30,000 tons

More than 5,000
tons but less than
10,000 tons

More than 1,000
tons but less than
5,000 tons

Less than
1,000 tons

TOTAL

Number of Insurance Number of Insurance Number of Insurance Number of Insurance Number of Insurance Number of Insurance Number ofaccidents
money
accidents
money
accidents
money
accidents
money
accidents
money
accidents
money
accidents

More than JPY one billion
More than JPY 100 million
but less than JPY one billion
More than JPY 50 million
but less than JPY 100 million
More than JPY ten million
but less than JPY 50 million

3

9,435

1

1,096

1

1,207

6

1,648

5

2,356

8

3,197

6

1,430

2

4

317

3

190

9

653

8

566

20

398

37

682

27

589

Insurancemoney

5

11,739

392

27

9,022

4

267

28

1,992

27

536

11

133

2,727

21

511

More than JPY ten million

34

11,911

29

4,040

55

5,738

41

2,585

33

1,196

1

11

193

25,481% of total amount

1%

43%

1%

15%

2%

21%

2%

9%

1%

4%

0%

0%

8%

92%

17

128

23

164

29

208

23

161

25

167

4

24

121

851

73

168

77

179

110

264

84

193

74

170

13

30

431

1,005

More than JPY five million
but less than JPY ten million
More than JPY one million
but less than JPY five million

1Less than JPY one million

365

85

364

95

495

136

303

88

189

57

20

7

1,736

468

Less than JPY ten million

455

382

464

439

634

607

410

442

288

394

37

61

2,288

2,324

% of total amount

18%

1%

19%

2%

26%

2%

17%

2%

12%

1%

1%

0%

92%

8%

Total

489

12,293

493

4,478

689

6,346

451

3,027

321

1,590

38

72

2,481

27,805% of total amount

20%

44%

20%

16%

28%

23%

18%

11%

13%

6%

1%

0%

100%

100%

Table 52
20

Ocean going vessels

Number of accidents and insurance money (by band of insurance amount and G/T)%

Ocean going vessels

Accident rate by G/T Fluctuation（Number of accidents ÷ Number of entered vessels at the beginning of the policy year）
More than 5,000 tons but
less than 10,000 tons
12.95%

15

More than 1,000 tons but
less than 5,000 tons
12.05%
More than 10,000 tons but
less than 30,000 tons
10.90%

10

Overall

10.54%

More than 50,000 tons
9.46%

More than 30,000 tons but
less than 50,000 tons
9.14%

5

Less than 1,000 tons
7.47%

0

2008 PY

2009 PY

2010 PY

2011 PY

2012 PY

2013 PY

2014 PY

2015 PY

over2016 PY Averagenine years

Graph 53 Graph 53 Ocean going vessels Accident rate by G/T Fluctuation（Number of accidents ÷ Number of entered vessels at the beginning of the policy year）

Meanwhile, on examining ocean going vessels, it was revealed that large accidents of more than JPY 10 million of
insurance money were concentrated on vessels of more than 10,000 G/T. Statistically, even if it makes contact with aquay at the same speed, a large ship will sustain huge damage.
On the other hand, regarding the accident rate of vessels that are more than 1,000 G/T but less than 10,000 G/T it isgreater because these vessels are larger than other large vessels. Though there is this kind of tendency, details into thecauses remain unknown.
－ 27 －JAPAN P& I CLUBP&I Loss Prevention Bulletin§4

Accidents regarding harbour andfishery facilities Causes§ ４－１

Accident Cause
Classification

Ocean goingvessels

Coastalvessels

Sum total%

Mooring winch trouble

11

5

16

1.2%

Onshore equipment trouble

16

16

1.2%

Cause

Equipment trouble

Human factor

Statistics on accident causes

Other ship's equipment trouble

8

6

14

1.0%

Equipment trouble during cargo handling

12

1

13

0.9%

Main engine and generator trouble

9

3

12

0.9%

Hatch cover trouble

1

1

0.1%

Other equipment trouble

2

2

0.1%

Equipment trouble subtotal

59

15

74

5.3%

Miss-maneuvering by ship

394

459

853

61.4%

Miss-maneuvering by pilot

106

1

107

7.7%

Other human-induced mistakes

38

53

91

6.5%

Insufficient lookout

12

26

38

2.7%

Miss-maneuvering of tug boat

29

29

2.1%

Miss-maneuvering by other ships

25

25

1.8%

Mistake by workers on shore

29

29

2.1%

1

0.1%

1

0.1%

Falling asleep

Weather and sea
conditions

1

Lack of knowledge and information

1

Human factor subtotal

634

540

1,174

84.5%

Weather and sea conditions

98

44

142

10.2%

791

599

1,390

100.0%

Sum total
Table 54

Equipment trouble
Weather andsea conditions

Statistics on accident causes

Ratio by accident cause
74 Cases5％

142 Cases
10％

Human factor
1,174 cases
85％

Graph 55

Total: 1,390 cases

Ratio by accident cause－ 28 －JAPAN P& I CLUBWe analysed 1,390 cases where the causes of the accidents could be investigated. Consequently, human factor causes(human error) came to 84% (1,174 cases) of the total number of cases. In the figure, miss-maneuvering by crew onboard (including Master) and the pilot occupies 69.1%.
Also, on analysing the accident report, 10% (142 cases) of the total number of accidents were caused by unforeseensquall and tidal streams. These are mainly caused by a lack of weather chart checking and weather information, and alack of thorough investigation concerning tidal stream information.
Because we are experienced crew and pilots, it is possible for us to be prepared if we are privy to such information,and can predict squalls with weather lore. Thus it follows that these accidents caused by weather and sea conditions
can also be regarded as human error.
Moreover, although equipment trouble (e.g. main engine stoppage and black out, etc.) induced accidents, these devices
are also maintained by humans. Thus, causes of damage to harbour and fishery facilities can be said to be 100% down
to human error.

Causes of damage to harbour and fishery facilities can be said

Human factor (Human error)

１００％
§ ４－２

Human Error Concept

Please refer to the details which were introduced in our Loss Prevention Bulletin Vol.35 “Thinking Safety”

Twelve human characteristics❶ Human beings sometimes make mistakes❷ Human beings are sometimes careless❸ Human beings sometimes forget❹ Human beings sometimes do not notice❺ Human beings have moments of inattention❻ H uman beings are sometimes only able tosee or think about one thing at a time
Table 56

❼ Human beings are sometimes in a hurry❽ Human beings sometimes become emotional❾ Human beings sometimes make assumptions
 Human beings are sometimes lazy
 Human beings sometimes panic H uman beings sometimes transgress when
no one is looking

Twelve human characteristics－ 29 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

Human Characteristics : Information Processing in case of taking action

Human Characteristics

Past Experience

Result of Training

・ Information Processing
Large amount ofInformation obtained
from external Sources

Table 57

Evaluate which
information to use

Take Action

Human Characteristics : Information Processing in case of taking action

Table 56 shows the 12 Human characteristics which may cause human errors. Everyone has these characteristics.
Table 57 shows how people behave when they act.
In other words, human beings process a large amount of information using the five senses and take action dependingon what information they believe should be used. In addition, because taking new action requires additional new
information, the cycle repeats.
When considering how to use the information, you look back at the outcome of past experience and training. For
example, in the event of attempting to walk on a rough road, we are careful so as not to fall over. Why are wecautious? One reason is that this comes from our common experience of feeling pain when we fell over and grazed
our knees when we were children. And, our memory of pain is stored somewhere in the brain. Even when we havebecome adults, we recall that information of the rough road experience from memory automatically and a message istransmitted telling us to “please be careful”.
It is said that the brain automatically lets us deal with almost 80% of the human
P&I Loss Prevention Bulletinbehaviours unconsciously. However, if there is an error in the memory source, thewrong signal will be transmitted. That is, unconscious errors are triggered, whichleads to accidents.
Also, regarding the remaining 20%, we think for a moment before taking action, or
think about it deeply prior to taking action. However, the fundamental is also thesame in this case, and errors that cause accidents are induced by wrong judgement,
if there were mistakes in past experience and memory. This root cause is shown in
the 12 Human characteristics indicated in Table 56.
Therefore, most accidents can be prevented by calmly recognizing the Human
characteristics that everyone has and measures can be taken to prevent the causes ofthe errors.
JAPAN P& I CLUBJAPAN P& I CLUB

Website●東京本部

http://www.piclub.or.jp〒 103-0013 東京都中央区日本橋人形町 2 丁目 15 番 14 号 ………… Tel：03-3662-7229 Fax：03-3662-7107

Principal Office（Tokyo） 2-15-14, Nihonbashi-Ningyocho Chuoh-ku, Tokyo 103-0013, Japan●神戸支部〒 650-0024 兵庫県神戸市中央区海岸通 5 番地 商船三井ビル 6 階…… Tel：078-321-6886 Fax：078-332-6519

Kobe Branch●福岡支部

Fukuoka Branch●今治支部

6th Floor Shosen-Mitsui Bldg. 5, Kaigandori Chuoh-ku, Kobe, Hyogo 650-0024, Japan〒 812-0027 福岡県福岡市博多区下川端町 1 番 1 号 明治通りビジネスセンター 6 階 … Tel：092-272-1215 Fax：092-281-3317
6th Floor Meiji-Dori Business Center 1-1, Shimokawabata-machi, Hakata-ku, Fukuoka 812-0027, Japan〒 794-0028 愛媛県今治市北宝来町 2 丁目 2 番地 1 ………………… Tel：0898-33-1117 Fax：0898-33-1251

Imabari Branch●シンガポール支部

2-2-1, Kitahorai-cho, Imabari, Ehime 794-0028, Japan

80 Robinson Road #14-01B SINGAPORE 068898 …… Tel：65-6224-6451 Fax：65-6224-1476

Singapore Branch● JPI 英国サービス株式会社 38 Lombard Street, London EC3V 9BS U.K. ……… Tel：44-20-7929-3633 Fax：44-20-7929-7557
Japan P&I Club (UK) Services Ltd－ 30 －

P&I Loss Prevention Bulletin Vol.35

The author

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

JAPAN P& I CLUBVol.35 July 2015

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

Thinking Safety
Bridge Resource Management and Engine Room Resource Management

JAPAN P& I CLUB§ ４－３

BTM (Bridge Team Management)/ETM (Engine Room Team Management)

Approximately 90% of total
marine accidents are causedby human error

12 Human characteristics
which induce human error.

Selecting wrong information causedby one of or some of the 12 Human characteristics,

this can cause human error which
can cause an accident and trouble.

There are various causes for marine accidents, however, in the event of a collision accident, for example, it is said thatapproximately 80 to 90% of all accidents are caused by a mistake made by a person, in other words, “human error”(as mentioned above) such as “Insufficient Look-out”. In addition, even though the vessel collided into a harbour andfishery facilities, not another vessel, such an accident regarding harbour and fishery facilities is also classified as anaccident. The cause can be treated the same as other collision accidents, namely, that it was down to “human error”.
Most of these accidents were not caused by only one error, rather, the error was part of chain of other errors.
On the premise that “human beings are error-prone”, BTM and ETM were established with the purpose of “achieving
safe navigation” in order to further prevent human error chains and to bolster team ability at the bridge and in theengine room.
In other words, the utmost purpose of BTM and ETM is to eliminate “one-man error” through mutual support in orderto maintain safe operation of the ship together with the all members and resources in the bridge and engine room. And,
it aims “to achieve safe navigation” by improving team ability in the bridge and engine room as always.
This is shown in Table 58. The person at the centre (Liveware: person responsible for the accident) is surrounded by
the following four resources.

－ 31 －JAPAN P& I CLUBP&I Loss Prevention Bulletin
If there is a gap in the system,
an error will occur

L : Liveware (You)If there is a gap in the system,Han errorwill: Hardware
occur

SL: Software: Liveware (You)

M

Error

E
: Hardware
H: Environment: Software(People Around You)
LS: Liveware

E : Environment
ＬＬ） (People Around You)M ： Management（managing
Error: Liveware
Mand utilizingLＳＨＥM

BTM・ETM： Management（managing
and utilizing ＳＨＥＬＬ）
Fig. 58 M-SHELL Model①

Liveware:

BTM・ETM(Persons other than the person responsible
for the accident.）② ①S: Software.
Liveware:

Brieﬂy, this will be in the form of a book or document,(Persons other than the person responsible
such as the Maritime Collisions Prevention Act
for the accident.）(COLREGs) or the Safety Management Manual.

Liveware（You）

Liveware（You）③④② S: Software.
H: Hardware:
Brieﬂy, this will be in the form of a book or document,such as onthetheMaritime
Equipment
vessel.Collisions Prevention Act(COLREGs) or the Safety Management Manual.

E: Environment:③In this
H: case,Hardware:it is rather external information such as
Equipmenton the vessel.
route
control, weather
charts, weather informationand so on.

④

E: Environment:

Fig. 59

Four resources.

In this case, it is rather external information such asroute control, weather charts, weather informationand so on.

－ 32 －JAPAN P& I CLUBL (you), the person at the centre of model, is required to always communicate with these resources and to manage
them (management). Each initial in the model collectively form the acronym M-SHELL.
People around us communicate with each other via speaking and listening. They also communicate via other voicelessmeans such as books: Maritime Collisions Prevention Act (COLREGs) and the safety management manual.
Also, although the hardware (equipment) does not utter any words, it provides us with a variety of information.
Automatic Radar Plotting Aids (ARPA) display the Closest Point of Approach (CPA) of other vessels or Time to
the Closest Point of Approach (TCPA). The action of confirming this information can be said to be communicatingwith ARPA. Or, crew in the engine department, including the chief engineer, in the engine room confirm using
their five senses to check the sound, for vibration, temperature and pressure generated by the main engine to assess
as to whether or not fuel is burning at a normal state. This is also a form of communication: communication withequipment.
Moreover, Environment means external information. It can be regarded a communication when one is speaking andlistening via VHF or reading a weather chart.
In addition, because each resource including the position of oneself (L) is constantly changeable, it can be represented
as a fluctuating square. If cooperation between oneself (L) and each resource is not adequate, a gap between the
resources is created, human error enters and safety is compromised. Then a chain of errors causes an accident.
On the other hand, if communication and cooperation is satisfactory, there will be no gap to cause error because eachresource is connected. Thus, it can be said that safety has been established.
For instance, let’s suppose that the Master gave a wrong steering order to the Helmsman. At that moment, if the duty
officer confirms the possible mistake with the Master and the Master admits and corrects the steering order, the error“careless mistake” (wrong steering order) will no longer pose a problem there and then.
Unfortunately, if the duty officer who even felt question did not confirm this, the Helmsman, who specialises innavigating, would steer following the wrong steering order. The Master noticed this after the vessel had started turning
round, but it was too late. That is, a gap into which an error could enter was generated.

－ 33 －JAPAN P& I CLUBP&I Loss Prevention Bulletin§5Case study

Through the following three cases, preventive measures will be postulated.

§５－１

Case ①Case ①

Quay contact

Quay contact▶▶ Date and time of occurrence :LOA: 108mGT: 4,740 G/T

Draft: Ｆ4.37m
Ａ4.80mOn an unspecified day of March 2011,
approximately 07:53 Japan time (JST)）

NE/3

07:47 2.9Kts▶▶ Accident site :At an unspecified port in Tokyo Bay

07:49 2.1Kts▶▶ Vessel particulars :4,440GT, Loa 108 ｍ General cargo ship
Fore draft 4.37 m Aft draft 4.80 m Loaded
Steel product with half-loaded

07:51 1.7Kts

07:53 1.7Kts（Collision）▶▶ Weather and sea conditions :Fine, NE wind, wind force 3, No influence
from tidal current, and good visibility▶▶ Crew members :Korean Master, chief engineer and othercrew were Indonesian (16 members on
board in total)

South Korean Master and Indonesian crew

Fig. 60－ 34 －JAPAN P& I CLUB

§５－１－１

Chain of events leading up to the accident

Time

Movement

Who

06:55

Pilot embarks. Presents Pilot Card. Confirms ship's particulars and draft. Pilot remarks that
there is only one tug boat on port side alongside. There was no explanation regarding shipmanoeuvring instructions. On questioning the pilot following the accident, the pilot explained"We planned a manoeuvre to turn round in front of the berth and then set parallel condition
with the berth as close as possible. "Master and pilot

07:47

Speed 2.9 kts. D.Slow ah’d、 Leeway 3°Leeward direction. The straight-line distance from thebow to quay is 320 ｍ eters（3L which is approximately three times that of hull length (L).

Pilot

07:49

Speed 2.1 kts. Stop Eng.. While allowing the tug boat to push on her starboard quarter, Start
right turn. Linear distance is at 220 meters (approximately 2L) from bow to quay

Pilot

07:51

Speed 1.7 kts. Stop Eng.. Continues starboard turning round. Linear distance is at 120
meters (approximately 1L) from bow to quay

Pilot

07:52

Because the Master felt anxious Half Ast.Eng..is ordered.

Master

07:53

Keeps Speed at 1.7 kts. collision into quay
Table 61

Master and pilot

Chain of events leading up to the accident

Table 61 shows the chain of events leading up to the accident. The pilot let the tug boat report the distance from thebow to the quay, but did not explain this to the captain. On the other hand, the chief officer who was allocated at thebow had a duty to report the distance between the bow and the quay to the Master, but the Master did not relay this tothe pilot, and he continued to entrust navigation entirely to the pilot.
The Master, now feeling anxious, ordered astern with engine only one minute before the accident was to occur and thevessel, unable to take corrective action, collided into the quay at 1.7 kts.

§５－１－２ Judgement and cause analysis by Marine Accident Tribunal
Judgement and cause analysis by Marine Accident Tribunal is as follows.
Main text of judgement:

Operation suspension as pilot for a month

Cause:The pilot did not sufficiently confirm the approaching state between the
bow and quay and delayed in carrying out speed reduction arrangement. In
addition, he did not adequately confirm the speed, despite the fact that it waseasy for the tug boat to push stronger into the half-loaded vessel which led tothe situation of increasing Head way. Also, he over relied on the approachingcondition reported by the tug boat.

－ 35 －JAPAN P& I CLUBP&I Loss Prevention Bulletin§５－１－３＝

AnalysisAnalysis according to Human characteristics
and Preventive Measures＝

Accident causes were analysed along with §4-2 Human Error Concept and §4-3 BTM (Bridge Team Management)/
ETM (Engine Room Team Management).
Firstly, we dealt with the direct and indirect causes separately.
Direct cause

Miss-maneuvering by the pilot caused the following trouble. This is the same as the Marine Accident Tribunal
cause analysis.
▶▶ Insufficiently confirmed approaching condition between the bow and quay.
▶▶ Did not reduce speed at a distance of 1L (approximately 100 meters) from the approaching quay.
Indirect cause

The cause was not only triggered by the pilot but by the Master also.

＝ Pilot ＝▶▶ Did not explain berthing plan to the Master▶▶ Used only the distance reported by the tug boat (Immediately before the collision, although the
distance from the tug boat was 60 meters, the chief officer reported it as being 35 meters.)＝ The Master ＝▶▶ Although the chief officer (Indonesian) who was allocated at the bow had a duty to report the
distance between the bow and the quay to the Master, the Master did not relay this to the pilot.
▶▶ He continued to entrust navigation entirely to the pilot.

In addition, we examined the “root cause” lurking behind the “direct cause” and “indirect cause” mentioned above
against the “Human characteristics” shown in Table 56 on page 29. We conclude that the error chain was broken
as a result of human error, when Human characteristics are applied. (Each number is applicable to that of Human
characteristics shown in Table 56)＝ Root cause ＝ Human beings are sometimes lazy (Master and Pilot)
After the pilot got on board, the Master continued to entrust navigation entirely to the pilot. Also, regardless of the factthat the chief officer, who was allocated at the bow had a duty to report the distance between the bow and the quay, theMaster did not relay this to the pilot. Immediately before the collision, the tug boat reported the distance at 60 meters to
the pilot, however, at the same time, the chief officer reported it as 35 meters. At this point in time, had they noticed that
there was a conflict between the two reports, and had the Master and the pilot communicated with one another, they
could have reconfirmed the correct distance to the quay.

－ 36 －JAPAN P& I CLUB❺ Human beings have moments of inattention （Master and pilot）
Finally, the Master ordered Astern engine, however, time did not permit this. On confirming Head way against the log and
GPS and deducing that the speed was excessive, the Master should have advised the pilot of this at that time.

❾ Human beings sometimes make assumptions (Master)
The Master assumed that the pilot would not miss-maneuver.

Summarizing these time sequences, chiefly, the root cause can be attributed to insufficient communication between
the crew on board (officer at the watch of the 3rd officer) and the pilot. We can deduce that BTM including the pilot
was not functional. In addition, the 3rd officer arranged at the bridge was expected to report the hull speed and theinformation relayed by the chief officer, who was allocated at the bow, to both the Master and the pilot, but was
negligent in doing this. Collapse of BTM caused this accident.

Lack of communication between crew onboard (including Master) and pilot

BTM is not functioning.
Generally, the tug boat and the pilot were communicating in the local language (Japanese in this case) usingtransceivers. In particular, because the Master and pilot stand alongside at the final stage of berthing maneuvering,
it is not possible to confirm visually the tug boat’s movement. Also, without an understanding of the local language,
it may be difficult to grasp what is going on between the pilot and the tug boat. Then, in the event that something
unpredictable occurs during the operation process that is different to what the Master intended, one of the humancharacteristics ⑪ Human beings sometimes panic may be triggered and this can induce human error.
Another reason may be that there is not enough time for the pilot to keep interpreting the tugboat’s instructions to the
Master. Therefore, as a precaution, it may be wise that the chief or 2nd officers, who are allocated at the bow, briefly
report when the tug boat changes movement. (A brief description such as “Started pushing (pulling) in the direction of
XX o’clock” is perfectly acceptable.)＝ Preventive measures ＝As described above, BTM collapse including the pilot can be considered a root cause. For this reason, both the Masterand the pilot should have fully recognised the importance of BTM, but again: ② Human beings are sometimes careless, ③ Human beings sometimes forget and ⑩ Human beings are sometimes lazy apply.
There should have been no problem with the ship maneuvering skills of the pilot and the Master. However, in light of
the Human characteristics mentioned above that can be the root cause, forgetfulness may suggest that re-training of
BTM in order to remember be one of the effective preventive measures taken.

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

Photograph 62 BTM training§５－２

Case ②

Photograph 63 Ship handling and manoeuvring simulator

Case ② Oyster raft accident that sustained damage

 yster raft accident thatO
sustained damage▶▶ Date and time of occurrence:
On an unspecified day of December 2015,
approximately 18:37 Japan time (JST)▶▶ Accident site:
Near Miyajima Seto, Eastern sea area of
Itsukushima, Inland sea▶▶ Vessel particulars:
2,988GTL × B × D = 118.03m × 16.60m × 11.99m
Pure Car Carrier (PCC) Fore draft 3.54m Aft draft
3.85m Loaded with 447 cars▶▶ Port of departure:
Departed Uno Port, Okayama prefecture. Cleared out
Kurushima Strait at approximately 15:00.

▶▶ Port of destination:
Ujina Port, Hiroshima prefecture▶▶ Crew members:
A Japanese Master age 63, a 3rd marine officer(navigation) and crew were Japanese (10 members
on board in total)▶▶ Weather and sea conditions:
The weather was cloudy, WNW wind, wind force 5
and the tide was at the middle stage of ebb
At that time, gales and high wave advisory were
continuously being announced for Hatsukaichi cityand Edajima in Hiroshima.

＝ Arrangement in place when the accident occurred ＝▶▶ Bridge:▶▶ Stern:

Master operated the ship, Chief Engineer operated
the engine and the 3rd Officer steered

The Chief Officer, Boatswain and Able Seaman (3 intotal) were preparing for entering port.

－ 38 －JAPAN P& I CLUB

Oyster rafts area

18:45

18:35

Itsukushima

18:40
18:37

Miyajima Seto

Onasabi Island

18:3

Wind from
W-NW
Windspeed５

0

18

:10

18:0

5

5

5

18:1

18:2

Turns round once

18:

20

for time adjustment.

Fig. 64

Aki Eno Shima light

18:44

Eno Island

Accident position

18:43

On an unspeciﬁed day of December 2015
18:42

light beacon

18:35

Oyster rafts area

:36

18:41

18:40

18:37

18:3

3

light beacon

light beacon

39

18:

18:38

:34

18

18

light beacon
light beacon

Onasabi Island

18:3

2

500

18:3

1

Fig. 65－ 39 －JAPAN P& I CLUBP&I Loss Prevention Bulletin§５－２－１

Chain of events leading up to the accident

Time

Movement

Who

10:40
(Approx.)

Received contact that cargo handling work of the previous vessel at the port of Hiroshima Ujina
berth was approximately 2 hours delayed.

Master

15:00(Approx.)Cleared out of Kurushima Strait. Predicted arrival at outside port of Hiroshima to be approximately
just under 3 hours from that point. Because she was to arrive at the outside port at approximately
18:00, it was decided that 30 to 40 minutes time adjustment was required.

Master

18:00 ～
18:30

At the Miyajima Seto South Side Area, adjusted by approximately 30 minutes by turning roundonce.

Master

18:33

Judged that further adjustment time was needed, intended to turn round at North Asami Island
Northwest Seas, and ordered that course be altered to starboard 10 degrees after confirming thestate of the surrounding environment via radar (4 nautical mile range).

MasterJust after
18:33

Boatswain completed preparation for entering port at the foreward station, returned to the bridgeand started lookout. Immediately after, he noticed the marked light of an oyster raft and reported it
to the Master.

Boatswain

He felt a shock to the hull and realized that the vessel had collided with the oyster raft.

MasterOrdered the Chief engineer to check the condition of the hull by sounding etc. After that, because
no flooding was detected, she continued to navigate as before.

MasterAfter completion of cargo handling, he contacted the Japan Coast Guard.

Master

18:37
18:40(Approx.)
21:55

Table 66

Chain of events leading up to the accident

The chain of events that led up to the accident are summarized in Table 66. They received a telephone call from thelocal agent requesting for time adjustment at around 10:40, because the cargo handling work of the previous vessel at
the port of Hirosima Ujina berth was delayed. Following this, they cleared out of Kurushima Strait at around at 15:00,
and it was decided that 30 to 40 minutes time adjustment was required. Then, at Miyajima Seto South Side Area atapproximately 18:00, time was adjusted by approximately 30 minutes by turning round once.
However, it was still decided that further adjustment time was needed. When turning round at North Asami Island
Northwest Seas, the accident, which was a collision with an oyster raft, occurred.
The Master explained the following when questioned by the Japan Transport Safety Board.
⿙⿙ Because the Master predicted arrival to be at approximately 15:00, which was earlier than ETA, he kept
maneuvering believing that the time could be adjusted following confirmation of the ship’s position and theprevious vessel’s situation at around 16:00 or 17:00.
⿙⿙ Although the Master knew an oyster raft was located at the North Asami Island Northwest offing, he did
not know the exact location as this was not his usual navigating area. He assumed that it might be locatedon the east side of the North Asami Island Northwest offing.
⿙⿙ Moreover, because his visibility was restricted by wind and waves, he experienced difficulty in confirming
the marked lights close to the sea level.
⿙⿙ Only after the accident, he thought that he should have looked more carefully at the radar screen or
electronic chart that displayed the oyster raft.

－ 40 －JAPAN P& I CLUB

§５－２－２ Analysis by Japan Transport Safety Board andMarine Accident Tribunal and Preventive Measures
Analysis of the accident and preventive measures by Japan Transport Safety Board are as follows.
（１）Analysis
Following the announcement of the gale warning and high wave caution, the situation was such that it was difficult to visuallyconfirm the marked lights near the sea surface. During the passage/navigation to the north-northeast of North Asami Island
Northwest offing, the Master started right turn in order to adjust the time. Because look-out was not appropriately arranged
utilizing the radar, he operated the right turn without noticing the oyster raft that was situated at the North Asami Island
Northwest offing, which caused a collision with the oyster raft during turning round.

（２）Preventive measures
・Keep appropriate look-out by utilizing radar etc.
・In the event of operating away from of a standard charted course, check the condition of the channel beforehand using a
Nutical chart etc.

In addition, the judgement and cause analysis by Marine Accident Tribunal was as follows.
Main text of judgement:

One month suspension of seamen’s competency certificate as operating Master◦ Insufficient hydrographic survey
Neglected to conduct a hydrographic survey, such as using navigational passage

Cause:

information and electronic chart data to check location information of the oyster raft.
◦ The Master didn’t think that there would be an oyster raft in the area of sea somedistance away from Asami Island.

§５－２－３

Analysis according to Human characteristics
and Preventive Measures＝ Analysis of root cause ＝
Similar to Case ① , accident causes were analysed along with the Human characteristics. We conclude that the error
chain was broken as a result of human error, when Human characteristics are applied. (Each number is applicable tothat of Human characteristics shown in Table 56)
Because the Master was experienced and actually had been on board the same vessel on several occasions, it isnaturally believed that maneuvering the vessel would not have been a problem for him and that he was sufficiently
aware of the hull motion characteristics. We shall examine as to why such an experienced Master caused an accident,
along with the “root cause” lurking behind the course of events.

 Human beings are sometimes lazy
At approximately 10:40, the local agent requested that the ETA time be adjusted, while he was steering the ship through a narrow channel leading towards Kurushima. From this we can understand that it was not reasonable to start adjusting time at thatmoment judging by the surroundings and it was too early to adjust the timing, if attempted.

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

However, even at that time, regarding the sea area he was navigating towards, if the circumstances, weather, sunset time(the sunset time of December in the Hiroshima region is around 17: 00 - 17: 10) and the twilight (stars of the first and second
magnitude can be seen and a horizon can be identified, approximately 1 hour before sunrise and 1 hour after sunset) were taken
into consideration, time adjustment would need to have been completed at approximately 18:00 at the latest, if this was to be
carried out by turning round.
However, in fact, assuming that time adjustment could be carried out at around 16:00 to 17:00 in ample time, the Master did
not examine the status of the sea area he was navigating towards or method by which he would adjust time (including reducing
speed and changing course).

❾ Human beings sometimes make assumptions
He believed that the oyster raft was located at the east side of North Asami Island Northwest offing. It can be said that there wasinsufficient investigation regarding route conditions in advance.

❺ Human beings have moments of inattention
Moreover, because his visibility was restricted by wind and waves, he experienced difficulty in confirming the marked lights close
to the sea level. Despite this, he did not set up an additional look-out.

❸ Human beings sometimes forget
Regarding the Pure Car Carrier (PCC), he understood that the pressure fluctuation of the wind was significant. However, as aconsequence of time adjustment by turning round in a narrow water area, the vessel also flowed significantly. It can be considered that the Master forgot about hull motion characteristics.
Also, in spite of maneuvering in a narrow channel, the bridge arrangement constituted a 3rd Officer as helmsman and the Chief
Engineer as engine operator, with only the Master actually Look-out steering. Considering the importance of BTM, the personnel
arrangement was not appropriate, which may mean that he forgot about the BTM concept.

On analysing this case we understand that human errors, derived from the above mentioned four Human characteristics, were the cause and may have led to the accident occurring as a result. If one of the errors can be eliminated, an
accident can be prevented.

It seems that the accident occurred as a result, because
the chains of potential human error related to these kindsof human characteristics could not be eliminated.

＝ Preventive measures ＝
The Marine Accident Tribunal reprimanded the Master with a one month suspension of his seamen’s competency
certificate and the file was closed. We appreciate that the Marine Accident Tribunal judged this case fairly under
the revised Act under Marine Accident Inquiry, however, even though the Master who caused the accident deeply
regretted it, this is not enough if an accident is to be prevented in the future: punishment is by no means conclusive.
As a preventive measure it will be more effective to analyse how to eliminate the human error, found in Human
characteristics, that was the root cause.
－ 42 －JAPAN P& I CLUBRegarding the following main Human characteristics that are at the heart of the error causes, preventive measures areto be examined.

 Human beings are sometimes lazy
The original problem emanated as a result of carelessness concerning turning round to adjust time, without sufficiently examining
route conditions, such as narrow sea area etc.
In the event of time adjustment, a reduction in speed and temporary anchoring are mainly required. It is recommended that work
instructions be created in accordance with the safety management manual, which state that, in the event of time adjustment by
turning round, it is to proceed into a sea area where more than four to five times of the tactical diameter can be assured, andmoreover, where marine traffic is not congested.

❸ Human beings sometimes forget
Regarding the Pure Car Carrier (PCC/PCTC), he forgot that the pressure fluctuation of the wind was significant. In addition, he
had undergone BTM training and understood the importance of it in theory, however he either could not recollect or could notcarry it out in practice, which is what caused the accident.
Thus, in order help them remember, if they forget, as a preventative measure, it would be effective to have in place a re-training
system requiring that training be retaken if a certain period of time has passed since the last BTM training.

§５－３
Case ③

Case ③

Fair way buoy damage

Fair way buoy damage▶▶ Date and time of occurrence:▶▶ Port of departure:
Port of Muroran, Berth 1-9▶▶ Port of destination:

On an unspecified day of December 2015,
approximately 21:27 Japan time (JST)Hanshin Port Osaka-ku▶▶ Crew members:▶▶ Accident site:

A Master aged 58 and 4 other members on board

Port of Muroran No.2 light beacon▶▶ Weather and sea conditions:▶▶ Vessel particulars:
499 GT L × B × D = 75.52m × 12.00m × 7.20m
Cargo ship Fore draft 3.65m Aft draft 4.75m Loaded
Steel product (1,599kt)

The weather was sunny, NNW wind, wind force 2, thetide was low wave and Good visibility. There wereneither marine navigational warnings or high waves.

Arrangement in place when the accident occurred
After leaving the wharf, the Bridge Watch personnel constituted the Master only. One radar had arange of 1.5 nautical miles and the other a range of 3 nautical miles. However, at the time of passing
the No.3 light beacon, the radars were switched off, and he increased speed while setting the engine
to full speed ahead.

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

Traffic condition in fairway

Hakucho Ohashi

Before entering the sea route, she passed a vessel
inbound. After, there were no other vessels concerned.
Damage condition▶▶ No2. light beacon:
Dent with a crack at the floating part and bending
damage to protective fence.

▶▶ Vessel particulars:
Bending loss on her port side bow and no flooding.

Photograph 67

Damaged state of No.2 light beacon

Label of No.2 light beacon: visible distance four nautical miles, red flash once every three seconds. Light height was 8.2 meters

Accident position

HOKKAIDO

MuroranVnspecitied day of December 2015 app 21:27 (JST)Centralbridge beacon

HakuchoOhashifairwayNo.2 light beacon

No.3 light beacon

Vesselwharf

Muroran port

N. break water headFig. 68

HakuchoOhashiCentral bridge beacon

fairway
Plann

ed ro

ute

21:27

No.2 light beacon

Actu

No.3 light beacon

al rouFig. 69－ 44 －

te

21:23

Vess

el

JAPAN P& I CLUB§５－３－１

Chain of events leading up to the accident

Time

Movement

21:13

Departed from port of Muroran Harbour. Dismissed Departure S/B mid-

(Approx.)
21:18(Approx.)
21:20(Approx.)channel and Master started steering by himself. Hand Steering.

Who
Master

Because he recognised that there was a ship in port at the west end of the
Fairway, he steered to starboard because of passing port to port. He saw the

MasterNo.3 light beacon on the starboard side, and altered course in order to pass.
Headed bow to Muroran port Hakucho Ohashi central bridge beam light at 90
meters south of No. 3 light beacon. Set engine to full speed ahead.

MasterJudged that there was enough time to reach Hakucho Ohashi. Moved to theengine operation console on the starboard side and adjusted Eng. R.P.M.

21:20 ～ 21:26

Mainly watched the M/E R.P.M indicator and from time to time confirmed

Mastervisual estimated distance to Hakucho Ohashi. When he noticed the red lightof the No.2 light beacon before his very eyes, it was too late to take action.

21:27(Approx.)Collision into No.2 light beacon. Contacted Japan Coast Guard.

MasterTable 70 Chain of events leading up to the accident

Table 70 shows the chain of events leading up to the accident.
At approximately 21:13, she departed the Port of Muroran harbour, and started navigating to Hanshin Port Osaka-ku.
Dismissed Departure S/B mid-channel with the Master being the only person at the bridge, where he commenced his
duties. (Hand steering)
Because he recognised that there was a ship (West end of Fairway) prior to entering the port at approximately 21:18,
he steered to starboard because of passing port to port. He saw the No.3 light beacon on the starboard side, and alteredcourse in order to pass. At the same time, he set engine to full speed ahead.
At Approximately 21:20, he headed the bow towards the beam light of Hakucho Ohashi central bridge and at approximately 21:23:30, he changed to automatic steering at the time of passing No. 3 light beacon which was on the
starboard side. At that time, because the main engine rpm did not increase, but rather fluctuated up and down, theMaster started engine adjustment. While mainly watching the main engine, he noticed the red light of the No.2 lightbeacon before his very eyes. Unable to act otherwise, the vessel made contact with the light beacon. Promptly, they
contacted the Japan Coast Guard.

－ 45 －JAPAN P& I CLUBP&I Loss Prevention Bulletin§５－３－２ Analysis by Japan Transport Safety Board andMarine Accident Tribunal and Preventive Measures
Analysis of the accident and preventive measures by Japan Transport Safety Board are as follows.

＝ Analysis ＝⿙⿙ Insufficient confirmation regarding ship’s position
Although a GPS chart plotter was available, the nautical chart that he was using at Muraran port was too old an editionand did not indicate the fairway side line and light beacon on the east side of Hakucho Ohashi (inside of port).
Also, one of the causes of this accident was down to the fact that he switched off the two radars. The radars at setting ranges
1.5 nautical miles and 3 nautical miles were used after leaving the wharf until around the time of passing the vessel inbound.
Because there was no record of the ship’s position on the nautical chart, it is presumed that the ship’s position fixing was
not originally conducted.

⿙⿙ There was a problem in setting the course.
After passing 90 meters south of No.3 light beacon, intending to take a short-cut, he headed bow to the beam light of thecentral bridge. Analysing the AIS record at the time of when the accident occurred, it was confirmed that there was nopressure fluctuation in tidal stream or wind.

⿙⿙ Human beings sometimes make assumptions
Because she was passing the edge of the starboard route, he assumed that she could pass to the north of the No.2 lightbeacon.

⿙⿙ Insufficient Look-out
He was preoccupied with adjusting the main engine rpm, and neglected to monitor what was happening ahead of thevessel. Also, he checked only the beam light of the central bridge which was located at 65 meters above the sea surface
without paying attention to the sea surface.

⿙⿙ Inappropriate feedback to abnormal situation
He believed that he could adjust the main engine rpm by himself and did not ask for help from the chief engineer.

＝ Preventive measures ＝
While solely watchkeeping at the bridge, concentration on maneuvering is a requirement. In the event that it is necessary
to adjust the remote control device, including the engine, take measures that allow the staff members of the engine
department to come up to the bridge.

In addition, judgement by Marine Accident Tribunal was as follows.
Main text of judgement:

Official reprimand of the Master

Cause:

Duty of care was insufficient regarding the carrying out of sufficient look-out of thesurroundings in order to not miss the light of No.2 light beacon located at the south of thesea route during night time. He was preoccupied with adjusting the main engine rpm, andneglected the duty of sufficient look-out.

－ 46 －JAPAN P& I CLUB§５－３－３

Analysis according to Human characteristics
and Preventive Measures＝ Analysis ＝Accident causes were analysed along with the Human characteristics in the same way. The following four of Human
characteristics are applicable and we again conclude that the error chain was broken as a result of human error. (Eachnumber is applicable to that of Human characteristics shown in Table 56)

 H
 uman beings sometimes transgress when no one is looking
It would appear that the next two are violations.
▶▶ Did not possess the most updated nautical chart. (It is supposed that both vessel and company had thisproblem.)▶▶ Navigated the Fairway diagonally by short cut.
Article 12 of Act on Port Regulations (Act No. 174 of July 15, 1948) is as follows.
When vessels other than Miscellaneous Vessels enter into or leave from or go through the Specified
Port, they shall use the Fairway provided in the Ordinance of the Ministry of Land, Infrastructure,
Transport and Tourism hereinafter simply (referred to as “Fairway” until Article 37 ; provided, however,that this shall not apply ) to the cases in which they intend to keep away from a marine accident or othercompelling reasons exist.
Here, “the Fairway provided” means to navigate alongside the sea route, and diagonal
navigation can be regarded as being in conflict with Port Regulations Law.

❺ Human beings have moments of inattention▶▶ Both radars were switched off.
▶▶ Did not confirm the ship’s position on the noutical chart.

❾ Human beings sometimes make assumptions▶▶ Because she was passing the edge of the starboard route, he assumed that she could pass to the northof the No.2 light beacon.
▶▶ Believed that he could adjust the main engine rpm by himself and did not ask for help from the Chief
Engineer.

❻ H uman beings are sometimes only able to see or think about one thing at a time▶▶ He was preoccupied with adjusting the main engine rpm, and neglected to monitor what was
happening ahead of the vessel.
▶▶ Only checked the beam light of the central bridge and did not monitor the sea surface.

－ 47 －JAPAN P& I CLUBP&I Loss Prevention Bulletin＝ Preventive measures ＝
It appears that the main root cause comes from over-confidence due to being accustomed with the work.
The Master was experienced just as the Master in Case ② was, he had entered the Muroran Harbour on many occasions. After the accident, the Master regretted and reflected adequately, however re-training will still be necessary.

The company determined the following are to be preventive measures and informed all vessels.
▶▶ Accident summary
 fter dismissed Departure S/B, all crew arranged at the bow are to go up to the bridge. They are▶▶ A
also to maintain watchkeeping arrangement on the bridge until outside of harbour and system
to assist the Master.
▶▶ Navigation speed that is slower than slow ahead engine is recommended in the harbour.

Photograph 71 （Image）

Photograph 72 （Image）

The guideline determined by this company can be amply evaluated, because of its specific watchkeeping arrangement
and operating guideline. However, it is necessary to get more involved in order to regulate it.
When trouble occurs, it is also necessary not to cope with it independently and to clarify priority order of work.
This time, the first priority is naturally to concentrate on maneuvering and look-out during ship operating in the
harbour. It is necessary to take action by asking for help from the chief engineer immediately, if the main engine rpm
does not increase.

The collapse of one person BTM was
the main cause and a gap between
each resource manifested. Furthermore,human error added to the equation.
－ 48 －JAPAN P& I CLUB

§6

Conclusion

The statistics of the accidents regarding harbour and fishery facilities and examples of three related cases that werereported to our Club were introduced.
As shown in Graph 13 on page 8, in coastal vessels, the ratio of the total number of the accidents regarding harbour
and fishery facilities is approximately 60% (the number of accidents) and approximately 40% (insurance money) of
the total respectively. In addition, it is presumed that almost 90% of the total marine accidents are caused by humanerrors, however, it is no exaggeration to say that collision accidents, groundings, and damage to harbour and fisheryfacilities are all 100% caused by human error.
All experienced Master, chief engineer and crew are on board. They are expected to obtain the technical skills andknowledge and to be more than familiar with the law including the Maritime Collisions Prevention Act (COLREGs).
However, even these professional technicians induce human error caused by a behavioural characteristic that anyone
may have, and it is these chains of errors that cause accidents.
Therefore, we can say that not causing human error leads to a the elimination of accidents. BTM and ETM are effective means.
On the premise that “human beings are error-prone”, BTM and ETM were established with the purpose of “achieving
safe navigation” in order to further prevent human error chains, and to bolster team ability at the bridge and in theengine room, in order not to cause an accident following one person’s direct human error.
In the event of coastal vessels, because there are a large number of operating ships with a single watchkeeping
arrangement, some crew might think BTM is not available. However, even during single watchkeeping, BTM can be
performed by imagining there is another L (yourself) who tries to find an answer to your own question.
For example, in the event that you recognize another vessel that does not change relative bearing while monitoring theradar display, you may check the Navigation Act along with the Maritime Collisions Prevention Act (COLREGs). If
the other vessel is a give-way vessel, you may think or even utter “Strange! This vessel does not seem to be changing
relative bearing.” This what your other self will tell you.
In the end, it is important to eliminate errors by supporting each other so that an accident is not caused by a single
person’s error by establishing communication with the surrounding resources including the other L (yourself), shownin the “M-SHELL Model” of Fig. 58 on page 32.

－ 49 －JAPAN P& I CLUBP&I Loss Prevention Bulletin
References• A collection of determinations by Marine Accident Tribunal• Report by Japan Transport Safety Board of Ministry of Land, Infrastructure, Transport and Tourism• ”Bridge Team Management -A Practical Guide” by Captain A.J.Swift• “Practical Navigator”, by Japan Marine Science Inc.
• Japan Captains’ Association, DVD “For Effective Practice of the BRM - Are you sure about your BRM?-”

CD-ROM
Ship maneuvering related English version of Loss Prevention Bulletin and technical reference
Please make a good use of the enclosed CD-ROM file which contains the following documents.
• P&I Loss Prevention Bulletin Coaster Vessel Vol.4.pdf (Japanese only)• P&I Loss Prevention Bulletin Coaster Vessel Vol.4 Technical Reference. pdf (Japanese only)• P&I Loss Prevention Bulletin Coaster Vessel Vol.4.pdf (English only)• P&I Loss Prevention Bulletin Coaster Vessel Vol.4 Technical Reference. pdf (English only)－ 50 －JAPAN P& I CLUB－ 51 －JAPAN P& I CLUBP&I Loss Prevention Bulletin

The author

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

JAPAN P& I CLUB
Websitehttp://www.piclub.or.jp● Principal Office（Tokyo） 2-15-14, Nihonbashi-Ningyocho Chuoh-ku, Tokyo 103-0013, Japan		● Kobe Branch

Tel：03-3662-7229  Fax：03-3662-7107

6th Floor Shosen-Mitsui Bldg. 5, Kaigandori Chuoh-ku, Kobe, Hyogo 650-0024, Japan		● Fukuoka Branch

Tel：078-321-6886  Fax：078-332-6519

6th Floor Meiji-Dori Business Center 1-1, Shimokawabata-machi, Hakata-ku, Fukuoka 812-0027, Japan		● Imabari Branch

Tel：092-272-1215  Fax：092-281-3317

2-2-1, Kitahorai-cho, Imabari, Ehime 794-0028, Japan		● Singapore Branch

Tel：0898-33-1117  Fax：0898-33-1251

80 Robinson Road #14-01 SINGAPORE 068898

		● Japan P&I Club (UK) Services Ltd

Tel：65-6224-6451  Fax：65-6224-1476
38 Lombard Street, London EC3V 9BS U.K.

		

Tel：44-20-7929-3633  Fax：44-20-7929-7557

Translated by: YUZEN Translation LLC－ 52 －