§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 −

§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.
・In 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.

❿ 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 −

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 −

Regarding the following main Human characteristics that are at the heart of the error causes, preventive measures areto be examined.

❿ 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 Fair way buoy damage

Case ③ Fair way buoy damage▶ Port of departure:
Port of Muroran, Berth 1-9▶ Date and time of occurrence:▶ 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 −

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.3 light beacon
No.2 light beacon

Vesselwharf

Muroran port

N. break water headFig. 68

HakuchoOhashiCentral bridge beacon
fairway
Plann

ed ro

ute

21:27

No.2 light beacon

No.3 light beaconActu

al rou

21:23

te

Vess

el

Fig. 69− 44 −

§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 −

§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 shipʼs 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 −

§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)⓬ Human 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 shipʼs 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 Human 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 −

＝ 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▶

After dismissed Departure S/B, all crew arranged at the bow are to go up to the bridge. They arealso 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 −

§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 −

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 −

− 51 −

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

JAPAN P& I CLUB
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Translated by: YUZEN Translation LLC− 52 −