## 3 MV Milano Bridge Accident and FRAM Application Data
### Cause Analysis Summary of the MV Milano Bridge Accident
#### 3.1.3 Analysis of the Result of the MV Milano Bridge Accident by Function Using FRAM  
A time-series analysis of the MV Milano Bridge accident was performed in the order in which the accident occurred after the ship was built in a Japanese shipyard, passed through a repair shipyard in China, and then entered Busan New Port. After complete repair shipbuilding in China, supplying fuel and ballast water, sailing the Yellow Sea, and entering the Busan coast, the ship entered the Busan New Port area through port services, such as pilotage, tugboats, and VTS. However, a collision occurred when the ship entered the port and an accident occurred. Figure 4 illustrates how the 31 functions related to marine accidents are organized into a time series, from ship construction to container terminal accidents. Unlike before the accident, the more complex causes were assumed to be related, as each granular factor was evaluated by Function 11 (collision at the terminal) using FRAM. The MV Milano Bridge accident was caused by a communication gap between the master and pilot of the ship, as they failed to explain the details of the voyage plan to each \begin{table}
\begin{tabular}{p{56.9 pt} p{56.9 pt} p{56.9 pt} p{56.9 pt} p{56.9 pt} p{56.9 pt} p{56.9 pt}} \hline \hline
**Functions** & **Input** & **Outcome** & **Precondition** & **Resource** & **Time** & **Control** \\ \hline F24: Environment & -Collision & \begin{tabular}{c} -Port construction \\ narrow channel \\ \end{tabular} & -Busan New Port & -Construction & Early & \begin{tabular}{c} Busan Port \\ Authority \\ \end{tabular} \\ \hline F25: Port construction & -Port construction & -Large alteration of courses & -Pilot on board & -Dredging & Early & \begin{tabular}{c} Busan Port \\ Authority \\ \end{tabular} \\ \hline F26: Narrow channel & -Narrow channel & -Large alteration of courses & -Pilot on board & -Construction & Early & \begin{tabular}{c} Busan Port \\ Authority \\ \end{tabular} \\ \hline F27: Large alteration of courses & -Large alteration of courses & -Lack of management & -Insufficient maneuvering & -Pilot on board & -Container of the ship & Early & -VTS -Master \\ \hline F28: Management & -Collison & -Bridge team management & -In the port & \
\begin{tabular}{c} -Navigation \\ officer \\ \end{tabular} & Early & Master \\ \hline F29: Bridge Team Management & -Bridge team management & -Lack of management & -In the port &
\begin{tabular}{c} -Navigation \\ officer \\ \end{tabular} & On & Master \\ \hline F30: Lack of experience in the master & -Lack of management & -Lack of management & -Insufficient maneuvering & & & On & Master \\ \hline F31: Improper pilotage & -Insufficient maneuvering & -Improper pilotage & -Indulge in mannersim & -Pilot & On & Master \\ \hline \hline \end{tabular}
\end{table} 
Table 2: _Cont._  
Figure 4: Analysis of the time series phenomenon until the crane contact accident. other, combined with a lack of adequate support from the port traffic infrastructure, which included the VTS, safety routes, and navigation aids. The functions applied to analyze the inappropriate pilotage that caused the accident are summarized and listed in Table 2.  
Figure 5 shows the time-series multiple analysis results of evaluating each factor subdivided into a multilayered structure for the MV Milano Bridge crane contact accident. The MV Milano Bridge accident occurred because of a combination of functions, such as vessel structure and management Function 12, port service Function 16, port environment Function 24, and management Function 28. In addition to the human errors introduced by the pilots, masters, and VTS controllers, technical factors that contribute to these human errors were derived. The factors included sufficient tugboat support; improvements to the ship operation environment in the port to minimize large angular course alternations; and comprehension, education, and simulation of the maneuvering characteristics that were observed when the ballast water of the ship was insufficient.