International Maritime Accident E

International Maritime Organization (IMO) has selected 2012
International Maritime Accident

Case Studies and Lessons
◆ FATA L I T Y 4 case
◆ F I 2 case
R 1 case
E 1 case
◆ S I N K I N G 1 case
◆ COLLISION
◆ CO N TA
CT

◆ F A T A L I T Y 4 case
◆ F I R E 2 case
◆ S I N K I N G 1 case
◆ CO L L I S I O N 1 case
◆ CONTAC 1 case
T
CONTENS
FATALI T Y
01. Fatal fall into cargo hold 02

02. Crew member loss of life as a result of an infectious disease 04
03. Man overboard while securing pilot transfer ladders 06
04. Worker trapped in unloading equipment 08
FIR E
05.
06. Ro-ro passenger ship fire 10
Explosion in machinery space 13
SI N KIN G
07.
Flooding and sinking of general cargo/containership 15
COL LISI O N
08.
Collision between chemical tanker and cargo ship 17
CON TACT
09.
Contact with a quay along a river 19
1
1 FATALITY
Fatal fall into cargo hold
[Accident-fell into the hold]
During cleaning of cargo holds by ship's crew while the ship was
u nder way at sea, the residua l ca rgo of iron ore was
removed f rom the bilge wells a nd placed in a pile in each
What hold before being lif ted up by means of buckets and a portable
happened? davit to the deck for disposal. The quartermaster and the oiler
climbed down to the bottom of a hold to f ill the bucket. The
cadet operated the w i nch a nd the bosu n worked the dav it a nd
d i rected the cadet. The bosun connected an empty bucket to the
cargo runner and signalled the cadet to hoist it. Once the cadet
had hoisted the bucket clear of the hatch coaming, he stopped
hoisting but the winch ran on a little. The bosun sw ung the davit
over the hatch coaming and then told the cadet to lower the
bucket. But it d id not move a nd the ca rgo r unner went slack
because the bulldog grips attaching a shackle to the w ire were
jammed at the head of the davit in between the sheave and the
davit head. T he bosun clim bed onto the hatch coa m ing, wa
lked a long the top of it and grabbed hold of and pulled on the
bucket tr y ing to release the shackle f rom the davit head, but
it did not come f ree. Then he pulled on the bucket again and,
as he did so, the davit moved. As the davit moved, the bosun
lost his balance and fell into the hold. He died of the in juries he
sustained.

2
International Maritime Accident Case Studies and Lessons
A working at height permit was not issued before the bosun
clim bed onto the hatch coa m ing a nd the r isk controls that
such a permit required were not implemented.
Why did
it O n boa rd sa fe t y cu lt u re h ad not be f u l l y a n d ef fec t
happen? i vel y d e v e l o p e d a s r e f l e c t e d b y c r e w w h o d i d n o t
t a k e t h e oppor t u n it y t o i mp r ove t h e f u t u re sa fe t y
b y e n g i n ee r i n g a solu t ion to a k now n p roble m ( ja m
m i n g of ca rg o r u n ne r of por table dav it ); a nd the bosun
who d isrega rded the SMS requirements relating to working
at height and climbed onto the hatch coaming of the open
cargo hold.
Take note of small problems and work out safe

solutions. In this case, the cargo runner of
portable davit became jammed in the head of
What the davit when the bucket was being hoisted
can too high. The situation could have been
we improved or avoided if a mark had been put
learn? on the cargo runner to indicate to the w inch
operator when to stop hoisting, or if a
preventer had been f itted to the cargo runner
to prevent it f rom jamming in the head of the
davit. Crews should never work at height
without the proper safety procedures being
implemented.
안전이 제일이야!
Safety
first!
[교훈사항-작업 전 안전수칙 준수]
3
[Less
on-
Safet
y
proce
dures
being
imple
ment
ed
befor
e
work]
1. F
2 FATALITY
Crew member loss of life as a result of
an infectious disease
A f t e r lea v i n g por t, a c re w m e m be r repor t ed t h a t h e h a

d a headache and chills to the Chief Of f icer. Believing that the
crew member had a cold, the Chief Of f icer prov ided cold
What medication a lthoug h the master was the desig nated med ica l ca
happened? re of f icer. The nex t day the crew member was g iven pa in
relievers f rom m uscle aches. T he c rew me m be r cont i n ued
to work a s us ua l for t he nex t 3 da ys u nt il, wh ile work in g
on deck du r in g t he morning, he was sent to his cabin to rest.
The crew member's t e m pe ra t u r e r ea c he d 42 ° C a n d t he C
h ie f O f f ic e r c a l le d t he International Radio Medical Centre.
Malaria tests were conducted and were positive for the ma
lignant ma laria t y pe Plasmod ium Falcipar um . The crew
member was given Malarone tablets, but he was vom it i n g
repea ted l y. T he sh ip a ltered its cou rse a nd increased its speed
in order to reach a position where evacuation by helicopter would
be possible.
Throughout the day the ship provided obser vations on the crew
mem ber's cond it ion a nd received i ns t r uct ions f rom t he Rad io
Medical Centre. Early in that evening, however, the crew member
died.
chief officer!
I had a I think you had a cold.
headache so I would provide
and chills cold
medication.
[Accident-Crew member loss of lifeas a result of an infectious disease]

4 International Maritime Accident Case Studies and Lessons

The crew member was most probably infected with the virus
du r in g t he por t sta y. Med icine on boa rd was not ma naged
properly by qualif ied crew. The procedures used on board the
Why did
sh ip d id not ens u re t hat on l y t he desig nated med ica l
it
happen? ca re of f icer handed out medicine to the crew members.
Due to the port being situated in a "No or low risk of malaria
area", the shipowner and shipboard management considered it
unnecessar y to prepare such a risk assessment, and no risk
assessment was made considering local conditions.
The importance of ensuring that all crew

members are made a w a re o f w h a t d i s ea s
e s m a y b e p re s e n t a t p or t, ho w t o
What minimize contracting the diseases and their
can symptoms.
we
T h e i mpor t a nce of not i f y i n g t h e des i g
learn?
na t ed m ed ica l ca re of f icer of any
symptoms exhibiting by crew members as early
as possible.
M a la r ia m ed ic i n e t o be a d m i n is te red
i n t rave nou s l y e x is ts ( w h ic h is a va i la
ble a t h osp it a ls ) a n d c o u ld poss i bl y h
a ve e n s u r e d t h a t t h e m e d ic i n e g i v e n
wa s e f f e c t i v e a n d no t rejected.
Y
o
u
m
u
s
t
n
o
t
i
f
y
to
office
[Lesson-
notifying
the
designa
ed
medi
care
officer]
2. F
3 FATALITY
Man overboard while securing pilot transfer
ladders
W hile a 12,000 gross tonnage containership was at sea, the chief

mate told the bosun and ratings that because of heav y weather,
the previous day's standing order/work permit that no one was
What allowed to work outside the accommodation w ithout permission
happened? from the master or chief mate was still in force.
A t a watch cha n ge, the bosu n told both the rel iev in g
ratin g a n d t he rel ieved ra t i n g t o f ol lo w h i m on t o t he f
oredec k i n order to secure the pilot transfer ladders. The relieving
rating, unawa re of the ch ief mate's order because there had been
no handover by the relieved rating, followed the bosun outside
of the accommodations. A lthough aware of the standing order/work
perm it, the relieved rating d id not da re cha llenge the bosun's
order.
A f ter secur ing the sta rboa rd side ladder they crossed over to
the port side, the windward side, to secure the port side ladder.
W h i le t h e t w o r a t i n g s w e r e w o r k i n g o n i t, t h e b os u
n w a s wa lk ing towa rd the accom modation on the por t side,
when he was washed overboard.
I m m e d i a t el y a f t e r t h e a c c ide n t, r esc ue e f f o r t s b y t
h e s h ip, passing ships and the Rescue Coordinating Centre were
initiated, but the bosun was not found.
[Accident-Man overboard while securing pilot transfer ladders]

6
The bosun d id not follow the chief mate's instr uctions that
prohibited working outside the accommodation. The bosun did
not consult with the master or the chief mate about a work
Why did
permit prior to the work on foredeck.
it
happen? T h e r e l i e v e d ra t i n g d i d n o t h a n d o v e r t h e c h i e
f m a t e's i ns t r uc t ions to t he rel iev i n g ra t i n g, w ho h ad
no conce r ns about working on the foredeck, resulting in
acceptance of the bosun's work order.
T he b o s u n w e n t t o t he f o r e d e c k d u e t o c o n c e r n s a
b o u t whether the pilot transfer ladders had been properly
secured.
The chief mate's instructions to crew on daily

work under the conditions of heav y weather
should be followed, and standing orders/work
What perm its should be sig ned by the master or the
can chief mate before commencing the work.
we
The crew should be encouraged to discuss the
learn?
decisions made b y t hei r s upe r iors w hen h
av i n g doubts or conce r ns a bou t safety.
Safet y notices should be posted on the
accommodation doors leading to outside alley
ways when work on deck is prohibited.
W hen heav y weather is anticipated, the pilot
transfer ladders and other movable objects on
deck should be secured prior to the departure.
[Lesson
-
Prohibit
to work
on deck
when
heavy
weather
]
3. F
4 FATALITY
Worker trapped in unloading equipment
A 20,000 gross tonnage bulk carrier was berthed alongside and

d ischa rg ing ca rgo. A round m id n ig ht a w iper was stationed
in the ship's conveyor belt tunnel to monitor the conveyor. He was
What equipped with a walkie-talkie to communicate.
happened? On a routine round of the cargo system, the chief mate found
t h e w ip e r t r a pp e d be t w e e n t h e r u n n i n g c o n ve y o r be
l t a n d roller. The chief mate immediately activated the
emergency stop button for the conveyor belt, sounded the
alarm and called for assistance. The wiper had already died
from his in juries.
Can you do better?

Have a good day
????
[Accident-Worker trapped in unloading equipment]

8
A lthough safet y meetings were conducted monthly, the
chief mate and watchkeeping mates did not confer with the
wiper about the r isks he wou ld encounter before com
Why did
mencing the task in the tunnel. Furthermore, there was no
it
happen? specif ied loading and unloading instructions on the conveyor
belt tunnels. The wiper neither might have become aware of
the hazard nor have known how to react when he spotted the
irregularities in the tunnel.
Since no r isk assessment of workplace was conducted a f
ter t he i ns ta l la t ion of g ua rd ra i ls b y t he compa n y,
mea s u res ta ken we re i nadeq ua te to p revent t he w ipe r
f rom g et t i n g t rapped i n t he r u n n i n g conveyor belt a
nd to a l lev iate t he da mages caused by it. As the result, the
w iper was trapped and could not stop the operation of the
conveyor belt.
To ensure that seafarers can work in a safe

environment, it is imperative that companies
conduct a hazard identif ication and risk
What assessment and that proper control measures
can are put into place.
we
Work instructions and standards operating
learn?
procedures, which ref lect the risk assessments
and control measures, should be developed a
nd that sea fa rers a re properly fa m ilia rized
w ith their use
Before com menci n g t he task, it is i mpor ta nt
to ma ke s u re that safet y issues are
communicated among the of f icers and crew.
Em e r g en c y s t o p s sh o u l d b e p l a c e d s o t
h a t t h e y a r e immediately in reach of the
seafarer at his working location.
Be careful Yes sir!!

that
risk of
conve
yor
blet
[Lesson-
on risk
4. F
5 FIRE
Ro-ro passenger ship fire
A 2 0,0 0 0 g r o s s t o n n a g e r o- r o p a s s e n g e r f e r r y , w i
t h 2 0 3 passengers, 32 crew members and a f ull load of cargo
units on boa rd, was on a voyage which norma lly ta kes about
What 20 hours. A bout two hours af ter departure and just a few
happened? minutes before midnight f ire broke out in one of the cargo
units in the garage deck. T he ma n ua l l y-ope ra ted d renche
r s ys te m wa s ac t i va ted f rom the bridge but did not deliver
any water. A n attempt was then made to start the drencher
system f rom the engine control room but th is was a lso u
nsuccessf u l. T he f ire spread rapid ly. Fire-f ig hting was dif
f icult due to the thick smoke and eleven minutes af ter the f
irst alarm the Master ordered the evacuation of the ship. W hile
all passengers and crew were safely evacuated
23 people were in jured, mostly from smoke inhalation.
manually-operated
drencher system was
not activated.
[Accident-fire broke out]

10
T he c re w we re u na ble t o s t a r t t he ve h ic le dec k d re
nc he r s y s t e m. T he i na b i l it y t o s t a r t t he d re nc he r s y s
t e m p u mp remotely f rom either the bridge or the eng ine
Why did
control room was most likely because a selector switch,
it
happen? which was located ad jacent to the drencher pump and
controlled the d ischarge valve on the drencher pump, was lef t
in the "manual" position.
A ccord i n g to t he voya g e d a ta recorde r a sel f-clos i n g f i
re door protecting a stair well f rom the vehicle deck remained
open d u r i n g t he f i re, a l low i n g smoke a nd f la mes to reach
accom modat ion a nd publ ic spaces. T he f ire door was f it
ted w it h a sel f-closi n g mech a n ism, bu t it was not possible
to determine whether this mechanism was f unctioning
correctly at the time of the f ire.
W hen the accom modation sprink ler s ystem activated, a pipe
connection parted, resulting in an uncontrolled f low of water
i n t o t h e e n g i ne r oom. T h e e n g i nee r-on-wa t c h, c
once r ned a bou t t he poss ib i l it y of wa ter d a ma g e to
mach i ner y a n d / or f lood i n g of m ach i ne r y compa r t m
e n ts moved rap id l y t o t he sp r i n k le r r oom, loca ted
som e d is t a nce f r om t he m a i n m ach i ne r y r oom, t o s t
op t he sp r i n k le r p u mp. I n so doi n g he was unable to
add ress other pressing issues such as the fa ilu re of the veh
icle deck d rencher s ystem to operate. For reasons u n k now n
no at tempt was made to open the cross- over va lve wh ich
wou ld have enabled the sh ip's f ire pu mps to supply the
drencher system. This valve was located in the sprinkler room.
Possibly because of his pre-occupation w ith

dea ling rapid ly w ith both the d rencher a nd
spr in k ler s ystem problems, the engineer-on-
What watch did not inform the command centre
can about t he lea ka g e f r om t he sp r i n k le r s ys
we te m so a n oppor t u n it y was lost for him to
learn? gain assistance to deal with both issues e f f
ic i e n t l y . T h i s e m p h a s i s e s t h e n e e d
t o m a i nt a i n g o o d communication at all
times.
T he speci f ic operat ion of d rencher s ys tems
va r ies bet ween insta llat ions. It is essent ia l t
hat crew mem bers responsible for the
deployment of the systems are made familiar
with all methods of their operation, including
necessar y valve settings and sequence of
actions. This can be assisted by:
5. FIRE
the provision of clear and simple schematic diagrams located at all operating
positions, being mindful that operators may not all share a common native
language;
the clear marking of valves and switches - perhaps assisted by standard
colour schemes;
induction training for new crew members; and
regular and realistic drills.
T he l i m i t a t i o n s o f d r e n c he r s y s t e m s n e e d t o b e r e c o g n
i s e d. T he i m p o r t a n c e of e a r l y d e p l o y m e n t i f t h e r e i s t o b e
a n y c h a n c e of containing a f ire needs to be stressed.
W it h reg a rd to t he fa i led coupl in g in t he spr in k ler s ystem a nd t
he open f ire door, while the reasons for these failures are not known, they
emphasise the need to report any equipment malf unctions immediately,
in order to allow for maintenance and repair work to be carried out.
W hen f ire spreads rapid ly th roug h public a nd accom modation spaces
good communication between the crew and the passengers is essential.
This can be assisted by:
crew members wearing high visibility safety vests to make them readily
recognizable as a point of contact to passengers; and
broadcasting emergency announcements in multiple languages to ensure
that as many passengers as possible understand the information.
The flooding is Take

expected to be another way
the
engine room
[Lesson-need to maintain good communication between birdge and engine room]

12
6 FIRE
Explosion in machinery space
A 2,500 g ross ton nage sh ip was propelled by a 1470k w d

iesel eng ine. A few hours a f ter the sh ip set sail, a n air
leak f rom a fau lt y a ir reg u lator was d iscovered in the ma in
What eng ine a ir supply. The ship was stopped to allow the faulty
happened? regulator to be changed for a spare.
W h i le t h e r e p a i r w a s t a k i n g p l a c e t h e t w o r u n n i
n g d ie s el g ene ra tors s topped. A t te mp ts to res ta r t t he m
led to a l l t he starting air being used up. A n attempt was made
to start one of the generators using ox ygen f rom a welding set
bottle connected to one of the engine cylinders. There was an
explosion and the Chief Engineer and an Oiler received serious
in juries.
O2
[Accident-fire broke out due to explosion]

6. FIRE 13
T he reason the eng ines stopped r unn ing was not d iag nosed
and rectif ied before tr ying to re-start them. In consequence,
starting air was wasted.
Why did
it The energ y released by the ignition of the injected fuel in an
happen? ox ygen-r ich atmosphere was much g reater tha n the eng ine
was designed for.
Pe r s o n n el p r es e nt d u r i n g t h e p r e p a r a t io n t o u s
e o x y g e n to sta r t the eng ine were awa re of the da ngers
but d id not challenge the decision to use ox ygen.
N e v e r a t t e m p t to u s e p r e s s u r i z e d o
x y g e n t o s t a r t a combustion engine.
D i a g n o s e t h e r o o t ca u s e o f a m a c h i n
What
e r y f a i l u r e b e f o r e attempting to restart
can
the unit.
we
learn? Cultivate a culture w ithin the Company-ashore
and a f loat- which encourages justif iable
challenges to unsafe decisions of superior
ranks.
Prepare to use oxygen

to start the engine. There is a risk
o
f
e
x
p
l
o
s
i
o
n
.
O
challenges to unsafe decisions of
superior ranks]

14 International Maritime Accident Case Studies and Lessons
[Lesson-
C
u
lt
i
v
a
t
e
a
c
u
lt
u
r
e
w
it
h
i
n
t
h
e
e
n
c
o
u
r
a
g
e
s
j
u
s
ti
fi
a
b
l
e
7 SINKING
Flooding and sinking of general cargo/containership
During the early hours of the morning while a small containership was
sailing, the engine-room bilge alarm sounded. The engine room was
manned and the duty engineer noted a rising level of water below the
What bottom plates. The Master and Chief Engineer were called. By the time
happened? they both arrived in the engine-room, water had begun to cover the
bottom plates.
No pumps were started in order to pump out the water. No other
actions were taken to reduce the f looding or the water level. The
source of the flooding was not established
The engine-room was abandoned half an hour after the ingress was
discovered, however no efforts were made to ensure that watertight
doors leading to the port and starboard passageways connected to the
engine-room were fully and effectively closed and battened down.
The Master ordered that the ship be abandoned around 45 minutes
af ter discover y of the f looding. The f reefall lifeboat was launched
another 35 minutes later with all crew on board (at 0320hrs). Problems
were encountered with the engine of the lifeboat, which failed after 5
minutes due to a clogged fuel filter. The crew were all seasick in the
lifeboat.
The Master reboarded the ship from the lifeboat around 0830hrs and
communicated with head office. By this time, the main deck was awash
in front of the accommodation, but the emergency generator was still
running.
The entire crew was rescued shortly before noon by another ship.
Although still afloat at 1700hrs, the ship eventually sank.
[Accident-Flooding and
Sinking]
7. SINKING 15
The engineer on duty took no immediate action to reduce the effect of
the flooding, e.g. opening the emergency bilge suction and starting the
ballast pump. (It has been calculated that the rate of water ingress was
Why did approximately the same as the capacity of the ballast pump.)
it
happen? On arrival in the engine-room, neither the Master nor Chief Engineer
ordered any action to reduce the flooding. FSI 21/18 Annex 3, page 5
The watertight doors leading from the engine-room to the port and
starboard passageways were not adeq uately secured. The ship had
sufficient stability to remain afloat if these watertight doors had been
secured.
In this case the decision to abandon ship proved to be

premature. Although safety of life must be the highest
priority, abandoning ship should be the last resort as it
What brings its own dangers and removes from the scene
can the people necessary to help save the ship.
we It is important for all ships to have contingency plans
learn? for dealing with the f looding of various
compartments and to drill the crew against these
plans.
A ll engineer of f icers should be able to take initial
remedial action against flooding in the engine-room by
opening the appropriate valves and starting pumps
immediately.
The importance of securing watertight doors in
emergency situation should be made clear to all
personnel on board.
Lifeboat engines require prolonged running on test
and not just a weekly run of a few minutes. This is
necessary in order to uncover problems such as debris
in the fuel tanks and lines.
A
p
p
r
o
p
r
i
a
t
e
initial
[Le
initial
action]
International
16 Maritime
Organization
(IMO) has
selected 2012
International
Maritime
Accident
Case Studies
and Lessons
8 COLLISION
Collision between chemical tanker and cargo ship
A nor t hbou n d ( cou rse 322˚) 11,100 g ross ton na g e che m

ica l ship collided with a southbound (course 162˚) 2250 gross ton
general cargo ship of f the coast in good v isibilit y. Initially
What
the two ships were going to pass clear of each other with the
happened?
chemical carrier passing ahead of the cargo ship, but when
the ships were 0.8 miles apart, the chemical carrier made a
late and bold alteration of course to starboard and towards
the cargo ship.
T he ca r g o s h ip, loa ded w it h sc rap i r on, t he n a l te red
he r course to port, away f rom the chemical carrier, but this
was insuf f icient to avoid collision.
The chemical carrier struck the cargo ship almost amidships,
hol i n g h e r. T h e c h e m ica l ca r r ie r appl ied f u l l a s t e r n
a n d pulled away f rom the cargo ship.
T he ca rgo sh ip, w ith both holds holed, sa n k w ith in a ver
y few minutes. Five members of the 10-man crew of the
cargo ship perished.
[Accident-Collision]
8. COLLISION 17
There was a failure to comply with International Regulations
for Preventing Collisions at Sea on both ships: no early and
clea r a lterat ion by bot h sh ips; a nd, t here was a fa i lu re to
Why did
assess the risk of collision. FSI 21/18 A nnex 3, page 6
it
happen? A n inappropriate alteration of course by the chemical
carrier when it was too close to another ship. Both ships
were still at f ull ahead at the time of the collision. The
chemical ship pulled out of the holed cargo ship allowing f
looding.
There were indications of fatigue on the part of both OOWs,
who were near the end of their 6-hour watches.
N e v e r a t t e m p t to u s e p r e s s u r i z
e d o x y g e n t o s t a r t a combustion
engine.
What
keeping a good lookout, maintaining
can
vigilance and complying with Collision
we
Regulations;
learn
? ensuring OOWs are well rested and alert;
taking remedial action once a collision is
unavoidable (stopping the engine, going astern);
and
not pulling out of a ship once a collision has
occurred.
Make
sure
suffic
eint
sea-
room
and
avoid
a
succe
ssion
of
small
alterat
ion of
course
[Le
good
International
18 Maritime
Organization
(IMO) has
selected 2012
International
Maritime
Accident Case
Studies and
Lessons
9 CONTACT
Contact with a quay along a river
A containership of about 18,000 gross tonnage lef t a berth

on a river with a tug and was heading towards the south
side of the river. As the ship's bow entered the main f lood
What
tidal s t rea m, t he bow u nex pected l y pa id of f to s
happened?
tarboard a f ter the pilot ordered the helm to por t. T he pilot
then ordered the helm to hard-a-port but the bow continued
to pay of f to starboard. The master and the pilot ag reed to
abort the manoeuvre and set the engine to f ull astern. The
pilot also ordered the tug to return immediately to assist the
ship, but the ship made contact w ith a q uay on the opposite
side of the river. The quay sustained superf icial damage but
the ship su f fered sig n if ica nt da mage to her bow w ith her
forepea k tank punctured. There was no pollution and no one
was hurt.
No problem that
ship
manoeuvring
[Accident-Contact with a quay along a river]

9. CONTACT 19
The f lood tide acting on the port bow, coupled with the
wind and the out wa rd f low of water creating a counter-f
low of f the berth acting on the starboard quarter, was suf f
Why did
icient to overcome the turning ef fect of the applied port helm.
it
happen? T he ma rg in for er ror in ach iev ing the intended ma noeuv re
was small and the pilot had unintentionally not applied port
helm until a f ter the ship's bow had entered the f lood tida
l s t rea m. T he en g i ne wa s se t t o f u l l a s te r n, b u t t he
sh ip's stopping distance exceeded the available space ahead.
It wa s t he p i lot's u s u a l p rac t ice t o relea se t he t u g a f te
r clearing the berth and establishing steerage. In his experience,
he did not feel the need to retain the tug for a ship of this
size. The port authority relies on the judgment of the pilot to
determine to what extent tug assistance is required.
The pilot had conducted the same manoeuv re, under similar
tida l cond itions, on a number of occasions w ithout
incident. T he I n f o r m a t io n e xc h a n g e d be t w e e n t he m
a s t e r a n d t he pilot was limited to the condition and
readiness of the ship. Bot h t he master a nd t he pilot
considered t he depa r t u re to be a rou t i ne opera t ion w h
ich d id not req u i re a n y f u r t her discussion or elaboration.
Similar accidents had happened before, but the port authority
had no mea ns for ensu r ing that the identif ied lessons had
been ef fectively promulgated to its pilots.
I t i s e s s en t i a l t h a t t h e ma s t e rs a n d t
h e p i l o t s s h o u l d exchange information
regarding hazards they may encounter and its
What control measures to be taken before
can commencing the navigation.
we
H a za r d ide n t i f ic a t io n a n d r i s k a ssess
learn?
m e n t r e g a r d i n g t h e ef fect of tidal
stream on ships manoeuv re should be carried
out appropriately.
Procedures for ships to use a tug when a
strong tidal f low is anticipated should be
established.
A n ef fective way to disseminate lessons learnt
to the pilots should be developed.
Communication among the pilots and the
bridge team should be e ncou ra g ed f or t he p
i lots t o be a ble t o d raw t he bes t decision-
making.
International
20 Maritime
Organization
(IMO) has
selected 2012
International
Maritime
Accident
Case Studies
and Lessons
Be careful!
Ship is likely to be
contact to pier due to
flow of
water
[Lesson-exchange information regarding hazard]

09. CONTACT 21

발간 해양안전심판원
339-012 세종특별시 도움 6 로 11, 정부세종청사 5 동 6 층, 해양안전심판원
Tel : 044-200-6123 / Fax : 044-200-6139 / E-mail : kmst_special@korea.kr
www.kmst.go.kr

International Maritime Accident E

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International Maritime Accident E

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International Maritime Organization (IMO) has selected 2012