211
1 INTRODUCTION
History of shipping is directly and consistently
connected with shipping casualties. These disasters
duetothesizeofvessels,numberofpeopleandcargo
carried by ships are events of great psychological,
economic and social impact. Historically, the causes
ofmaritimedisastersduetolackofinformationwas
a
ttributedtotheforcemajeure(GodʹsWill).Growing
up in recent centuries, ships technical systems,
communicationandcontrolarrangementofthevessel
allowforamoreprecisedeterminationofthecauses
ofthedisasteranditsstages.Knowledgeofcauseand
effect is the basis for the analysis of disasters and
disaster countermeasures drawing conclusions or to
rectifytheconsequences.
The purpose of thi
s article is to present the
problem of assessing maritime casualty in terms of
the SHELL system which consists of: the ship, its
crew,themarineenvironmentandprocedures.
Currently, the rules and principles of analysis of
causes and effect
s are oriented on technical aspects,
humanfactorsandtheimpactof weatherconditions
and correlation between them, but often without
gradation of factors. Reports describing sea casualty
include detailed analysis of the failure process and
large amounts of information about the different
weightandimportance.Thus,theanalysisofdisasters
andsynthesisofimport
antinformationinrelationto
theprocessofdisasterisdifficulttocarryout.Mostof
the accidents analysis is based on calculations,
simulations and expert opinion. Conclusions are
drawn principally based on expert opinions within
limitedrangeofknowledge.
The casualty indicat
ors allow assessing the
casualty and comparing the processes of casualty.
Also casualty factors determine the validity of the
variousfactors.Inaddition,thecasualtyindexfactor
can be used to determine the reliability of expert
opinions.
Methods of Vessel Casualty Process Assessment
J
.Soliwoda
GdyniaMaritimeUniversity,Gdynia,Poland
ABSTRACT: Maritime casualty is an event of considerable economic and social impact
. For this reason,
implemented the reporting systems ofaccidents at sea, and the Administrationwas obligatedto establish a
Commission of Maritime Accidents. On the basis of casualty analysis and reports are developed proposals
preventing similar casualties in the fut
ure. However, there is no uniform evaluation system which check
references of existing regulations and recommendations to the occurred casualties. This paper presents a
methodtoevaluatetheusedmethodsofcasualtypredictionwithrespecttotherealincidentandcatastrophe.
http://www.transnav.eu
the International Journal
on Marine Navigation
and Safety of Sea Transportation
Volume 8
Number 2
June 2014
DOI:10.12716/1001.08.02.06
212
2 RULESAFFECTINGINVESTIGATIONINTO
MARITIMECASUALTY
Nationally and internationally reported statistics on
marineaccidentsshowthat80%ormoreofallmarine
accidentsarecausedfullyorinpartbyhumanerror
(Human Factors). In order to prevent similar
casualtiesandincidentsinthefuture,itisnecessaryto
ident
ify the circumstances of the casualty under
investigation and to establish the causes and
contributing factors. IMO (International Maritime
Organization) adopted Casualty Investigation Code
with the guidelines for the Investigation of Human
FactorsinMarineCasualtiesandIncidentsinorderto
promote a common approach to the safety
investigationofmarinecasualtiesandincident
s,and
also to promote co‐operation between States in
identifyingthecontributingfactorsleadingtomarine
casualties.TheCodeentered intoforceon 1 January
2010.
1
Figure1.InvestigationProceduresacc.toIMORes.884
Theobjectiveof te Code is to provide a common
approachforStatestoadoptintheconductofmarine
safety investigations into marine casualties and
marineincidents.Marinesafetyinvestigationsdonot
seektoapportionblameordetermineliability.Instead
a marine safety investigation is conducted with the
objectiveofpreventingma
rinecasualtiesandmarine
incidentsinthefuture.TheCode envisages that this
aimwillbeachievedthroughStates:
1 applyingconsistentmethodologyandapproach,to
enable and encourage a broad ranging
investigation,where necessary, inthe interests of
uncovering the causal factors and other safety
risks;and
2 providingreportstotheOrganizat
iontoenable a
wide dissemination of information to assist the
1
CodeoftheInternationalStandardsandRecommended
PracticesforaSafetyInvestigationintoaMarineCasualty
orMarineIncident,IMO,RESOLUTIONMSC.255(84)
(adoptedon16May2008)
international marine industry to address safety
issues.
A marine safety investigation should be separate
from, and independent of, any other form of
investigation. However, itis not the purpose of this
Code to preclude any other form of investigation,
including investigations for action in civil, criminal
andadministrativeproceedings.Further,itisnotthe
int
entof the Code foraState orStates conductinga
marine safety investigation to refrain from fully
reportingonthecausalfactorsofamarinecasualtyor
marine incident because blame or liability, may be
inferredfromthefindings.
Amarinecasualty meansanevent,orasequence
of events, tha
t has resulted in any of the following
which has occurred directly in connection with the
operationsofaship:
1 thedeathof,orseriousinjuryto,aperson;
2 thelossofapersonfromaship;
3 theloss,presumedlossorabandonmentofaship;
4 ma
terialdamagetoaship;
5 the stranding or disabling of a ship, or the
involvementofashipinacollision;
6 materialdamagetomarineinfrastructureexternal
to a ship, that could seriously endangerthe
safetyoftheship,anothershiporanindividual;or
7 severedamagetotheenvironment,orthepotentia
l
for severe damage to the environment, brought
aboutbythedamageofashiporships.
Final element of an investigation is report which
provide necessary information for avoid mentioned
threats and errors in the future. A marine safety
investigationreportcontains:
1 asumma
ryoutliningtheba sicfactsofthemarine
casualty or marine incident and stating whether
any deaths, injuries or pollution occurred as a
result;
2 theidentityoftheflagState,owners,operators,the
company as identified in the safety management
certificate,andtheclassificationsociety(subjectto
anynationallawsconcerningpriva
cy);
3 where relevant the details of the dimensions and
engines of any ship involved, together with a
description of the crew, work routine and other
matters,suchastimeservedontheship;
4 a narrative detailing the circumstances of the
marinecasualtyormarineincident;
5 analysis and comment on the causal fact
ors
including any mechanical, human and
organizationalfactors;
6 a discussion of the marine safety investigation’s
findings, including the identification of safety
issues, and the marine safety investigation’s
conclusions;and
7 whereappropriate,recommendationswithaview
topreventingfuturemarinecasualtiesandmarine
incident
s.
3 INVESTIGATIONPROCEDURESAND
TECHNIQUES
Each State is obliged to develops of investigation
procedures. Classification Societies provide
Collectoccurencedata
Determineoccurencedata
Identifythreatandunsafecondition
Identifyerrororthreat
Identifyunderlayingfactors
Identifypotentatalsafetyproblems
Developsafetyactions
213
investigation guidance which makes this process
withouterrorsandunnecessarydelay.
2
These guidance provide instructions for the
performance of incident investigation activities,
including:
IncidentInvestigationInitiation
DataGathering
DataAnalysis
RootCauseDetermination
GeneratingRecommendations
Reporting and Trending of Incident Investigation
Results
Marinecasualtyinvestigationcanbedividedinto
threemainsteps:
3.1 Step1:Datacollection&occurrencesequence
d
etermination
Thefirststageoftheinvestigationinvolvescollecting
theaccidentinformationasfaraspossiblewhichmay
be of interest in determining causes. Once the
information has been collected, the next stage is to
develop a sequence of events and circumstances. In
thisstage,theunsafeact
sanddecisionsorconditions
canbeidentifiedusingthecognitiveprocessmodel.
Figure2.SHELLModel&CognitiveProcessModel
3.2 Step2:Factorsidentificationandclassification
The objective of this stage is to classify unsafe acts
and/or conditions identified during previous stages
2
GUIDANCENOTESONTHEINVESTIGATIONOFMA‐
RINEINCIDENTS,ABS,2005
intohumanfactorgroupas:slip,lapse,mistakesand
violation. Also during this step environmental and
hardware factors should be identified. Identification
and classification process can be realized by experts
andsimulationsofthecasualtyprocess.
Main problem in this step is identifying of
underlyingfactorsthatmightcauseidentifiedunsafe
act
stooccur usingthe HumanFactorsIdentification
and Classification Model. Underlying factors are
classified into three categories, i.e., external
underlying factors, ship‐related underlying factors
andshippingcompany‐relatedunderlyingfactors.
Step3:Safetyactionsdevelopment
Thefinalstepofthefactorsinvestigationistoidentify
potential safety problems and to develop safety
act
ions in order to reduce the probability of
occurrence of human error and vessel construction
witharrangementand/ortomitigatetheconsequence
ofmarine accidents.Inthisstep, causal chains (with
brainstorming technique) can be used to assist the
identificationandtheselectionofthesafetyactions.
American Bureau of shipping develops ma
rine
incident investigation methodology MaRCAT™
(Marine Root Cause Analysis Technique) which is
designedforuseininvestigatingandcategorizingthe
underlying causes of incidents, including accidents
and near misses, with safety, health, environmental,
quality,reliability,productionandfinancialimpacts.
Figure 3. Task Triangle Showing Possible Depths of
Analyses
ABS GUIDANCE NOTES ON THE INVESTIGATION OF
MARINEINCIDENTS,2005
4 CASUALTYFACTORS
In necessity to provide for the development of the
emergency state will be introduced the following
definitions:
Incident‐themomentoftheevent,whichwillfind
ashipinadangerouscondition.
Loss event‐the moment of occurrence of the
sequence of events leading directly to the
destructionoftheship.
Ca
sualty period‐for the purpose ofthis studyit
wasassumedthatthisistheconditionofthevessel
requiring rescue action to saving the ship,
passengersandcrew.
214
Figure4.Maritimecasualtyprocess
Intheaimofmaritimecasualtyprocessdescribing
followingfactorswillbeused:
C
I – a priori factor shows the parameters which
determines casualty process track by statistical
analysis, model testing, simulation and heuristic
methods. A priorifactor is calculatedon basis of
rules, vessel construction, procedures and
assumed conditions of the casualty. CI shows
expectedimpactofeachfactorforthecasualty.
C
F–aposteriorifactorshowstheclassparameters
of the casualty process track on the basis of the
research, simulation and expert judgment after
casualty investigation.CI shows achieved impact
ofeachfactorforthecasualtyanditiscalculated
onthebasisofcasualtyinvestigation.
Stagesofoperationcrewinadangerouscondit
ion:
Figure5.Stepsofavesselscrewcasualtyactions
Generally qualitative estimates of the potential
outcomesfortheincidentareused.Itisnotpractical
to develop quantitative estimates of the potential
consequences for each incident. Therefore, the
incident investigation team will often use a loss
potential matrix to estimate potential consequences.
Although this is a very subjective estimate, it will
provide the guidance needed to develop effect
ive
correctiveactionsandtoperformincidenttrending.
Theprobabilityofrecurrence should estimate the
probability that the incident occurs again, assuming
that no corrective actions are taken. Estimating of
probability of each dangerous event and process
whichleadtothecatastropheisverydifficult
.Easier
method is using of classes for determining factors
influenceoncatastrophe.
Classofindividualfactorsdeterminetheirimpact
ontheprocessoffailureinrelationtothedestruction
of the ship or its evacuation. Class 5 indicates the
factorsleadingtothedirectdestructionofthevessel
or to prevent the escape, class 1 denotes no such
effect
s.
Factors are divided into six categories: threat,
crew, weather, vessel constructionand arrangement,
cargoandseasarea.
Table1.Casualtyfactors
_______________________________________________
ClassDescription
_______________________________________________
5 thedurationoftheshipinemergencycondition
shorterthanthatfortheevacuation,thefactorcaused
immediatedestructionoftheship,crewisnotableto
takeanyactionleadingtotheevacuationand/or
vesselrescue,thedesignoftheshipandthetechnical
solutionsmakesimpossiblerescu
ingtheshipand
evacuation,seaareamakesitimpossibletosavethe
shiporsurvivors
4 thedurationoftheshipinemergencynotsufficientto
completetheevacuationand/orrescuevessel,the
factormadeitimpossibletoevacuateandcaused
shorteningthetimetodestroytheshipcrewtook
actiontoevacuateandshiprescu
e,thedesignofthe
shipandthetechnicalsolutionsmakesimpossible
rescuingtheshipandmakesitdifficulttoevacuate,
seaareamakesitimpossibletosavetheshipand
makesitdifficulttorescuesurvivors
3 thedu
rationoftheshipinadangerouscondition
sufficienttoevacuate,butnotenoughtosavetheship,
thefactorhamperedtheevacuationandresultedin
shorteningthetimetodestroytheship,thecrewtook
allpossibleactionstosecuretheevacuationandship
recue,shipdesig
nandtechnicalsolutionshampering
oftheshiprescueandmakesdifficulttoevacuation,
seaareamakesitdifficulttosavetheshipandmakes
itdifficulttorescuesurvivors
2 thedurationofashipinadangerouscondition
sufficientthanneededforevacuationorrescuevessel,
thefactorhamperedtheevacuationbutdidnotresult
inthedestru
ctionoftheshipthecrewhastakenall
possibleactionstosecuretheevacuationand
restrictedtorescuetheship,shipdesignandtechnical
solutionsmakesitdifficulttosavetheshipandnot
hinderevacuation,seaareamakesitdifficulttosave
theshipandnothamperedrescu
esurvivors
1 thedurationofashipinadangerousconditionmuch
longerthanneededforevacuationorrescuevessel,
thefactordidnotaffecttheshipinanemergencyor
evacuation,thecrewhastakenallpossibleactionsto
secu
retheevacuationandrescuevessel,shipdesign
andtechnicalsolutionsdonothinderofrescuethe
shipandnothinderevacuation,seaareadoesnot
affectthepossibilityofsavingtheshipandsurvivors
_______________________________________________
Indexofaccidentpredictability:
IiFii
CCCAT
C
F and CIindex allows to assess the impact of
various internal and external factors on the
catastrophe.
C
Ffactorisevaluatedba singonassumptionofthe
theoretical impact of a given indicator for casualty.
DamageCondition
Incident Lossevent
OperationalCondition VesselDestroying
Casualtyperiod
Emergencyaction
Assessmentofsituation
Predictionofthesituation
development
Theabilitytorescueaction
Rescueaction
Thepossibilityofconducting
ofemergencyactions
callforSAR/evacuation
Identificationoftheincident
215
Thefactorclassescanbeachievedbeforetheaccident
basing on the event tree analysis or failure tree
analysisbytheheuristicevaluation,performedbyan
expertparticipating in disaster investigationand the
reports developed after. The expert may present
valuesof the parameterscharacterizingthe vessel in
relationtothedisaster:
typeofvessel
designsolutions,
spatialpla
nsoftheship,
technicalequipmentoftheship,
proceduresfortheship,
theorganizationofwork,
thequalityoftheshipʹscrew,
characteristics of the transported cargo and
passengers.
FactorC
Imaybe determined alsoonthe basis of
simulationandexperimentalanalysisofcasualty.
Factor C
F is determined based on the obtained
effectofthe(i‐th)factorintheprocessofcasualtyand
catastrophe. The index value is determined on the
basisofareportbytheexpertconsultants.
CATindexvaluesareobtainedfrom4to‐4.The
resultingvalueoftheCATdefines:
4‐
failure developed by an unexpected scenario,
the shipʹs structure, equipment, procedures,
organization of the crew did not work properly,
theweathermuchbiggerimpactthanexpected.It
couldalso mean errors of experts indetermining
thevalueofeachindicator.
0‐posed were correct assumptions about the
disasterandfitofallparameterscharact
erizingthe
ship,crewactionswereeffective.
‐4‐Failuredevelopedbyanunexpectedscenario,
the impact of each factorwas much smallerthan
expected, there was an overstatement of the
negativeintheanalysisofthedisaster.Thismeans
thaterrors of experts indet
erminingthe value of
eachindicator.
Theindexvalue4indicatestheneedforchangesto
thelawortheorganizationstaffonmattersrelatingto
the safety of the ship, a value of 0 does not require
any changes, while the value of‐4 suggests
overestimationofvesselconstructi
on,safetysystems,
organizationstowardsthesafetyofthecrew.
CATindexmaybeusedtoevaluatepredictionsof
events in relation to the individual experts. They
indicatewhenanoverstatementorunderstatementof
theimpactfactorsofthecrashforasingleexpert,or
you can refer to the individual fact
ors of failure,
pointing to their widespread underestimation or
overestimation.
Table2.CATindex
_______________________________________________
CATApriori
5 4 3 2 1
_______________________________________________
Aposteriori 5 0 1 2 3 4
4 ‐1 0 1 2 3
3 ‐2‐1 0 1 2
2 ‐3‐2‐1 0 1
1 ‐4‐3‐2‐1 0
_______________________________________________
To evaluate the obtained indicators CAT can use
averagevaluesofabsoluteerrors(MAE)orrootmean
squareerror(RMSE):
n
CATmCAT
MAE
i
n
CATmCAT
RMSE
i
2
RMESEismoresensit
ivetoextremevaluesofthe
error.CATmfactoristheexpectedvalueof0.
SumofallCindicatorsindicatesthequalityofthe
ship and its crew in relation to the presumed data
weatherconditionsindesignatedwaterareas.
Disadvantages of determining predictability
casualty factor depend on knowledge ab
out the
effectsofacatastrophewhichcansignificantlyaffect
theevaluationindexapriori,aposteriorifactorsare
alsodeterminedonthebasisofthereport,evidences
andtestimonyofwitnesses,soitmaybeanerroron
the assessment of causes. However advantages of
determining casualty predict
ability factor give the
possibilityof segregation casualty factorsand assess
theirreliability;allow ccheckingthe reliabilityof the
methods used for modeling and simulations and
generatetheabilitytoavoidtragedyinthefuture.
For most organizations, the first step towards
performing an investigation is the generation of a
Corrective Action Request (CAR). Although CAR
s
canbegeneratedformanyreasons,someoftheCARs
willresultintriggeringaninvestigation.
Table3.Maritimecasualties
__________________________________________________________________________________________________
No Name IMOno Date& PositionThreatCatastrophe Consequences
__________________________________________________________________________________________________
1 Riverdance 7635361 31.08.2008 Cargoshifting Capsizing TotalLossduetocapsizingand
OffLuneDeep grounding.Nobodydie
2 StarPrincess 9192363 23.03.2006
passagefromGrand Fire Fireon Thedamagedareacovered3
CaymantoMontegoBay boardverticalfirezoneson5decks
Nobodydie
3 Bou
rbon9351983 12.04.2007 ExternalCapsizing Totallossduetocapsizing
Dolphin Rosebankoilfield Forcesandlack 15crewmemebersdie
ofvesselstability
4 CouguarAce 9051375 23.07.2005 Debalsting Capsizing TotalLossofcargo
SouthofAleutianIslandsandweather
5 Rozgwiazda 17.10.2008 Wateringress Capsizing 5crewmemebers
SouthBaltic
andweather
__________________________________________________________________________________________________
216
Table4.Casualtyfactors
_______________________________________________
VesselC1 C2 C3 C4 C5 C6
_______________________________________________
Riverdance2 3 3 2 2 4
StarPrincess3 2 1 1 3 1
BourbonDolphin 5 5 2 2 3 1
CouguarAce2 2 1 2 2 2
Rozgwiazda5 5 3 2 3 1
_______________________________________________
In the table are shown parameters for a experts
judgementfactorsandtheCATindex.Firstshowsthe
mostoptimisticexpertiseofcasualtyfactors,thefifths
showsthemostpessimisticexpertise.
Table5.CATfactordeterminingfortheexamplecasualty.
_______________________________________________
I II III IV V
_______________________________________________
C1‐4‐2‐1 1 3
C2‐3‐1 0 1 4
C3‐2‐1 0 1 2
C4‐2‐1 0 1 3
C5‐4 0 0 1 2
C6‐3‐1 0 1 2
_______________________________________________
I II III IV V
MAE
‐3.00 ‐1.00 ‐0.17 1.00 2.67
‐4.00
‐3.00
‐2.00
‐1.00
0.00
1.00
2.00
3.00
4.00
MAE
I II III IV V
RMSE
3.109 1.155 0.408 1.000 2.769
0.000
0.500
1.000
1.500
2.000
2.500
3.000
3.500
RMSE
Accteptancelevel
Figure6.CATindexwithMAEandRMSE
Acceptance level can be established to skip
expertises with a great divergence. That method
eliminate methods witch conduct to unreal results
withacasualtyanalysis.
5 CONCLUSIONS
Rating disasters by the media is unreliable
informationleadingtoanincorrectassessmentofthe
causes and consequences of maritime disaster. This
implies the
actions of politicians influencing the
introductionofrulesonthesafetyofthevessel.
The media casualty assessment ischaracterized
by:
Visual aspects of maritime disasters‐as the
ʺgreaterʺarejudgedcrashrecordedbythemedia,
asexemplifiedbytherecentdisastersrelationships
passengershipsCostaConcordia.
Large asymmetry ratings events, resulting from
the nationality of the ship, survivors or body of
water , which was a disaster. The catastrophe in
the waters or the participation of citizens in
developed countries is consideredʺgreaterʺthan
occurring in underdeveloped countries , such as
theEUandthePhilippines;
Thelackofreliable,documentedknowledgeofthe
disaster;
Suggestandinterpreteventsbeforeexaminingthe
disaster;
The use of so‐calledmedia Experts (publicly
suggesting the cause of the crash, the predicted
failure scenarios‐without the knowledge of the
disasterbeyondtheformalreports).
Theuseof
indicatorscatastrophe(CAT)willallow
foraccurateassessmentofthepotentialactionsofthe
crew,theimpactoftheconstructionandequipmentof
the vessel and the impact of weather and local
conditions on the casualty process.It is necessary
therefore to introduce a wider range of indicators,
which
are able to describe ship crews activities in
emergency condition, vessel construction, vessel
arrangementandseaworthinessinfluence.
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XXXVIIIZimowaSzkołaNiezawodności,Szczyrk2008
SoliwodaJ.,Factorsdeterminingvesselsafetyassessmentin
operation,JournalofKONBIN,Wrocław2008
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Practices for a Safety Investigation into a Marine
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