399
1 INTRODUCTION
This paper presents the findings of the EU-funded
Erasmus+ project OPTIMISM, which builds upon the
outcomes of several earlier initiatives, including
Mai’der, SURPASS, SeaTALK, MarTEL, ACTs, ACTS
Plus, PROMETHEAS, and others [1]. Collectively,
these projects analysed over 1,000 maritime accidents
with the overarching goal of reducing incidents at sea.
The OPTIMISM project focuses on developing a
comprehensive training programme aimed at
supporting the effective implementation of the
International Safety Management (ISM) Code—a
framework introduced by the International Maritime
Organization (IMO) to enhance maritime safety. The
ISM Code consists of 12 core elements and provides
guidance on verification and certification processes. A
key feature of the OPTIMISM project is the systematic
analysis of past maritime accidents in order to extract
lessons learned and promote safer practices onboard
vessels.
The main objective of this paper is to explore further
insights that can be gained from accident investigation
reports and to determine whether ISM Code audits and
port inspection reports can contribute to a reduction in
the number of maritime accidents at sea and in ports.
For this purpose, a sample of approximately 130
accidents was selected from over 1,000 investigation
reports—many from 2010 onwards, with most
occurring in recent years. These incidents span various
ship types and accident categories, including collisions,
groundings, capsizing, falls from height, onboard fires,
and toxic fume inhalation in enclosed spaces. Each
accident was systematically recorded across several
parameters: accident number (1), vessel name (2), type
of vessel (3), type of accident (4) such as collision or fire,
description of the incident (5), cause of the accident (6),
Project OPTIMISM: Novel Means of Finding Root
Causes of Accidents and Incidence at Sea and Port,
as Well as Identifying Key Factors for Improved Safety
from Ship Audit and Inspection
R. Ziarati
1
, G. de Melo Rodriguez
2
, H. Koivisto
3
, J. Uriasz
4
, L. Singh
1
, A. Barzegarsedigh
5
,
A. Lazempour
1
, V. Makar
1
& A. Chronopoulos
6
1
Centre for Factories of the Future, Alingsås, Sweden
2
Technical University of Catalonia, Catalonia, Barcelona, Spain
3
Satakunta University of Applied Sciences, Pori, Finland
4
Maritime University of Szczecin, Poland
5
Centre for Factories of the Future, Kenilworth, United Kingdom
6
IDEC SA, Piraeus, Greece
ABSTRACT: This paper presents a set of methodologies for analysing accident investigation reports to enhance
learning from past incidents. While these reports are primarily designed to prevent accident recurrence, they
often overlook key contributing factors such as personal, organisational, and cultural influences—particularly
leadership practices and potential mental health issues that may have played a role. Moreover, accident
investigation reports vary in quality and do not always adhere to standardised frameworks, limiting their
effectiveness. This paper proposes a novel approach to accident analysis, offering a structured method to
distinguish whether an accident is crew-related or company-related - an essential differentiation, as these factors
require distinct management and preventive measures. The study draws on findings from multiple recent
projects, analysing over 1000 accident reports to develop a new taxonomy. This taxonomy aims to facilitate a
more systematic approach to accident analysis while identifying management deficiencies and crew-related
challenges, ultimately improving safety and operational practices.
http://www.transnav.eu
the International Journal
on Marine Navigation
and Safety of Sea Transportation
Volume 19
Number 2
June 2025
DOI: 10.12716/1001.19.02.08
400
casualty information (7), actions taken or
recommendations made (8), and whether the accident
is likely to recur (9). Additionally, in nearly all cases,
the ISM Code element or sub-element contributing to
or causing the accident was identified (10). The results
provide valuable insights into how adherence to the
ISM Code and targeted training can help prevent
future maritime incidents and enhance safety across
the sector.
Figures 1, 2 give details the year of the accidents
selected followed by type of accidents and the ship
type.
Figure 1. Accidents each year vs. Year of accidents
Figure 2. Number of accidents vs. Ship Type
2 MARINE SAFETY INVESTIGATION REPORTS
The marine safety investigation reports selected for
analysis in this study were chosen to represent a range
of recent accidents involving various ship types and
incident categories. During the review of these reports,
it became evident that many were less than satisfactory
in terms of providing comprehensive evidence and
actionable insights to reduce the likelihood of similar
accidents occurring in the future [1, 2, 3]. A significant
number of reports featured inadequate or poorly
substantiated conclusions, with recommendations that
were either vague or lacked practical relevance. In
several cases, critical details were inconsistent or
missing—for instance, the nature of casualties was not
clearly stated, and there was often no mention of the
key organisations involved in the incident.
This lack of clarity suggests that some investigators
may not have had a thorough understanding of the
requirements associated with the Safety Management
Certificate (SMC) or the Document of Compliance
(DOC). Frequently, there was no clear indication of the
administration responsible for the vessel, nor were
there references to ownership, crew, or even essential
documentation such as crew timesheets. Human factor
analysis was generally superficial, often reduced to
vague statements about inadequate training, with little
distinction between potential deficiencies under the
STCW Convention or specific ISM Code sub-elements,
such as non-conformities related to sub-element 6.5.
Furthermore, the quality and relevance of many
recommendations and corrective actions were found to
be insufficient for the purpose of accident prevention.
In most cases, key contributing factors were barely
addressed.
The primary sources for the accident data used in
this study were reports listed in the Global Integrated
Shipping Information System (GISIS) and those
maintained by the European Maritime Safety Agency
(EMSA). The study placed a strong emphasis on
evaluating the actions and recommendations provided
in these reports, comparing and validating them
against other significant works, including a report
submitted to the IMO titled “Lessons Learned and
Safety Issues Identified from the Analysis of Marine
Safety Investigation Reports” [2]. As part of this effort,
a new framework for reviewing accident reports was
developed (Ziarati, R. et al., 2024; De Melo Rodriguez
et al., 2024) [3, 4].
These analyses focused primarily on identifying
whether the root cause of each accident was
attributable to a quality assurance (QA) failure (Error)
or a human or systemic deficiency (Mistake), based on
the available data. Findings consistently highlighted
communication failures, human vulnerability, and
poor decision-making as the most common issues, with
other contributing factors such as crew members' lack
of knowledge and inadequate risk assessments by
companies also playing significant roles. The review
process also included an assessment of management
accountability, including whether issues related to
manning contributed to the incident.
Furthermore, the review of selected accidents,
including those reported in a recent paper submitted
by Sweden to the IMO (Zachau, J., 2023), highlighted
specific areas where the implementation of the ISM
Code could be strengthened [2].The methodology used
in accident report reviews is shown in Figure 3.
Figure 3. Flowchart Analysis of Investigation Results – Error
vs Mistake - Based Bains Simmons’ Behaviours Flowchart [5]
– See also Karakasnaki, M., et al., (2018) [6].
401
Figure 3 presents the Centre for Factories of the
Future’s (C4FF) methodology for accident reviews, a
diagnostic tool developed to systematically classify the
outcomes of maritime incident investigations. The
framework is grounded in rule-based behavioural
assessment and organisational analysis, helping
investigators determine not only what went wrong,
and hopefully why, with emphasis on the role of
intention, decision-making, and contextual constraints
focusing as to whether primarily this is a crew or
company/management fault.
This taxonomy begins first by distinguishing
whether rules were intentionally broken, forming the
primary bifurcation that determines the investigative
direction. If intentionality is confirmed, the analysis
evaluates whether the consequence was as intended.
When both conditions are satisfied, the act is deemed
sabotage, signalling deliberate and harmful
misconduct.
If the intended consequence did not materialise, the
model queries whether the task could have been
completed within the boundaries of existing rules. This
distinction captures instances where rule-breaking
may have been perceived as necessary. Where
compliance was feasible, yet substantial and
unjustifiable disregard for risk is evident, the action is
categorized as recklessness. If the risk was not
egregious, the model examines motivational intent,
differentiating between organisational gain (e.g.
efficiency, performance pressures) and personal gain,
to arrive at more nuanced classifications of non-
compliance.
In scenarios where the rules could not realistically
be followed, the model explores whether the event
occurred outside standard practice. If so, it is labelled
as situational rule breaking, acknowledging external
pressures or novel circumstances. If not, the case is
considered exception rule breaking, typically
involving procedural blind spots or gaps in rule
coverage.
In contrast, if rules were not intentionally broken,
the framework evaluates whether the correct plan of
action was selected. A “no” leads to a crew-related
classification, highlighting individual or team-level
errors. A “yes” redirects the focus to company-related
deficiencies, such as flawed procedures, inadequate
training, or systemic weaknesses in safety
management.
This figure operationalises investigative analysis by
aligning behavioural intent with procedural structure
and organisational accountability. It integrates human
factors, system limitations, and environmental context,
making it especially valuable for accident analysis,
compliance auditing, and continuous improvement in
safety-critical domains such as maritime operations.
The taxonomy also supports fair and consistent
attribution of responsibility, avoiding premature
blame while promoting evidence-based learning.
Once it is established whether root cause or
contributing factor to the accidents is company-related
then it has to be decided if it is a QA related matter or
not. The same is true if the accident is classified as
crew-related, the question is then is it negligence the
cause of or factor in the accident happening or a lack of
knowledge/competence.
With regard to root causes of or contributing factors
to the accidents, the current accident investigation
practice and reporting methodology do not provide a
uniform means of identifying the cause(s) of an
accident or incident. Therefore, it is difficult to learn
more about key ISM Code deficiencies/non-
conformities from the accident investigation reports.
The GISIS has made an attempt to establish a standard
for learning from accidents more systematically.
An in-depth analysis of some 130 accident reports
selected from 1000 accidents, taken place since 2010 by
C4FF, clearly show that the reports produced by
accident investigation agencies are primarily produced
to ensure these accidents do not occur again and often
do not specifically mention the ISM non-conformities.
Thus, they do not contain all the necessary information
to deduce effectively all the contributing root causes of
accidents or apply a standard means of reporting them.
When analysing accident investigation reports the
primary intention was to consider if the wrongdoing
was also as a result of recklessness or violation of the
rules (IMO’s or company’s policies, procedures and
plans) and to what extent the accident happened due
to inadequacy of the QA components (Error) or non-
QA factors (Mistake). If the latter it could highlight the
need for more training or lack of knowledge by a crew
member or that the failure was a system/machinery
failure; a good account of these is given in Horck (2007)
[7]. Also, the caveat that the company could be
deficient in providing the support to the crew members
to gain knowledge and skills or competence needed to
operate its systems and machineries. There is also a list
all other possible areas which could have had an
impact on the accident happening or making it worse.
Some 25 possible causes were found based on past
studies which corroborated well with the findings
from recent studies such as Stroeve et al (2023) [8].
Figure 4 offers a conceptual framework that
synthesizes the taxonomy discussed earlier in this
paper. It visually maps the hierarchical structure of
root causes of accidents and contributing factors into
four broad categories:
1. Quality Assurance (QA) Errors – These are typically
rooted in organisational oversight and reflect
compliance gaps that can lead to recurring non-
conformities.
Figure 4. Root Causes of Accidents
402
2. Non-QA Errors (Mistakes) – These encompass
human errors that fall outside formal QA processes,
including lapses in communication, decision-
making, and personal/team vulnerabilities. Here,
leadership and supervision emerge as critical
influencing factors. This category closely aligns
with what Baines and other scholars identify as
operational and managerial contributors to
incidents.
3. System Work Environment Errors – These errors
stem from physical and procedural conditions
aboard the vessel, such as machinery, process, and
design-related maintenance deficiencies. Failures in
these areas often have cascading effects, leading to
system-level breakdowns that compromise safety.
4. Natural Factors – External conditions like weather
and sea currents, while uncontrollable, often act as
amplifiers of latent system weaknesses. Though not
always preventable, these factors must still be
accounted for in risk assessments, voyage planning,
and emergency preparedness protocols
By mapping out these interdependencies, the C4FF
model offers a practical, easy-to-interpret guide that
aids in categorizing root causes during incident
analysis. It reinforces the argument that maritime
safety cannot rely solely on procedural compliance;
instead, it requires a multidimensional approach that
integrates technical, organizational, and human
factors.
Figure 4, further identifies four key areas for
consideration when deciding on root causes or
contribution factors for a non-conformity or an
accident/incident as presented below:
− O - Organizational Factors
− P - Personal Factors
− PPS - Psychological, Physiological and Behavioural
Factors
O = Organizational Factors
− Health and safety policies that are missing or
inadequate – Leading to stress and other health and
safety issues on board as opportunities are not in
place to identify and manage them appropriately
− Poor communication – Resulting in confusion not
knowing what to do and feeling that the crew is not
supported
− Poor management practices - Failing to explain
roles and responsibilities, unclear reporting lines,
failure to provide sufficient resources and failure to
manage crew effectively
− Inflexible working hours and long stints which do
not support seafarers in managing work/life
balance
− Giving seafarers tasks which are unsuitable for their
competencies or insufficient training or knowledge
and type of support provided with tasks which may
lead to non-achievement of objectives
− High or unrelenting workloads which mean
seafarers do not have time to complete tasks
− Unfair distribution of group work where one or
more persons are not doing their job properly and
others have to compensate for them
− Lack of procedures to deal with bullying or
psychological harassment
P= Personal Factors
− Vulnerability such as low self-esteem and
insecurity, or inadequate coping mechanisms that
seafarers may experience
− Lifestyle choices, for example alcohol and drug use
which can put seafarers at risk of developing mental
health problems
− Family history of mental ill health which may be
hereditary
− Problems at home such as domestic violence,
neglect, divorce or family breakdown
− Feeling cut off from family and friends or from the
local community which can lead to feelings of
isolation or rejection
− Negative or traumatic life experiences such as
threat of unemployment, homelessness,
bereavement, sudden illness, or being assaulted or
abused
− Big life changes even where these are positive such
as getting married, having children or moving
home which can be stressful
− Financial worries arising from threat of
unemployment, redundancy or business failure, as
well as mounting debt or worries about the
managing the cost of living
− Community or local environmental problems such
as prejudice and discrimination, violence and crime
or poor living conditions.
PPS = Psychological, Physiological and Behavioural
Factors
The Psychological, Physiological and Behavioural
Factors often putting pressure on seafarers’ mental
well-being are summarized in Table 1.
The model further connects these as cross-cutting
influences that underpin various types of Mistakes.
These categories mirror the human-centric aspects
outlined earlier in the paper, showing how internal
stressors and external conditions interact to impact
crew performance and safety .
Table 1. Factors Affecting Mental Health at Sea
(Source: Ziarati R., et al. 2020) [8].
403
3 ACCIDENT INVESTIGATION REPORT
ANALYSIS
A methodology was developed to extract notable
information from these accident investigation reports,
including the description of each accident, actions
recommended by investigators, the main root causes,
and any contributing factors such as inadequate risk
assessment, insufficient knowledge, inappropriate
decision-making, poor supervision, and similar
shortcomings. One column was dedicated to assessing
the likelihood of the accident recurring, with a
particular focus on how effectively investigators
addressed the core investigative task.
The information used to compile the accident
summary table was derived from C4FF’s structured list
of diagnostic questions and categorizations of causes
and contributing factors. This approach aimed to
accurately identify the primary root causes of each
accident while also distinguishing between types of
human error, such as Mistakes, Errors, Recklessness,
Lapses, Slips, Violations, or Sabotage. Two examples of
these accident investigation review summaries are
presented in Appendix 1, Tables 1.1 and 1.2.
In the final stage of summarising each accident, the
designated sub-focus group determined the primary
root cause and also assessed whether Human
Vulnerability, Decision Making, or
Communication played a role in initiating or
exacerbating the accident.
In Appendix 2, Tables 2.1 and 2.2, it is noteworthy
that the majority of safety issues identified were related
to Quality Assurance (QA), although non-QA factors
also played a significant role—either as the primary
cause or a contributing factor. In nearly all cases, there
were identifiable deficiencies linked to Human
Vulnerability, Decision Making, and Communication.
Furthermore, in almost half of the reviewed accidents,
issues relating to inadequate knowledge, skills or
competence were evident. This finding strongly
suggests that quality assurance systems within many
shipping companies require urgent improvement.
Throughout the review of reports from various
accident investigation agencies, particular attention
was paid to identifying whether factors such as Human
Vulnerability, Communication (including technical
and language-related deficiencies), and Decision
Making contributed to the incidents under
investigation.
4 LEARNING FROM NON-CONFORMITIES
(AUDITS) AND DEFICIENCIES (PORT
INPECTIONS)
Ziarati et al (2024) in their paper viz., Pareto Analysis
of ISM Code Deficiencies, demonstrated that a great
deal can be learned from non-conformities reported in
ISM Code Audit reports. Table 2 shows that there is a
correlation between ISM Audit non-conformities and
causes of accidents, viz., issues with non-compliance
with rules and regulations, maintenance and
shipboard operations. This clearly showed a lack of
rigid and robust ISM Code verification by flag States,
and while understandable, it is in need of serious
review.
Table 2. Pareto Analysis of ISM Non-conformities as against
those observed in LR Audits
In the same paper references were made to
deficiencies observed during port inspections and
concluded that again risk of accidents could be reduced
if deficiencies could be reviewed and eliminated.
Table 3. Learning from Port Inspections
The categories of the ISM Code deficiencies,
identified by the Black Sea Memorandum of
Understanding (MoU), as follows, has provided the
identified categories of the ISM Code deficiencies .
These encompass various aspects of maritime safety
management, starting with the core safety and
environment policy, company responsibility and
authority, and the specific roles of designated person(s)
and the master. Deficiencies also relate to operational
readiness, including the provision of adequate
resources and personnel, the conduct of shipboard
operations, and emergency preparedness.
Furthermore, the framework addresses procedural
integrity through the handling of reports of non-
conformities, accidents & hazardous occurrences, the
maintenance of the ship and equipment, proper
documentation, and the essential process of company
verification, review and evaluation to ensure ongoing
compliance and system effectiveness. It is worth
mentioning that other MOUs such as Paris MoU
consider several other deficiencies which are not
directly ISM Code related.
404
5 CONCLUSIONS
A comprehensive review of maritime accident
investigation reports was conducted with the objective
of identifying recurring safety issues and enhancing
the effectiveness of accident analysis. The findings
revealed that a common problem across many cases
was the lack of adequate risk assessments. In a smaller
proportion of the cases, the International Safety
Management (ISM) Code had not been properly
implemented.
As illustrated in the sample case studies (Tables 1.1
and 1.2), several ambiguities remain, particularly in
determining whether safety failures resulted from
insufficient crew knowledge or from the absence of
appropriate company-provided training and guidance
(as referenced in ISM Code, section 6.5).
Furthermore, the analysis of data in Tables 2.1 and
2.2 (Appendix 2) identified three recurring
contributory factors in maritime accidents: ineffective
communication, poor decision-making, and the failure
to properly consider human limitations.
This research led to the development of a taxonomy
categorising the causes and contributing factors of
maritime accidents. In parallel, methodologies were
introduced to distinguish between incidents
attributable to crew actions and those caused by
organisational failures. It also enabled differentiation
between non-conformities identified during ISM
audits and deficiencies detected during port state
inspections. These methods helped to determine
whether issues stemmed from management failures,
manning inadequacies, or other structural weaknesses.
In many instances, ISM deficiencies recorded
during port inspections should have been identified
earlier through ISM audits. A critical issue uncovered
is that even when non-conformities are flagged by
Administrations, Recognized Organizations (ROs), the
International Association of Classification Societies
(IACS), or Port State Control Officers (PSCOs), a
significant number of companies fail to implement
corrective measures.
A recent survey conducted by C4FF found that
more than half of the Administrations/ROs had
evidence of recurring deficiencies from previous ISM
Code audits. This points to a systemic shortcoming
among certain companies in addressing safety issues
identified during audits or port inspections.
As part of the OPTIMISM project, a follow-up study
has been launched to assess whether accident
investigation reports can reliably identify ISM Code
elements or sub-elements as either root causes or
contributing factors in maritime accidents. Where ISM-
related causes are evident, further analysis will seek to
determine the specific ISM Code components involved.
This continued work could have significant
implications for future reporting, analysis, and
classification of maritime accidents.
The OPTIMISM training programme is supported
by data from IACS and Lloyd’s Register, both of which
reveal thousands of non-conformities that, if
addressed, could help mitigate the risk of accidents at
sea. Likewise, thousands of deficiencies are recorded
annually during port inspections. Notably, within
Paris MoU regions, ISM Code deficiencies consistently
rank among the top ten most frequent inspection
findings.
APPENDIX 1 - INVESTIGATION REVIEW
SUMMARIES
Table 1.1.Micro Presentation of a Review of an Accident
Reference
RZ/GDMR1
Description
While chief officer (C/O) was checking the cleanliness
of the empty tanks prior to loading cargo at the next
destination port, he discovered dampness and
residue remaining inside one of the tanks and
decided to remove them with support from the bosun
and two ordinary seamen (OS), A and B without
having conducted gas freeing or checking oxygen and
gas levels beforehand and without carrying a
portable detector or wearing personal protective
equipment (PPE). The OS A felt drowsy and dizzy
and noticed OS B lying on the floor at the bottom of
the tank. Bosun was informed and the incident was
reported to C/O. Later, OS B recovered but the C/O
did not.
Key root
causes or
contributing
factors
Company-related (Error) - Inappropriate policy
manual - Inappropriate procedures, Inadequate risk
assessment.
Crew-related (Mistake) – Failure to have conducted
gas freeing or checking oxygen and gas levels
beforehand and without carrying a portable detector
or wearing personal protective equipment (PPE) -
Inadequate supervision - Problems with safety
culture - Inadequate decision-making/leadership of
operational tasks, including a lack of correction of
unsafe practices - Inadequate team composition -
Inadequate Knowledge - Inadequate
competence/skills - Incorrect perception.
Casualties
1 Fatality
Action taken
Shipping companies must constantly provide training
programs for crewmembers so that they do not let
their experience, practices, and work efficiency
concerns override the need to be safe in confined
spaces. The shipping companies, too, need to
maintain strict guidance and supervision through
internal audits.
Would it
happen
again?
No, if SMS was enforced and the crew were trained
and had access to a detector and wore the correct
PPE.
Table 1.2. Micro Presentation of a Review of an Accident
Reference
RZ/GDMR2
Description
Grounding and capsizing due to unsafe passing
distance to shore at high speed. The collision
caused severe income of water which led to the
immediate loss of propulsion and general
services.
Key Root Causes
Crew-related (Mistake) - Poor leadership and
Team operation - Captain's inattention/distraction
due to the presence of persons extraneous to
Bridge watch and a phone call not related to the
navigation operations. Company-related (Error) -
ISM non-conformity due to inadequate risk
assessment - The General Emergency Alarm was
not activated immediately after the impact. This
fact led to a delay in the management of the
subsequent phases of the emergency. The
analysis of crew certification, of the Muster List
(ML) and of the familiarization and training
highlighted some inconsistencies in the
assignment of duties to some Crewmembers.
Casualties
32 fatalities: 16 passengers, 4 crew and 4 still
missing.
405
Action-
Recommendation
The human element was the root cause in the
Costa Concordia casualty, both for the first phase
of it, which meant the unconventional action
which caused the contact with the rocks, and for
the general emergency management. A complete
review of safety culture recommended. About the
different scope of the Minimum Safe Manning
(MSM) document and the Muster List (ML), the
SOLAS regulation V/14.1 requires that the ship
shall be sufficiently and efficiently manned -
Marine Casualties Investigative Body – C/S Costa
Concordia Page. 7. This regulation makes
reference, but not in a mandatory way, to the
Principles of Safe Manning adopted by the
Organization by Resolution A.890(21) as
amended by resolution A.955(23).
Would it happen
again?
No, if the Master not distracted/inattentive and
did not sail too close to the coastline and pass at
an unsafe distance at nighttime and at high speed
(15.5 kts).
APPENDIX 2 - QA RELATED ACCIDENTS VS.
NON-QA ACCIDENTS AND COMMON CAUSES
OF, CONTRIBUTING FACTOR TO, ACCIDENTS
Tables 2.1 and 2.2 show the outcomes of micro analysis of
50 accidents divided equally for review by two different
focus group respectively. What is significant here is that both
focus groups are the view that company-related mistakes
(Errors) are more dominant than crew-related mistakes and
human vulnerability, poor decision-making and ineffective
person to-person communications are key causes of, or
contributing factors to, accidents.
Table 2.1. The First Set of Micro Analysis of Accident
Reviews
Table 2.2. The Second Set of Micro Analysis of Accident
Reviews
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