IMPLEMENTATION OF ACCIDENT

REPORTING TO REDUCE MARITIME

ACCIDENT ONBOARD SHIP

A Thesis Report Submitted to Bangabandhu Sheikh Mujibur Rahman Maritime

University,
Bangladesh (BSMRMU) in Partial Fulfillment of the Requirement for the Award of
Bachelor of Maritime Science (Engineering) Degree

Submitted by:
MD. SAIFUR RAHMAN MOLLAH

BMS Roll: E-52032

BMS Reg. No: 0102011600610
Cadet No: 4561
7th Batch Engineering

Supervised by

Mr. Engr. Dr. SAJID HUSSAIN

Commandant
Bangladesh Marine Academy, Chattogram – 4206
Bangabandhu Sheikh Mujibur Rahman Maritime University,

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IMPLEMENTATION OF ACCIDENT
REPORTING TO REDUCE MARITIME
ACCIDENT ONBOARD SHIP
 DECLARATION BY STUDENT

Name of Program: Bachelor of Maritime Science (Engineering)

Topic Name: Implementation of accident reporting to reduce maritime accident
onboard ship, I, MD. SAIFUR RAHMAN MOLLAH, hereby declare that report
presented here is genuine work done by myself under the supervision of MarEngr.
Dr. Sajid Hussain , Commandant, Bangladesh Marine Academy. The thesis or a
part of it thereof has not been published or submitted for an academic award of any
other university or institution. Any literature, data or work done by others cited
within this thesis has been given due acknowledgement and listed in the
bibliography section.

MD. SAIFUR RAHMAN MOLLAH Date:

Bachelor of Maritime Science (Engineering Department)
Bangladesh Marine Academy
Cadet No: 4561
Roll Number: E-52032
Registration Number: 0102011600610

3
 DECLARATION BY SUPERVISOR

This is to certify that the thesis entitled, "Implementation of accident reporting to

reduce maritime accident onboard ship", submitted by MD. SAIFUR RAHMAN
MOLLAH, bearing Cadet No:4561, Roll Number: E-52032, Registration Number:
0102011600610 to the Department of Engineering, Bangabandhu Sheikh Mujibur
Rahman Maritime University, in partial fulfillment for the requirements of Honors
in Bachelor of Maritime Science, is based on his original research and
investigation carried out under my guidance and supervision.

Supervisor

_______________________
MarEngr. Dr. Sajid Hussain
Commandant
Bangladesh Marine Academy
Date:
 Certification

This is to certify that the thesis titled, “Implementation of accident reporting to

reduce maritime accident onboard ship” was conducted by MD. SAIFUR
RAHMAN MOLLAH, bearing Cadet Number: 4561, Roll Number: E-52032,
Registration Number: 0102011600610, Department of Engineering, Bangladesh
Marine Academy, completed under my supervision. However, the student bears
full responsibility for the contents of this thesis.

Approved By

______________________________
MarEngr. Dr. SAJID HUSSAIN.
Commandant
Bangladesh Marine Academy
Date:

5
 Dedication

This research paper is dedicated to my Parents for their love,

prayers and encouragement throughout the duration of the
course.
 Acknowledgement

In the name of Allah, the Most Beneficent and the Most Merciful. First of all I am
thankful to Almighty Allah, who blesses me with sound health, abilities and gives
courage me to complete writing this thesis report successfully. I am cordially
thankful to Bangabandhu Sheikh Mujibur Rahman Maritime University, presenting
the undergraduate thesis program and allow the professionals to care about, handle
and contribute in the field.
I would like to express my profound and sincere thanks to my supervisor Mr. Engr.
Dr. Sajid Hussain Sir for his valuable guidance, direction and advice for the
successful completion of this paper. The names I would like to remember with
deepest sincerity are my friends and honorable seniors guiding me to carry on with
this study till the last moment with their valuable practical experience of bachelor’s
thesis paper writing.

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 Abstract

The objective of embedding technology on board ships, to improve safety, is not

fully accomplished. The paper studies marine accidents caused by human error
resulting from improper human-tech- neology interaction. The aim of the paper is
to propose measures to prevent reoccurrence of such accidents. This study analyses
the marine accident reports issued by Marine Accidents Investigation Branch
covering the period from 2012 to 2014. The factors that caused these accidents are
examined and categorized. Analysis shows that 31% of the marine accidents are
associated with technology.

Poorly designed and/or inadequately trained-for ship systems, as well as changes in

job perform- acne requirements and attitudes towards practices and procedures
influenced by technology de- feasted a safety system, contributed to the occurrence
of a human error and lead to accidents. The user-centered design and
improvements in training and organization of the ship’s crew are proposed as
preventive measures. This study underpins the importance of effective teamwork in
the effort to improve safety on board ships.
 List of Abbreviations and Acronyms

MAIC - Marine Accident & Incident Investigation Committee

ARPA- Automatic Rudder Plotting System

IUMI- International Union of Marine Insurance

IBS- Integrated Bridge System

INS- International Navigation System

ECDIS- Electronic Chart Display & Information System

MAIB- Marine Accident Investigation Branch

ISM – International Safety Management

SMS – Safety Management System

IMO- International Maritime Organization

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 Table of Content

Part 01 Introduction

1.1 Introduction……………………………………………………………. 12

1.2 Background of the study………………………………………………. 14

1.3 Objective of the study……………………………………………….…. 16

1.4 Limitation of the study………………………………………………….16

1.5 Organization of the study…………………………………………….... 17

Part 02 Literature Review

2.1 General duties and responsibilities of the master…………………… 18

2.2 General duties and responsibilities of the ship-owner………………. 20

2.3 Inadequate equipment design………………………………………… 24

2.4 Safety Culture ……………………………………………………...….. 26

2.5 The role of safety culture in preventing accidents………..………….. 28

2.6 Key features of an Effective Safety Culture………………………….. 28

Part 03 Research Methodology

3.1 Sequential Procedure…………………………………………………... 30

3.2 Study Area……………………………………………………...………. 30

3.3 Data collection...................................................................................…... 31

3.4 Data analysis……………………………………………………...……. .31

Part 04 Reducing Accident Implementation

4.1 Reduce maritime accident & General shipboard safety…………….. 32

4.2 Use of chemicals………………………………………………………... 34

4.3 Electrical and other fittings………………………………………….... 35

4.4 Shipboard emergencies and emergency equipment…………………. 37

4.5 Poor knowledge of own ship systems…………………………………. 39

4.6 Complacency…………………………………………………………… 41

4.7 Preventive measures…………………………………………………… 43

Part 05 Results and Discussion

5.1 Maritime Casualties……………………………………………………. 47

5.2 Serious Oil Spill………………………………………………………… 48

5.3 Lives lost onboard……………………………………………………... 48

5.4 The causation of accidents…………………………………………….. 49

5.5 Self-Regulation…………………………………………………………. 50

5.6 Culture of Compliance …………………………………………………50

Part 06 Conclusion

6.1 Conclusion………………………………………………………….…. 51

6.2 Recommendations………………………………………………….…. 52

References…………………………………………………………………. 53

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 PART 1 INTRODUCTION

(1.1) Introduction:

Fast technology development has strongly influenced maritime transport. In order to

reduce the risk of accidents, simplify handling of vessel’s systems and increase efficiency
in marine traffic, automated systems such as Integrated Bridge System, IBS, Integrated
Navigation System, INS, Central Alert Management Human Machine Interface, CAM-
HMI, Electronic Chart Display Integrated System, ECDIS, have been introduced.

However, in contrary to the widespread opinion that increased level of automation means
more safety, technology can contribute to the occurrence of accidents caused by human error
and hence defeat the aim that it had been introduced (Lutzhoft and Dekker 2002). A rise of
automation level amid reducing manning level could conduce to increased cognitive demands
resulting from the need to determine and maintain the mode awareness, the flexibility of a
supervisor to trace and to anticipate the behavior automated systems (Sarter and Woods 1995).
The increased capabilities and thus the high level of autonomy of automated systems present a
challenge for monitoring, integrating and interpreting in- formation provided by automation.
Additional problem comes from the problem of keeping track of the many systems
simultaneously, particularly in cases when it is hampered by poorly designed displays and
weak feedback. In these cases detriment in perform- acne on one task could occur, resulting in
potentially dangerous situations (Hetherington et al. 2006).

Complete understanding and dealing knowledge of functions and options provided by

automation for winding up tasks under various conditions, especially in unusual or
emergency situations, are required so as to avoid dysfunctional interaction between
operator and technology. On the other hand, a perception of technology as fully reliable
and trustful, can lead to underestimating risks and consequently to the change of attitude
toward seamanship practices and procedures, thus enabling occurrence of human error
(Schröder –Hinrichset al.2012).
Human error causes between 80 and 90% of maritime accidents (Ugurlu et al. 2015). An
analysis of 100 accidents confused showed that an outsized proportion of casualties are
caused by multiple errors made by multiple people (Wagenaar and Groeneweg 1987).
Furthermore, it had been demonstrated that each human error that was made was essential
for the accident to happen; in other words, if any of those errors within the chain of events
was prevented, accident wouldn't happen. Therefore, examining the role of the human
element is that the central issue in improving Maritime safety.

In this study, we have analyzed 55 accidents that occurred from 2012 to 2014 as reported

by MAIB1 (MAIB 2012; MAIB 2013, MAIB 2014). According to our review causes of
31% of the analyzed accidents are related to technology. To work out preventive
measures, it's important to spot the error-inducing conditions. Therefore, questions of
safety associated with technology are discussed and examples where they directly
contributed to the accident are provided parenthetically the foremost significant impacts
on the occurrence of human error. Some recon- emendations for fostering safety culture
are developed. A more in-depth have a look at the question of improving the organization
of the ship’s crew, as a vital fortification, is taken.

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(1.2) Background of the study:

There are various causes of marine accidents a number of these accidents caused by
collision of ships or internal setting fire or exposure to storms or stranding ships or direct
pollution incidents. Most of those incidents resulted from shortage in applying
international regulations associated with maritime safety. “Shipping is probably the
foremost international of all the world’s great industries and one in all the foremost
dangerous”, considering “the billions of plenty of material shipped on the high seas per
annum, the numerous miles of wake left behind, and also the seeming infrequency of
major accidents, shipping may well be said to be a rather safe industry” (American Bureau
of Shipping 2004).

Shipping accidents, “many involving spills of oil, are a catalyst for environmental
protection regulation over the past 40 years, environmental risk is linked to the sort and
amount of oil and/or hazardous substances being carried and therefore the sensitivity of
the marine area where any accident happens, a transparent link will be made between
environmental protection and shipping safety, with shipping accidents, often the topic of
dramatic media coverage, provoking a robust response from civil society and politicians”

“Maritime safety is increasingly significant in an exceedingly growing, global industry

where major accidents have wide reaching impacts, the industry picture is one in all
continual improvement with Lloyds List Casualty Survey noting an 18% decrease within
the number of accidents and also the International Union of Marine Insurers recording a
unbroken downward trend both in tonnage and therefore the percentage of the globe fleet
lost since 1980 (over the past 30 years)” (Arendt, Haasis, &Lemper, 2010).

In general, “accidents that involve property loss, death, injury, or environmental damage
are subjected to investigation, often with the target of identifying liability and culpability,
other uses for accident and incident data. one in every of these is to seek out, assess, and
review existing maritime incident/accident databases to spot causal factors and trends
related to those maritime events”.
The IMO “has long made a concerted effort to improve the safety record of all ships,
particularly those registered under flags of convenience, but that effort understandably
focuses on the safety of the ships themselves” (Hoppe, 2000). Therefore, accident research
code has been accepted as “an obligation in the 84th meeting of Maritime Safety
Committee (MSC), which was held by International Maritime Organization (IMO) in
London on dates between 7th and 16th May 2008. Such code includes a safety research,
recommended practices and international standards for marine accidents or marine
incidents” (IMO, 2005). “Parties to the convention shall undertake a marine safety
research for each serious marine accident in accordance with that code and provide its
findings in researches to be transferred to IMO. Within the internet site of IMO, a database
is available, which is called as GISIS. This database includes a module by the name of
marine incident and accident. This module contains marine accident reports which have
been reported to IMO” (IMO, 2010). “The international maritime authorities have made
significant efforts to promote safety at sea in the shipping transportation industry” (O’Neil,
2003). “The lessons taken from marine accidents experienced in the history form a basis
for the conventions and contracts produced for the prevention of marine accidents”
(Ugurlu, 2011)

The “IMO” adopted on 27 November “the Investigation of Marine Casualties and

Incidents” Code by “(resolution A.849 (20))” amended by “resolution A.884 (21)” and
“(resolution A.849 (20)”. “IMO” on 16 May 2008 also issue new version of “the
international standards and recommended practices for a safety investigation into a marine
casualty or marine incident” “(Casualty investigation Code)” This Code entered into force
on 1\1\2010 by “resolution MSC.255 (84)”.

The investigation of all dangerous marine accident are required by IMO, and that
investigation should determine the total loss of the ship, the victims of persons, and any
different types of damage to marine environment. The main aim of this study is to remedy
the shortage of applying the international provisions issued by the IMO regarding marine
safety to protect the environment.

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The importance of applying legal Measures to support safety of navigation is explored, the
shortage of application of “the International Safety Management (ISM) Code”2 provided
by IMO is reviewed also. Finally, the shortage of civil liability of damage resulting from
marine accident under International and National Jurisdiction is discussed with some
illustrative cases.

(1.3) Objective of the study:

The objectives of the study are implementation of accident reporting to reduce maritime
accident onboard ship. At first we are looking a countries current accident situation and
then we are looking forward to how can us able to remove accident.

(1.4) Limitation of the study:

In these studies the main limitation is information. In online and offline there are not lots
of information where I am able to get information. So in these things real life experiences
is very important effect in this study. I have lots of friends and senior they are sharing their
real life experience and in their real life experience I am able to complete thesis report.
Otherwise I have fallen problem.

(1.5) Outline of the Study

Part 1: This chapter mainly deals with the introduction, background, statement, objective,
significance and limitation of the study.

Part 2: This chapter is dedicated to illustrate the relevant literature

Part 3: The methodologies adopted for this study are in this chapter.

Part 4: This chapter discusses the procedures to reduce accidents.

Part 5: This chapter mainly deals with the result and discussion of this study.

Part 6 Conclusion and Recommendations of study is given in this chapter.

 PART 2 LITERATURE REVIEW

(2.1) General duties and responsibilities of the master:

The master should implement the ship owner’s safety and health policy and programmer
on board the ship. The policy and programmer, including safety rules and directions,
should be clearly communicated to any or all members of the crew. The master should
confirm that employment carried out on or from the ship is carried out in such how on
avoid the likelihood of accidents and also the exposure of seafarers to conditions which
might cause injury or damage to their health. The master should confirm that any work
requiring several seafarers to work together and which poses special hazards is supervised
by a competent person. The master should confirm that seafarers are assigned only to work
to which they're suited by age, state of health and skills.

The master should confirm that no younker is assigned to inappropriate duties. The master
should issue appropriate notices and directions during a transparent and easily understood
manner, in a very language or languages understood by the entire crew and verify, as
appropriate, that such instructions are understood. The master should ensure, in
compliance with national laws and regulations, moreover as collective agreements, where
they exist, that each one crew on board have: (a) a tolerable workload; (b) reasonable
hours of work; (c) reasonable rest periods during working hours, having special relevancy
work which is strenuous, hazardous or monotonous; and (d) rest days at reasonable
intervals. The master should investigate all accidents or near accidents and record and
report those in compliance with national laws and regulations and so the ship owner’s
reporting procedures.

The master should confirm the provision of operating manuals, vessel plans, national laws
and regulations, safety procedures and other such information to those seafarers who need
such information to conduct their work safely. Specifically, the master should ensure that

17
any necessary instructions and notices concerning the protection and health of the crew are
posted in prominent and suitable places or dropped at the crew's attention by other
effective means. Protection of Young Seafarers Recommendation, 1976 General duties
and responsibilities.

Where shipboard safety and health committees are established, the master should hold
regular meetings of the committee, at intervals of 4-6 weeks or pro re natal, and confirm
that the reports of the committee are given due consideration. The master should ensure
that safety equipment, including all emergency and protective equipment, is maintained in
good order and stowed properly. The master should confirm that everyone statutory drills
and musters are administered realistically, effectively and conscientiously at the specified
intervals and in compliance with any applicable rules and regulations. The master should
confirm that practice and training are given in emergency procedures. The utilization of
any special emergency equipment should be demonstrated to the crew at regular intervals.
Unless contrary to national law or practice, the master should confirm that one or more
designated persons are assigned to function safety officer. The master should institute the
"permit-to-work" system on board ship.

(2.2) General duties and responsibilities of ship-owners:

Generally, the ship-owner is primarily accountable for the security and health of all
seafarers on board ship. However, the day-to-day responsibility generally lies with the
master, who should observe the ship owners’ reporting procedures. Ship-owners should
provide adequate means and organization and may establish an acceptable policy on the
protection and health of seafarers per international and national laws and regulations. The
policy and programmer should come into being the responsibilities of all relevant parties,
including onshore staff and any subcontracting companies.
The development of the necessary degree of safety consciousness and the achievement of
high standards of safety depend on foresight, good organization and the wholehearted
support of management and of all seafarers. Therefore, ship-owners should consult with
seafarers' organizations with regard to the safety and health policy. Ship-owners should
ensure that design of their ships takes account of ergonomic principles and conforms to
relevant international and national laws, regulations, standards or codes of practice. Ship-
owners should provide and maintain ships, equipment, tools, operating manuals and other
documentation, and organize all planning and operations in such a manner that, as far as is
reasonably practicable there is no risk of accident or injury to seafarers. In particular,
activities should be planned, prepared and undertaken so that:

(a) Dangers likely to arise on board ship are prevented;

(b) Excessively or unnecessarily strenuous work positions and movements are

avoided;

(c) Organization of all work takes into account the safety and health of seafarers;

(d) Materials and products are used safely and pose no danger to seafarers' health;
and

(e) Working methods are employed which protect seafarers against the harmful
effects of chemical, physical and biological agents.

Ship-owners should observe the acceptable national and international laws when deciding
manning levels, and take into consideration the required standards of fitness, state of
health, experience, competence and language skills to confirm the security and health of
seafarers within the performance of their duties and responsibilities when operating on
board. In doing therefore the Ship-owners should:

(a) take account of the links between shipboard safety and acceptable working and living
conditions, including working hours, rest periods, bedding, mess utensils, adequate
accommodation and nutrition;
(b) Verify that the seafarer holds appropriate medical and competency certificates and
endeavor to confirm their validity
(c) recognize fatigue as a potential hazard to safety and health, therefore operations on
ships should be planned to take into account the expected period of work and the
prevailing conditions on board in order to minimize fatigue;
(d) Where circumstances do not allow adequate rest periods for seafarers, either the crew
complement should be supplemented or the vessel's work programmer should be

19
reassigned; and
(e) Take account of reports and recommendations made by the master or safety committee
regarding adequacy of numbers of seafarers, their degree of competence and skills
required for accident-free operation of the ship. Ship-owners should provide such
supervision as will ensure that seafarers perform their work with due regard to their safety
and health.

Ship-owners should direct the master and also the master should instruct the officers that
the work of all on board are organized in such the simplest way on avoid unnecessary risks
to safety and health. Ship-owners should make masters and seafarers fully tuned in to all
activities on board that might affect their safety and health. Ship-owners should arrange
for a delegated person from shore side Operations, preferably someone at the best possible
level within the management structure, to:

(a) Consult closely with the master and crew on all matters concerning safety and
health;

(b) Review the reports of shipboard safety and health committees and consider
any suggested improvements and other feedback information received from the
ship; and

(c) Monitor the performance of equipment and personnel. Ship-owners should

establish safety and health committees on board ships or make other suitable
arrangements consistent with national laws and regulations for the participation of
seafarers in the establishment of safe working conditions.

The duties and responsibilities of such committees, additionally as those of designated

safety representatives, are described below in section. When drawing up procedures
concerning safety and health committees and safety representatives, Ship-owners should
consult the relevant seafarers' organizations. Ship-owners should arrange for normal safety
inspections of all parts of their ships by competent persons at suitable intervals. The
inspection should also include tools, equipment and machinery on which the protection of
the seafarers may depend. Precautions should be taken in performing the inspection, as an
example, ensuring that tanks are ventilated or gas freed. Such inspections should, as a
minimum, accompany any national requirements. Ship-owners should ensure that, before
usurping their responsibilities, all seafarers are suitably instructed within the hazards
connected with their work and so the shipboard environment and trained within the
precautions which must be taken to avoid accidents and injury to health. The training
should address day-to-day shipboard operations additionally as contingency planning and
emergency preparedness. A training manual containing information and directions on
lifesaving appliances and survival methods should be kept in each mess room and toilet or
in each cabin.

The manual should be written in easily understood terms and illustrated wherever possible.
Ship-owners should take all practicable steps to create sure that, before seizing their
responsibilities, seafarers are made conscious of the relevant national and international
laws, regulations, standards, codes of practice, instructions and advice regarding the
prevention of accidents and injuries to health. The linguistic abilities of the seafarers
should be taken into consideration within the dissemination of material. Ship-owners
should provide appropriate medical equipment and trained personnel in accordance with
national laws and regulations.

The International medical guide for ships, or a national equivalent, should be carried on
board. Ship-owners should report occupational accidents, diseases and dangerous
occurrences to the competent authority in accordance with national laws and regulations.
All accidents to seafarers resulting in loss of life or serious injury should be reported
forthwith to the competent authority2 and an investigation of these accidents should be
distributed. Other injuries resulting in incapacity from work for periods of it slow as could
even be per national laws or regulations, similarly as prescribed occupational diseases,
should be reported to the competent authority within such time and in such form as is
additionally specified. Ship-owners should investigate all accidents and near accidents,
analyses their underlying causes and convey what's learned throughout the company as

21
appropriate. Ship-owners should also consider establishing a near-accident reporting
system.

Ship-owners should encourage seafarers to report all unsafe and unhealthy conditions or
operations. Ship-owners should provide each ship with the mandatory equipment; manuals
and other information to form sure that everyone operation are applied in such how on
reduce to a minimum any adverse effects on seafarers' safety and health. Ship-owners
should provide proper information to the seafarers regarding safety and health hazards and
measures related to the work processes. This information should be presented in a very
form and language which crew members can easily understand.

2.3 Inadequate equipment design:

A comprehensive understanding of the working environment on board is critical to style

equipment that fit the particular needs of seafarers under all conditions. Otherwise, the
planning of technology can present a challenge for working safely and efficiently. For
instance, layout of workspaces and arrangement of controls and displays could also be
inadequate or brightness and loudness of important alarms and displays might not be
enough to warn the operator about important changes, like automatic or inadvertent mode
transition. In 8 out of 55 analyzed accidents, one in all the most contributing factors was a
poor equipment design.

To illustrate an impact of poor design on human performance, several examples are

provided. Control console ergonomics was one of the factors contributing to heavy contact
of ferry Sirena Seaways with the berth at Harwich (MAIB 2014a). The master and officer
of the watch were not in full command of the vessel’s propulsion system, partly due to the
layout of the propulsion control con- soles. Two buttons on the bridge central console were
positioned closely, and one of them, starboard controllable pitch propeller (CPP) back-up
control button, not fitted with a protective cover, was most likely pressed inadvertently
together with ‘lights up’ button. Unaware of the fact that the back-up control system is
activated, the master thought that he transferred full control of the vessel to the port
bridging. The transfer of the combinatory lever control between consoles was confirmed
by ‘in-command’ lamp. However, combinatory levers had not control of the CPP, because
once activated, the back-up control systems` commands overrode those from the
combinatory levers. The facts that ‘in-command’ lamp was lit regardless whether the
back-up control system was active and that was hard to see the glow of the back-up control
lamp on the bridge wing console enabled misunderstanding over which the system hand
control.

The importance of designing equipment considering under what circumstances it can be

used is illustrated by the case when the master wasn't able to warn the passengers and crew
of the upcoming contact of the vessel Millennium Diamond with the London Tower
Bridge (MAIB 2015). The mate, who was at the helm, became distracted while replaying
an unexpected VHF message from London VTS about the closure of the Tower Pier, the
vessel’s destination. The mate wasn't ready to maintain a correct lookout and monitor the
rudder angle indicators while operating the VHF set because of the layout of wheelhouse
equipment and he didn't notice that the vessel was heading towards the south pier of the
Tower Bridge. Immediately before the vessel struck the bridge, the master used the
general public address (PA) microphone in a trial to instruct the passengers to take a seat
down and brace themselves. However, ergonomic deficiencies of the arrangement and
settings of the communication system, which weren't significant during routine operation
of the vessel, became crucial in emergency situation because they disabled broadcasting of
the master’s message. Namely, the PA system was set to the river guide mode and
activating the microphone didn't automatically take priority over pre-recorded broadcasts.
In an exceedingly situation of an inevitable contact, the master forgot to vary the electric
switch before approaching the microphone. Later, when he was standing by the
microphone, located on the starboard, he couldn't reach the switch, located on the port
side.
On the other hand, ergonomically efficient bridge de-sign was one of the contributing
factors to the grounding of the general cargo vessel Fri Ocean due to the unaccompanied
officer on the watch who felt asleep (MAIB 2013b). The bridge layout was designed to
enable a watch keeper to monitor the vessel’s position and adjust the vessel’s course while

23
seated in the port bridge chair. An opportunity to conduct much of the watch sitting down
increased the potential for a fatigued officer to fall asleep.

2.4 Safety Culture:

This brochure provides some basic advice on the successful implementation of a good
safety culture within shipping companies as required by the IMO International Safety
Management (ISM) Code. The intention is to assist companies, managers and seafarers to
fulfill the spirit moreover because the letter of the ISM Code. Following the complete
implementation of the ISM Code, which became mandatory for all ships via the SOLAS
between 1998 and 2002, there has been a significant reduction in maritime casualties,
serious oil spills, and – most significantly – the amount of lives lost on board international
cargo ships (see graphs). However, variety of recent status incidents suggest that the
absence of a completely implemented safety culture is still a difficulty which some
shipping companies may have to address with additional rigor. In particular, this includes
the vital need for all concerned to know the link between unsafe acts and heavy incidents
that will cause loss of life or serious damage to property and also the environment. The
importance of fixing behavior, and avoiding negative attitudes or complacency towards
safety and environmental protection is additionally underlined. As well as exploring what's
meant by a good safety culture, the subsequent contains some basic guidance on risk
assessment and risk management, which are important tools in delivering an efficient
safety culture. Safety culture is the collection of beliefs, perceptions and values that
employees share in relation to risks within an organization, such as a workplace or
community.

Safety climate is the perceived value placed on safety in an organization at a particular

point in time. These perceptions and beliefs can be influenced by the attitudes, values,
opinions and actions of other workers in an organization, and can change with time and
circumstances.
International Labor Organization (ILO) estimates that worldwide around 340 million
occupational accidents and 160 million work related illnesses occur annually.
Approximately 2.3 million individuals lose their lives due to work-related accidents or
diseases every year which is an astounding 6000 deaths every single day, and costs the
global economy a staggering $1.25 trillion or 4% of the world’s GDP annually (ILO,
2012). American businesses incurred annual losses to the tune of USD 170 billion (Leigh,
2011), while in the UK, in 2011/12, workplace illnesses cost an estimated £13.8 billion,
(HSE, 2013), and in Australia $60.6 billion in the 2008–09 financial year (Safe Work
Australia, 2013).

Shipping is one of the most dangerous industries in the world; between 2003–12, the fatal
accident rate in shipping was 21 times that of the general British workforce, 4.7 times of
that in the construction industry and 13 times of that in manufacturing (Roberts et al,
2014). Kristiansen (2005) found that shipping has a fatality frequency of 1.9 – 2.1 per
thousand, against 0.15 for industry, 0.3 for construction and 0.9 – 1.4 for mining. Ship
operators, through the P&I industry, are estimated to deal with third party liability claims
for personal injury, illness and death totaling more than $400 million a year (UK P&I,
2013). The Club finds that despite the number of personal injury and illness claims
stabilizing, the per capita cost of the individual claims has risen by over 300% in recent
years, and individual injury and illness claims now cost more than cargo claims. Between
2005 and 2010 the average cost of Members’ claims was about $12,000 per claim. For the
Swedish Club (2013), the claim costs for illness and injury made up 8% of all claims
between 2009 and 2013, as opposed to 10% for pollution claims, while Scald (2013)
reported that injury claims were second highest after those related to cargo. Data provided
by a major P&I Club revealed that in the period between February 2007 to November
2011, there were 3,580 injury claims, resulting in costs of USD 111,622,000. NEPIA
(2012) reported that over the past 5 years, crew illness and injury claims accounted for
20% of all of claims, UK Club (2014) reported net notified claims of approximately $50
million in the year 2013, while American Club (2012) reported average cost of injury
claims to be at around $28,000 per case. For P&I clubs, the big concern continued to be
the “human element”, and human error remained the major factor in many claims.

25
2.5 The role of safety culture in preventing accidents:

At the risk of stating the obvious, the underlying purpose of a Safety Management System
(SMS) that embraces an effective safety culture is to prevent ‘accidents’. Accidents and
unintended pollution incidents do not just happen – they are caused, usually by more than
one factor coming together at a particular place and time. Change any one of these factors,
even slightly, and the accident would probably not occur. Instead one would experience
what is termed a ‘hazardous occurrence’ or a ‘near miss’ – in other words a ‘near
accident’.

By its very nature, safety culture is multidimensional, and factor analysis is the most
widely used technique for its analysis (Havold, 2007). Field and social media survey was
done, while an analysis of the responses would provide information on the alignment of
safety climate and safety culture and accident reporting is a major part of safety culture
onboard ship.

2.6 Key features of an Effective Safety Culture:

1. Recognition that all accidents are preventable and only usually occur following unsafe
actions or a failure to follow established procedures.

2. Management and personnel who think constantly about safety. An effective safety
culture will support a shipboard environment that encourages and requires all on board to
proactively considering their own and others’ safety. In this way individual seafarers
assume responsibility for safety rather than relying on others to provide it. Through mutual
respect, increasing confidence in the value of the safety culture results in a more effective
Safety Management System.

3. Always setting targets for continuous improvement, with a goal of zero accidents and
ISM Code non-conformities.
 PART 3 RESEARCH METHODOLOGY

3.1 Sequential Procedure

Primarily, the topic was selected based upon the research interest and analysis of the
alarming issue in the present maritime industry. The reasons and objectives behind
selecting the topic have been illustrated in the first chapter. The limitations and difficulties
for the study were analyzed and the suitable method to carry out the study was selected.
The existing literature on the topic was studied for further information.

The sequential procedure reflects the methodology and overview of the thesis. What is the
goal? The way and the probable outcome after completing the thesis have been mentioned
in this section accordingly. After observing the methodology i.e., the chronological
development, the procedure will be started. In the end, we will get the limitations in our
study and terminate the project with recommendations in the conclusion.

3.2 Study Area

A major issue of shipping is the accidents onboard. The IMO has put many regulations in
order to combat this problem. The maritime sector is always searching for ways of
reducing accidents. Accident reporting is gradually increasing relevance and interest to the
global maritime sector. The study area of this paper consists of maritime regulations
regarding safety culture, automation, culture of compliance, implantation of ISM code etc.

27
3.3 Data collection

This study has been carried out based on secondary data entirely. Secondary data were
collected from topic related articles, journals, thesis, relevant books, magazines,
publications, government websites, multimedia and information through the use of
Internet.

3.4 Data analysis

Data collection and analysis has been carried out from Science Direct, which is a website
that can provide access to a huge database of scientific research and studies. For the
statistical analysis and tabulation of this study, Microsoft word 2013 and Microsoft Excel
2013 were used. All the graphs and tables had been illustrated by the usage of these
particular software’s. The statistical measures like numbers and percentage distributions
were used mathematically in order to describe the variables of this study.
 PART 4 REDUCING ACCIDENT IMPLEMENTATION

4.1 Reduce maritime accident & General shipboard safety:

Minor deficiencies within the structure, equipment or furnishings (for example, protruding
nails and screws, loose fittings and handles, uneven and damaged flooring, rough and
splintered edges to woodwork and jamming doors) may cause cuts, bruises, trips and falls.
They should be repaired as soon as they're noticed. Any spillage of oil or other substance
likely to cause a hazard should be removed immediately. Accumulations of ice, snow or
slush should be removed from working areas and passages on deck. If asbestos-containing
panels, cladding or insulation work loose or are damaged within the course of a voyage,
the exposed edges or surfaces should be protected pending proper repair by a suitable
coating or covering to forestall asbestos fibers from being released and dispersed into the
air.

Known asbestos-containing materials should only be disturbed for the aim of essential
maintenance and then only in strict compliance with national or international
requirements, as appropriate. In general, the use of asbestos insulation should be
prohibited. Flickering lights may indicate faults in wiring or fittings which might cause
electric shocks or fires. They should be investigated and repaired by a competent person.
Failed light bulbs should get replaced as soon as possible. Instruction plates, notices and
operating indicators should be kept clean and legible. Heavy objects, particularly if placed
at a height above deck level, should be stowed securely against the movement of the ship.
Similarly, furniture and other objects likely to fall or shift during heavy weather should be
properly stowed or secured. Doors, whether open or closed, should be properly secured.
Coils of rope and wires on deck should be located so on not pose a tripping hazard.

Under no circumstances whatsoever should seafarers exchange a bight of a rope or wire

which is lying on deck. Seafarers should never stand or move across a rope or wire that's
under strain. Accident prevention on board ship. Ropes and wires are frequently under
strain during mooring operations and seafarers should, the utmost amount as possible,
always interchange a section of safety from whiplash should ropes or wires break. The

29
stowage and dispersal of deck or machinery equipment should be planned and arranged so
each item has its proper place. Seafarers should stand faraway from any load being lifted
and cannot walk near or

Underneath any load being lifted or while it's suspended. Litter presents a health risk and
should cause slips, falls or conceal other hazards. It should be disposed of in compliance
with the acceptable MARPOL legislation.1 Tasks should be applied with account being
taken of possible risks to other persons; as an example, water from hosing down the deck
may enter other spaces and lead to slips and falls. Aerosols having volatile and
inflammable content should never be used or placed near naked flames or other heat
sources even when empty. (1) Seafarers should have appropriate and up-to-date
vaccinations and inoculations. (2) Small cuts and abrasions should be treated immediately.
(3) Precautions should be taken to avoid insect bites. Specifically, anti-malaria precautions
should be taken before, during and after the ship visits ports where malaria is thought to
exist.
High standards of non-public cleanliness and hygiene should be maintained the least bit
times. Washing facilities should be provided in toilets. Hands must always be washed after
using paints or after possible exposure to toxic substances. Working in conditions of high
humidity and warmth may cause heat hyperpyrexia or heat stroke. Sensible precautions
should be taken, including the drinking of sufficient water and therefore the taking of
additional salt, if appropriate. Seafarers should protect themselves from the sun in tropical
areas and learn that prolonged bathing, even when the skin is protected, could also be
harmful. Seafarers should be made conscious of the health hazards associated with
smoking.

4.2 Use of chemicals:

Toxic and other hazardous substances and products should be used and stored in such a
way those users and others are safeguarded against accidents, injuries or particular
discomfort. A record (product data sheet) should, when obtainable, be kept on board,
available to all users, containing sufficient information to determine the degree of the
danger posed by the substances. If possible, the substance should be stored in the original
packaging or in another correspondingly labeled packaging that cannot give rise to
confusion. Such substances must be stored in a locked, well-ventilated room. Chemicals
should always be handled with extreme care, protection should be worn and the
manufacturer's instructions closely followed. Particular attention should be paid to
protecting eyes. Some cleaning agents, such as caustic soda and bleach, are chemicals and
may burn the skin. A chemical from an unlabeled container should

31
Never be used. Exposure to certain substances such as mineral oils, natural solvents and
chemicals, including domestic cleaning agents and detergents, may cause dermatitis.
Suitable gloves should be worn when using such substances and the owner should provide
suitable barrier creams which may help to protect the skin.

4.3. Electrical and other fittings:

Unauthorized persons mustn't interfere with electrical equipment and fittings. All electrical
faults in equipment, fittings or wiring should be reported immediately to the appropriate
responsible person. The overloading of a circuit should not be permitted because it can
cause fires. Portable heaters carried as ship's equipment mustn't be used except in
exceptional circumstances and with due warning of their accompanying dangers. Personal
heating appliances mustn't be used under any circumstances. All portable electrical
appliances should be isolated from the mains when not in use. All personal electrical
equipment in accommodation areas should be connected only by standard plugs fitting
into the sockets provided. Extension leads and multi-socket plugs should not be employed
in accommodation areas for connecting several items of electrical equipment to 1 plug or
socket. When seafarers use portable equipment or portable lamps they have to confirm that
any flexible cables passing through doors, hatches, manholes, etc., are protected which
their insulation isn't damaged by the closing of doors, covers or lids. Seafarers mustn't site
private aerials within the vicinity of the vessel's aerials. Seafarers shouldn't try and work
on or repair their personal mains powered radios, storage device players or other
equipment without removing the mains plug, and can have the equipment checked by a
competent person before plugging it in again. Wall charts giving instructions on
emergency first-aid treatment to seafarers who have suffered electric shock should be
displayed in appropriate places about the vessel – all seafarers should understand and be
able to follow the procedures shown on the notices.

33
4.4 Shipboard emergencies and emergency equipment:

The master should make sure that a muster list is compiled and well-kept up to now which
copies are displayed in conspicuous places throughout the ship. The muster list should
contain details of the final alarm signal and other emergency signals and also the action to
be taken when such signals are activated. The means by which the order to abandon ship is
given should even be included. The muster list should indicate the individual duties of all
personnel on board and every one crew members should lean written details of their own
duties. All seafarers concerned should muster at a drill wearing the suitable clothing. The
aim of drills is to familiarize personnel with their respective duties and to confirm that
they will do those duties in an appropriate manner. Each trained worker should participate
in drills in accordance with national and international requirements.

The timing of drills should be varied to make sure that seafarers who thanks to their duties
haven't taken part during a particular drill may participate within the next drill. Seafarers
should receive training as soon as possible, if possible before joining the ship, to confirm
that there's no period of your time when the seafarer is incapable of polishing off safety-
related responsibilities. Drills often involve the entire crew but it'd be preferable to confine
certain drills to crew members with specific tasks. Although drills are a necessary a part of
emergency training, a training scheme should encompass over just drills. Information
should be to the whole. Fire protection devices, fire-extinguishing appliances, device and
other safety equipment should be provided in accordance with the regulations applicable
to the ship and to the satisfaction of the suitable authority.

This equipment should be maintained in good order in accordance with the manufacturer's
instructions and kept available to be utilized in the smallest amount times. Seafarers
mustn't interfere with or discharge any device without due cause, and will report any faults
or cases of accidental discharge to a responsible officer. Immediately after joining, when
appropriate, seafarers should familiarize themselves with the location of the fire-fighting
appliances on board, the operation of such appliances and their effectiveness on differing
kinds of fires. This information should be verified by a responsible officer. (For guidance
with relevance passenger vessels. Appropriate crew members on board should be trained
within the employment of the next fire-fighting appliances: (a) all types of portable fire
extinguishers carried on board; (b) self-contained breathing apparatus; (c) hoses with jet
and spray nozzles; (d) any fixed fire-fighting system like foam or carbon dioxide; (e) fire
blankets; and (f) firemen's outfits.
When possible, fire drills should be held in port yet as perplexed. Although many fires
occur in port, it should prove difficult to rearrange a drill with the local fire authorities.
This problem could also be partly resolved by instructing the crew on the character of
shore requirements using the contents of the fireside wallet (which should be positioned by
the access arrangements and which contains information required by shore fire authorities
who are required to fight a fire on board ship).

It is important that the symbols used on a ship's readying plan are understood by shore fire
personnel. Graphic symbols should be used the maximum amount as possible. as an
example, a replica of the IMO Pocket guide to cold water survival, might be provided to
every seafarer. 2 SOLAS, 1974, Chapter II, as amended. 3 These are the symbols
recommended in Resolution A.654 (16) (1989), of the IMO. Accident prevention on board
ship. Efficient fire-fighting requires the total cooperation of personnel altogether
departments of the vessel. For the aim of a fireplace drill a scourge of fireplace should be
assumed to possess occurred in some a part of the ship, the alarm should be activated and
therefore the requisite actions taken be in accordance with the ship's safety and health
policy.

The type and position of the fireside scenario should be varied during a very well-
conceived sequence which covers most parts of the ship and each one sorts of fire-
fighting. Locations could include: (a) holds, tanks and other spaces like forepeak stores
and paint lockers; (b) engine or boiler rooms; (c) accommodation spaces like cabins and
laundry rooms; and (d) galleys. 6.2.11. Fire drills should be as realistic as circumstances
permit. When possible, local fire-fighting equipment, like extinguishers, should be
activated and also the visibility of self-contained ventilator masks should be reduced to
present the impression of operating within a smoke-filled atmosphere. The fixed water

35
fire-fighting system should be used and room staff should confirm that the fireside pumps
are operated which full water pressure is on the fireplace mains. The emergency fire pump
should even be used for fire drills and personnel should be trained within the operation of
other fixed systems like foam and acid gas. All equipment activated during fire drills
should be immediately replaced with fully loaded appliances. Seafarers should be
exercised within the closing of openings and so the closing down of ventilation systems.
Fire place drills are often held because the primary stage of an abandon ship drill.

4.5 Poor knowledge of own ship systems:

Maritime education and training must enable the crew members to use equipment properly
under various and changing conditions. An operator must have an adequate knowledge on
the device operation, its abilities and limitations in order to avoid mishaps. However, new,
more complex automated systems are constantly introduced on board vessels and it is
difficult for a seafarer to keep pace with rapid changes. Additionally, equipment designs
not MAIB –

Marine Accidents Investigation Branch standardized, and it can differ even on board
vessels by the same company. For example, over 30 different designs of the interface user
of ECDIS equipment exist (MAIB 2014b). The International Maritime Organization
(IMO) mandates generic ECDIS training, but decision on the necessity and deform of the
type specific training is made by Flag States and owners. Therefore, seafarers have of- ten
to familiarize with their own vessel systems and de- vices, which they have not used
before, immediately after embarkation. They have to do that as soon as possible,
simultaneously with familiarization or refreshment with company rules and procedures.
Furthermore, operating manuals are often extensive, sometimes written without full
insight into user requirements and it could be difficult to extract the most important
information within a limited time. Furthermore, there are cases when some equipment is
completely renewed but old usage instructions and maintenance manuals are not replaced.
That can be dangerous, especially when the equipment breaks down and needs to be
repaired quickly for safety reasons. These issues contribute to stress and fatigue, factors
that cause maritime accidents (Berg2013)

The introduction of a new technology sometimes re-quires delivering go for type specific
training in short period of time. Therefore, it could be difficult to provide effective and
sufficient training. Poor knowledge of the town ship systems contributed to 15% of the
analyze accidents.

A grounding of the oil/chemical tanker Viton the Verne Bank in the Dover Strait, England,
is an example of accident caused by an insufficient level of knowledge about the ship
equipment (MAIB 2014b). Ovit’s primary method of navigation was an ECDIS. All of
Ovit’s deck officers had attended a generic ECDIS course and a type specific ECDIS
training. However, they were not able to safely navigate using it. The intended route
through the Dover Strait, prepared by inexperienced and unsupervised junior officer,
contained errors including passing directly over an area with shallow waters. The route
was not properly checked for navigational hazards using the ECDIS check-route function.
ECDIS safety settings were not appropriate. The scale of Electronic Navigation Charts in
use, selected by the chief officer, was unsuitable for the area and the ECDIS ‘auto-load’
feature was switched off. It had not been reported that the system audible lamas not
functioning, indicating that the crew members were unaware of the significance of the
system’s alarms. The accident investigation revealed that ECDIS training under- taken by
the ship’s master was not effective due to the fact that it was delivered to ship’s officers of
varying ranks and experiences. That prevent the ship’s matter or even his lack of

37
knowledge and ask questions.

4.6 Complacency

Along with the increased computerization and automation on board vessels, the role of
the seafarer has changed considerably, from the foremost operator au fate of the systems
to more or less passive observer. Since cognition and skills don't seem to be needed to
perform passive control actions, there is a prospect of losing such knowledge and skills
(Bielić et al. 2011). Simultaneously, dependence on and trust in technology is growing,
giving rise to new error sources and risks.

The highly automated systems of recent vessels may foster complacency, a way of self-
satisfaction within the course of a loss of awareness of potential dangers. As a result, the
operator’s vigilance decreases. A complacent behavior is manifested as a failure to
closely monitor and check instruments, looking forward to at least one source of
knowledge instead utilizing all navigational aids, overlooking procedures, resorting to
incorrect practices, missing important signals, misinterpreting signs. Consequently,
detection of probably dangerous situations could also be delayed or missed.

One of the factors which will end in complacent behavior is over reliance on new
technology (Parasuraman and Manzey 2010). Operators are lulled to thinking that the
system won't make an error, which it's safe to shift alertness to other tasks. This false
sense of security develops especially if technology has been operating acceptably for a
protracted period. As a results of the substandard monitoring and checking of the
technology functionality, a malfunction, anomalous condition or failure passes un-
noticed. Furthermore, information provided by technology might be trusted completely
and not verified by alternative sources. There are cases where seafarers misinterpreted or
ignored information obtained by visual lookout because it differed from those expected
and supported au- tomato (Schager 2008; Schröder-Hinrichs et al. 2012) as an example,
as previously mentioned, the vessel Ovitz approached the Verne Bank, the assigned
lookout was on the bridge and was searching through binoculars. However, he did not
 identify the lights from the cardinal buoys marking the Verne Bank or report the sighting
to the officer of the watch (OOW) (MAIB 2014b). A complacent behavior contributed to
11% of the analyzed accidents.

Complacency nurtured by automation was one among the factors contributing to accident
and involving the cargo ship Rockers Dubai, unmanned crane-barge Walcon Wizard and
tug Kingston (MAIB 2014c). The collision happened while Rickmers Dubai was
overtaking Kingston and Walcon Wizard thanks to Rickmers Dubai’s OOW, who didn't
notice Kingston and Walcon Wizard until it had been too late to avoid a collision. Several
facts indicated that OOW was relatively idle during his watch. The Rickmers Dubai was
fitted with X-band radar and also the radar targets of Kingston and WalconWizard were on
display for pretty much one hour. However, OOW didn't use ARPA or visual lookout to
work out if risk of collision had existed. Therefore, it may well be concluded that wasn't
monitoring the radar is play or looking of the window. Instead, he relied solely on the AIS
information displayed on the ECDIS, ignoring in- he rent limitations of AIS which include
the likelihood that a whole picture of situation might not be obtained. Furthermore, the
content of two safety broadcasts is- sued by the Coastguard advising of Kingston and
Walcon Wizard’s position passed unnoticed. Similarly, behavior of OOW caused a
grounding of the final cargo vessel Owenton Gainsborough Sand within the North Sea
(MAIB 2014d). During this case, he relied solely on the worldwide positioning system
(GPS) to observe the vessel’s position and thus he didn't notice that Document departed
from the intended route. Namely, the waypoint selected because the destination within the
GPS receiver differed from that de- tailed within the voyage plan. Furthermore, the
convenience of monitoring the knowledge available from GPS contributed to an absence
of stimulus which led to him falling asleep. The facts that he told to a seaman that he
wasn't required to stay on the bridge which the bridge watch alarm was changed indicated
that he underestimated risks and ignored the requirement for following rules on bridge
watch keeping practice.

39
4.7 Preventive measures:
To determine appropriate preventive measures, a holistic and systematic approach to safety is
required (Kim et al. 2016). All components in complex socio-technical systems like maritime
transportation can have employment in promoting errors and accidents. Therefore, it is important to
analyses all links within the human chain error, not only the mariners. Safety-critical decisions are
also made on other levels: shipbuilding companies, ship-owning companies, classification societies,
industry associations and government regulatory authorities.

An answer to the matter of poor ergonomics of kit design is that the appliance of user-centered
design, within which the necessities, wants and limitations of operators are taken into account at
each stage of the planning process. Equipment designers should be completely conversant in all
tasks performed by mariners in many situations is in a position to} exist on board and around the
ship soon be able to design equipment which is able to cooperate with its human operator under all
circumstances (Lutzhoft and Dekker 2002). Otherwise, maritime equipment is supposed for work-
as-imagined not for work-as- done which can cause significant questions of safety because there is a
substantial difference between them even during routine operations on board ships and particularly
in unexpected or emergency situations. Additionally to general technology acceptance variables:
perceived simple use and usefulness, a sway of technology on decision performance (such as
situation awareness, threat avoidance, Situation monitoring, voyage plan monitoring) and decision
process (stress, confidence, satisfaction, mental and physical effort, vigilance and fatigue) should be
considered so on enhance safety and aid human higher operation (Dhami and Grabowski 2011).

As technology becomes more complex and autonomous it's crucial to style it during some way that
it complements humans and becomes an honest team player so on avoid assessments and
miscommunications (Lutzhoft and Dekker 2002). Kind of improvements in design is also made to
sustain this task. As an example, activities of automated systems should be observable, not just
available and representation of automation behavior would should be event-based, future-oriented
and pattern-based. Because a ship is also a particular working environment, a feedback from end-
users is vital to spice up design. Therefore, it is important to stimulate all mariners to report possible
is- sues or problems with technology which occurred without consequences. All crew members
should be involved within the method because users with different roles and responsibility could
experience significantly diverse technology impacts over time (Dhami and Grabowski 2011).
One of the important steps to forestall the occurrence of accidents caused by insufficient level of
knowledge of the own ship systems is that the development of coaching. Generic and type specific
trainings should focus not only on working knowledge of the functions of the automation in routine
situations, but also in unusual or emergency situations. Furthermore, planning and deliverance of
the training should take into consideration differences between attendees involving not only
previous knowledge and knowledge with technology, but also cultural influences and possible
issues arising from the perception of ship organization as a robust organization. A special attention
should be paid to emphasizing capabilities and limitations of apparatus so on supply an under-
standing that it's a necessity to induce information from all available sources and to prevent a
complacent behavior. The usage of simulators during shore-based trainings can improve the
seafarers’ complacency awareness and equip them with practical knowledge on the systems they go
to use on board. If simulators, used during trainings, exactly represent systems and equipment that
seafarer will use on board, it'll shorten the time needed for familiarization and enable on board
teams to function efficiently even when a replacement member embarks on board a vessel. The
ship- ping companies should ensure that every one instruction manuals also as procedures and work
instructions given within the security management system correspond to actual equipment on board
and actions to be taken in emergency situations. Crews should be encouraged to report situation on
board and fire more precise instructions or more adequate manuals from the company or equipment
manufacturers. Equipment standardization would diminish hazard of poor design and reduce the
length of the operator cross training between ship types.

Effective teamwork is crucial for optimizing safety on board vessels. Productive interactions among
crew members can preclude accidents caused by deficiencies in technology design, inadequate
familiarity with systems and overreliance on technology. However, traditional relations on board
ships with steep authority gradient could even be difficult to beat. As an example, within the
previously described case of Serena Seaways the engineers noticed that back-up system was
activated in time to prevent an accident, but they didn't ask or inform the bridge team (MAIB
2014a). The master has the foremost important role to play to facilitate effective communications

41
among crew members. Achieving and sustaining a positive safety culture isn't possible if the master
isn't able to maintain a balance between his authority and so the crew members’ initiative. He
possesses to contemplate reasonable challenges from crew members and acknowledge positively
and explain his decisions during briefings to encourage crew members to speak up if they spot a
blunder. To motivate crew members to report equipment deficiencies, weaknesses in safety and/or
near-misses, it is vital to avoid attributing the blame whenever it's possible. Instead, the role of
supplying safety-related information as useful defense should be emphasized.
 PART 5 RESULTS AND DISCUSSION

5.1 Maritime Casualties

From this grapes, we can see that, General Cargo ships have the most accidents, then we
have Bulk Carriers & Tanker ships have the lest numbers of accidents though tanker ships
are theoretically the most dangerous. This happens because as the tanker ships are the
most dangerous, extra safety measures need to be taken like IG System. Also this graphs
show that the number of accidents have been reduced of all ships in recent years.

43
 5.2 Serious Oil Spill

As there were no international regulations regarding oil spills, 1970’s have the maximum number
of oil spills. As MARPOL 73/78 were introduced & implemented, gradually the number of oil
spills were reduced. Here we can see that this decade has the lest number of oil spills.

5.3 Lives lost onboard

From this chart we can see that every year the maritime trade is gradually increased
because of all transportations, shipping is the most preferred for trade worldwide. We can
also see that the lives onboard were gradually decreasing until the Somalian Pirates attack
cost many lives. Then again the numbers have been dropping in the recent years.
5.4 The causation of accidents:

The above illustrative model can be used to show the concept of causal factors combining
to lead to an accident. The model uses the concept of ‘Swiss cheese slices’ to represent
barriers, physical and procedural, that are placed by the company to prevent accidents.

In an ideal scenario, we have many protective layers against the Hazardous. Companies
develop the layers of defenses to prevent accident. However, in reality, it is more like the
possible holes in the barriers; this poor system provides a trajectory for an accident to
occur.

45
5.5 Self-Regulation:

The introduction of the ISM Code in the 1990s was an attempt by governments to create a
culture of self-regulation of safety and pollution prevention, in which the application of a
safety culture goes beyond unthinking compliance with externally imposed rules. The ISM
Code places particular emphasis on internal management of safety, and requires
companies and their personnel to establish targets for performance. Self-regulation
requires every individual in the company, both at sea and ashore, to be responsible for
every action taken to improve safety, rather than seeing such measures as being imposed
from outside. The ISM Code requires the development of both company specific and ship
specific Safety Management Systems (SMS), with safety procedures that are organized by
those who will be directly affected by the implications of any failure. It may be helpful to
recall that the development of regulations governing safety and environmental protection
for shipping has progressed over time through interrelated stages, all of which still have
relevance to the 21st Century shipping industry.

5.6 Culture of Compliance:

A second stage developed throughout the 20th Century which involved the regulation of
safety by prescription, where the industry was given sets of rules and regulations to
follow. For example, the provisions of the SOLAS, MARPOL and STCW Conventions,
together with the Collision Regulations, Load Line Convention and various specialist IMO
Codes, provide the basis of the external regulatory framework for international shipping.
This stage was an advance because it was designed to attack known points of danger
before actual harm occurred. This has led to the modern culture of compliance with
external rules. However, a number of serious maritime accidents during the 1980s
confirmed that compliance with regulation was not always enough to achieve safety and
pollution prevention. Although still of utmost importance, adherence to external rules is no
longer seen as an end in itself.
 PART 6 Conclusion and Recommendations

6.1 Conclusion

Despite the efforts of a global maritime community, maritime accidents caused by human
error still occur. In order to reduce their number, it is vital to understand which human and
organizational factors determine how the work on board a ship is carried out. Our analysis
of the accident reports confirms that ineffective relation- ship between human and
technology remains one of the factors that contribute to the development of human error.
Inadequately designed, baffling and insufficiently understood technology created error
pathways that lead to accidents. On the other hand perception of technology as fully
reliable resulted in an inadequate crew members’ performance.

To decrease the likelihood of an occurrence of human error related to technology, several

actions are necessary. Because bridge standardization is a huge challenge and it will
probably not happen in the near future, it is important to conduct trainings using same or
very similar systems to those installed on board ships. Furthermore, a favor able learning
environment should be created and all trainees should be encouraged to participate in
confirming understanding and to be sure that training was effective. During delivering
training courses, it is essential to accentuate that human operator should use technological
aid critically and obtain information from as many sources as possible. All crew members
should provide safety-related information. To establish and maintain an effective safety
culture, it is necessary to abandon old-established methods of ship organization and regard
crew as a team with the master as a leader.

47
6.2 Recommendations:

• Take account of the links between shipboard safety and acceptable working and living
conditions, including working hours, rest periods, bedding, mess utensils, adequate
accommodation and nutrition.
• Verify that the seafarer holds appropriate medical and competency certificates and
endeavor to confirm their validity.
• Recognize fatigue as a potential hazard to safety and health, therefore operations on
ships should be planned to take into account the expected period of work and the
prevailing conditions on board in order to minimize.
• Where circumstances do not allow adequate rest periods for seafarers, either the crew
complement should be supplemented or the vessel's work programmer should be
reassigned.
• The master should ensure, in compliance with national laws and regulations, moreover
as collective agreements, where they exist, that every one crew on board have:
• Reasonable rest periods during working hours, having special respect to work which is
strenuous, hazardous or monotonous.
• The master should make sure the availability of operating manuals, vessel plans,
national laws and regulations.
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