Reconstructing Maritime Incidents and Accidents Using Causal Models for Safety Improvement: Based on a Case Study

Lucjan Gucma,Marko Perkovič,Andrej Androjna,Kinga Łazuga,Peter Vidmar

doi:10.3390/jmse9121414

Lucjan Gucma, Marko Perkovič + Show 3 more

Open Access

https://doi.org/10.3390/jmse9121414

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Abstract

No advance in navigation has yet to prevent the occurrence of accidents (incidents are always implied when we discuss accidents) at sea. At the same time, advances in accident models are possible, and may provide the basis for investigations and analyses to help prevent future adverse events and improve the safety of marine transport systems. In such complex socio-technical systems models that treat accidents as the result of a chain or sequence of events are used most commonly. Such models are well suited to damage caused by failure of physical components in relatively simple systems. Although these often include methods for modeling human error, they do not cover broader aspects related to the management of the organization using the means of transport itself (shipowners) nor errors that may occur in the design phase. In particular, they do not cover changes in the systems over time. The paper presents accident investigation approaches and uses a modified causal model to analyze an incident that occurred in January 2019 on the city ferry in Świnoujście. The results of the analysis were used to provide guidelines for increasing safety at the crossing and to evaluate the accident analysis model used. Additionally, incidentally, through the study of this case we uncovered a problem in communication among stakeholders that unnecessarily complicates the models for the models for the improvement of safety.

Highlights

Maritime transport is a complex socio-technical global system and many of the risks particular to sea transport are greater than those of the other three main modes of transport
The European Maritime Safety Agency (EMSA) is obliged by the European Union (EU) Directive 2009/18/EC [3] Article 8 to establish the principles for accident investigation and each EU Member State should establish an independent and permanent accident investigation body
In Poland, the State Marine Accident Investigation Commission (PKBWM) is responsible for accident investigation and the present case study was investigated within the framework of the PKBWM [4]

Summary

Introduction

Maritime transport is a complex socio-technical global system and many of the risks particular to sea transport are greater than those of the other three main modes of transport. It should come as no surprise—because accidents and incidents continue to occur— that new models are constantly being developed [11,22,23]. Along these lines, it may be worth considering larger issues, such as the economic model that appears to require constant growth at a time when environmental concerns, no matter how serious they sound, are never serious enough to affect the workings of large businesses. The fact is, the changes forced on stakeholders in the maritime industry themselves create a danger, as the best safety measures available are generally outmoded in too short period of time An element of this principle emerges in this case study, though primarily we are concerned with a particular type of incident that occurs all too often among ferry services. The practical results of these studies will make it possible to evaluate the causes of such unanticipated abnormalities as the problematic motion of the ferry “Bielik IV” (the subject of our case study) after the failure of the main propulsion and to develop recommendations for improving the safety of navigation of ferries of this type

Material

Determination of the Shuttle Emergency Propulsion Thrust

The Forces and Effectiveness of the Emergency Stopping of the Ferry at Anchor

Findings

Conclusions