Task description – please deliver in Englis Language, in

written form.
Please upload work to the MSTerams or send it on my email address by 15.06.2024

1. Find marine accident in flag state investigation commission (any of my link or own
research)

2. Fill the data in table below taking into account following description
Please focus on answer if any implementation of ISM could be observed? Find
accidents from year 2012 onwards. When filling this form, please take the
following into consideration:

Many of the accidents could happen under 4 headings:

Human vulnerability – Poor attention span, panicking or not absorbing or perceiving

in time what needs to be done i.e. use or instigate a plan of action due to visual
retention (0.5 – 1 s) or audio retention (2 -8 s) or memory series (10 -20 s),
intoxication/drug usage, having a bad day, complacency or laziness.

Decision making – No or late or incorrect plan/information to make correct decision.

Communication – Ineffective communication, language deficiencies or shallow

language skills (evaporating when in a panic situation)

Violation, Mistake, Error, Recklessness and Sabotage

Violation – Intentionally disregarding policy/procedure specially to benefit the

company (or when the rule/policy/procedure not intentionally broken and the
consequence was not intended but correct action could not have been taken and
the situation was not outside the normal practice).

Mistake - Rule or policy/procedure/practice applied correctly but incorrect plan of

action taken.

Error – Rule or policy/procedure applied correctly and correct plan of action taken.

Recklessness - Rule/policy/procedure not intentionally broken and the consequence

was not intended but there was conscious disregard for the risk imposed.

Sabotage - Rule/policy/procedure was intentionally broken and the consequence

was intended
 3. Enclose accident report (pdf file, doc, web links or any other source)

4. Ship data to be given

1. Vessel Information

Name of the vessel

Flag state

Type of vessel

IMO Number

Age of vessel

Date of last safety inspection

Date of last ISM audit

Type of Audit

Auditor Organisation

2. Incident Information (from last 10 years of accidents i.e. year 2012 onwards)

Date of incident

Location of incident

Type of incident (e.g., collision, grounding, fire, explosion, etc.)

Brief description of the incident

Severity of the incident (e.g., minor, moderate, severe, catastrophic)

Number of crew and passengers on board at the time of the incident

Any injuries or fatalities resulting from the incident

Damage to the vessel or other property/ Environment

Investigation conducted?

If Yes, what was the outcome

Was the accident related to previously identified deficiencies?

Did the corrective measures (i.e. audits) to address any of the

deficiencies found previously were properly addressed?

3. ISM-related Information
Which method/standard the company used to prepare its ISM policy No data
manual and procedures manual?

Were the ISM Document of Compliance (DoC) and Safety Management

Certificate (SMC) valid and up to date at the time of incident?

Were any ISM-related deficiencies found during the investigation of

the incident?

Was the crew properly trained in ISM procedures and protocols?

Where did the crew receive the maritime education/training related to

ISM.

Were any deficiencies in the vessel's safety management system

identified as contributing factors to the incident?

4. Investigation and Findings

What was the cause of the incident? Please highlight the

options that applies from
the following reasons of
the accidents:

B - Personal

3. Inadequate Knowledge 7.
Poor team operation,
working towards different
goals, no cross-checking, no
means of reporting or
speaking up, no quality
circles.

9. Lack of focus/incorrect
awareness leading to
misinterpretation of the
operation by a crew
member – lack of attention,
confusion, distraction,
discoordination,
stress/poor mental
perception.

C – Leadership

2. inadequate risk
assessment, inadequate
team composition,
inappropriate pressure to

perform a task and a

directed task with
inadequate qualification,
experience or

equipment.

3.Inadequate leadership of
operational tasks, including
a lack

of correction of unsafe
practices, no enforcement
of existing rules, allowing
unwritten

policies to become
standards and directed
deviations from
procedures.

D - Organisation

1. Inappropriate policy
manual

1.
Inappropriate/inappropriat
e procedures

2. Inadequate supervision

3. problems with safety

culture, lack of culture of
reporting, learning or just
culture, social and status
barriers causing
misunderstandings.

2. Unsuitable documented
policy or procedures,
limitations of

proactive risk management,

reactive safety assurance,
lack of safety promotion
and training
What were the contributing factors to the incident? Please highlight the
options that applies from
the following reasons of
the accidents:

Human vulnerability – Poor

attention span, panicking or
not absorbing or perceiving
in time what needs to be
done i.e. use or instigate a
plan of action due to visual
retention (0.5 – 1 s) or
audio retention (2 -8 s) or
memory series (10 -20 s),
intoxication/drug usage,
having a bad day,
complacency or laziness.

Communication –
Ineffective communication,
language deficiencies or
shallow language skills
(evaporating when in a
panic situation)

Technical factors – The wire

sling failed because the eye
splice comprised of 3 partial
tucks and not the full 5
tucks as required by the
standard. It was also noted
that the load carrying tucks
were made under one
strand, and not under
several strands

Were any human errors identified? Violation, Mistake, Error,

Recklessness and Sabotage

Mistake - Rule or
policy/procedure/practice
applied correctly but
incorrect plan of action
taken.
 Error – Rule or
policy/procedure applied
correctly and correct plan
of action taken.

Recklessness -
Rule/policy/procedure not
intentionally broken and
the consequence was not
intended but there was
conscious disregard for the
risk imposed.

What corrective actions were taken to prevent similar incidents in the

future?

Were any recommendations made to improve the vessel's safety

management system?

5. Conclusion

Summary of the incident and its impact

Lessons learned from the incident

Recommendations for improving safety management practices on

board ships.

5. Give your personal view on sources of accident taking into account perspective of
automatization (weekness, misunderstngin, misjudged etc)

6. Propose novel solution preventing similar accidents in the future incorporating for
instance:
• New regulations
• New features
• New tools
• New competences
• ISM/SMS/Quality procedures
• Unmanned