High Accuracy Pseudolite-based Navigation System: Compensating for Right-Hand Circularly Polarized Eect

IMSC 2012

1IMSC 2012

9

Maritime accident investigation and risk assessment data with the review of Costa Concordia caseCapt. Davor Vidan(Pomorski Fakultet Split)((E-mail: davor.vidan@pomorstvo.hr)

Abstract

The use of risk assessment requires availability of maritime accidents reports data, but also "Near-Miss" cases and "Best (Safe) Practices" solutions in order to properly identify the risks, assess their probability and consequences, and determine safeguards. The amount and the quality of the data available should be improved by implementing the "Just Culture" and "Open industry" in the maritime world in order to share information about all such cases that have happened around the world.

The size of ships today makes the accident consequences untolerable due to high number of possible casualties and high costs of salvage, if salvage is possible at all, and clean-up operations, as more and more ships has to be demolished on the site of the accident due to their sizes.

Therefore, it is of great importance to improve the error prevention, and one of the best available sources are the data that should be collected and made available by sharing reports not only about accidents, but also about "Near-Miss" cases and "Best Practices" solutions.KEY WORDSMaritime Accident InvestigationRisk assessment.Near-Miss.Best (Safe) Practices.

1. INTRODUCTION

IMO adopted amendments1 to SOLAS Chapter XI-1, MSC 84th. session in May 2008, in force from 1 January 2010, making mandatory parts I and II of the new Code of International Standards and Recommended Practices for a Safety Investigation into a Marine Casualty or Marine Incident (Casualty Investigation Code). Part III of the Code contains related guidance and explanatory material.This ammendments expand requirements by International Maritime Conventions for Administrations to undertake to conduct an investigation of any casualty occurring to any of its ships when it judges that such an investigation may assist in determining what changes in the present regulations might be desirable or improving safety at sea, but mandatory in all very serious and serious accidents causing loss of life or serious injury or serious damage to ships or to the marine environment.The findings of this investigation should be reported to IMO and made public2.EU has adopted directive3 2009/18/EC on the fundamental principles governing the investigation of accidents in the maritime transport sector and introduced the obligation of the Member States to send a copy of the reports to the European Commission and publish them.IMO and EU have set up a electronic databases, GISIS and EMCIP, containing data from received accident investigation reports.2. Maritime Accident Investigation The Flag and Coastal State right and the obligation to investigate the maritime accidents was already included in the most important maritime conventions, like SOLAS, LOAD LINE, MARPOL, and UNCLOS, and the adoption of the above regulations indicate the importance of the availability of accident data to the improvement of the safety at sea and the need to improve the current investigation conduct standard practices by the Administrations4.

Republic of Croatia has implemented the above regulations by amendments to the Maritime Code Law and new regulations on investigation of maritime accidents. The accident investigations should be carried out by accident investigations agency5.

Risk assessment has been made mandatory by the amendments6 to the ISM Code in force from July the 1st 2010.Formal Safety Assessment7 (FSA), as part of IMO rule-making process, was adopted in 2002, with the goal to ensure that action is taken before a disaster occurs, unlike the more common practice in the past that the new regulations are adopted as a consequence or answer to the serious accidents. We can remember "Titanic" or "Estonia" only as examples of the reactive regulatory approach.

FSA is used to evaluate proposals for new regulations or to compare proposed changes with existing standards enabling a balance to be found between the various technical and operational issues, including the human element, and between safety and costs of implementation of the new rules, as "a rational and systematic process for assessing the risks associated with shipping activity and for evaluating the costs and benefits of IMO's options for reducing these risks8."FSA consists of five steps:

1. identification of hazards (a list of all relevant accident scenarios with potential causes and outcomes);2. assessment of risks (evaluation of risk factors);3. risk control options (devising regulatory measures to control and reduce the identified risks);

4. cost benefit assessment (determining cost effectiveness of each risk control option); and5. recommendations for decision-making (information about the hazards, their associated risks and the cost effectiveness of alternative risk control options is provided).

The results of the maritime accident investigations contribute to the effectiveness of FSA in the steps 1, 2, 3, and 5, as it is clearly visible when these steps are reduced in simple terms as on IMO web page:

1. What might go wrong? = identification of hazards (a list of all relevant accident scenarios with potential causes and outcomes):

a. can be found in accident investigations reports, as causes and consequences of maritime accidents, and Near-Miss reports;2. How bad and how likely? = assessment of risks (evaluation of risk factors):

a. can be assessed from statistical data of same or similar risks and by competent analysis of all available data from accident investigations;3. Can matters be improved? = risk control options (devising regulatory measures to control and reduce the identified risks):

a. can be found in the safety recommendations in all properly conducted maritime accident investigation report, as well as Best (Safe) Practices and Near-Miss reports;4. What would it cost and how much better would it be? = cost benefit assessment (determining cost effectiveness of each risk control option);5. What actions should be taken? = recommendations for decision-making (information about the hazards, their associated risks and the cost effectiveness of alternative risk control options is provided):

a. can be found in the safety recommendations as well.

Therefore, maritime accident investigation and risk assessment have become the necessary steps for improving safety at sea also contributing to the efforts that action is taken before accidents happen, as a part of proactive regulatory approach, as FSA is based on the analysis of all available and relevant data about maritime accidents, but data from Near-Miss reports and Best Practices can be a valuable source of information and knowledge.

Without speculating into what caused the Costa Concordia case, I have to ask myself what measures could be taken in order to prevent this accident?2.1. Accident investigation methodsIMO Casualty Investigation Code, (MSC 84/24/Add.1, PART I, 2.12.5) requires that a marine safety investigation contains an analysis and comment on the causal factors including any mechanical, human and organizational factors, not only the active error that triggered the accidents.

Most of the investigation methods are based on The Reason Model9, also known as Swiss Cheese, and categorization of errors as Active or Latent Errors.

Later version of the Reason Model:

The most important conclusion of all worldwide researches into errors and investigation methods is that the active error is not only result of the operator acts, but also the result of accumulated latent errors in the systems, and that the human element is the most important part of the safe work and error prevention.Every system consist of at least this components:

Regulatory framework

Organization and management

Hardware (Construction and equipment including maintenance)

Procedures and instructions

Workplace conditions

Operator capability (education and training)Latent errors in any component may remain hidden for years until an active error occurs as an accident waiting to happen.

What could have been the latent errors in case of Costa Concordia?

In case that all areas are in ALARP range the possibility of accident is acceptable.

In case of Costa Concordia the above diagram may look like this:

We can see how the increase in failure rate of any component in the system above the ALARP range makes the increases the probability of error and accident indicated by the angle of the arrow. Investigation results of the case will, as they always do, determine some latent errors in all areas, at least as possibilities for improvement, so the picture may look like this:

Following the old saying: The chain is as strong as its weakest link, we can conclude that no effort in the lower level component can reduce the risk of accident due to the errors in the higher level component, only the effective barriers of the error prevention.

Using the same tragic case again, if the error was in the hardware, construction of the ship water tightness system, the risk of the damage that have actually occurred could not be reduced by operators actions, but only triggered by operators error. If the vessel could sustain such the damage, she could at least be towed to the port big enough to accommodate the ship of such size.

At this moment we can not speculate on the scope of the damage, as much as it reassembles the Titanic, but it is an accident that should not have happened.Is the complete loss of power and multiple compartment flooding acceptable?2.2. Non-Conformities, corrective and preventive actions, Near-Miss and Best (Safe) Practice

Company has to implement the procedures ensuring that non-conformities, accidents and hazardous situations are reported to the Company, investigated and analyzed with the objective of improving safety and pollution prevention, and establish procedures for the implementation of corrective action, including measures intended to prevent recurrence10.

In so called "Just Culture" organization11 a large number of such cases will be reported, but in "Blame Culture" organizations, most of these cases will remain unreported, possible corrective or preventive actions will not be implemented, and hazardous occurrence may easily happen again, unnoticed until it becomes an accident that can not be hidden.

Unfortunately, a maritime industry is still a "closed type" industry in which the information are not shared with others. Many cases remain not reported even to the company, companies do not report all such cases to the class, insurer or administration. At the same time the companies, recognized organizations, insurers and administrations do not share information between themselves. Available data is censored, subjective, and almost always un-auditable12.The available near-miss data is very often submited anonymously for the fear of consequences by the crew, and as such published on the web. There are very few sources of such reported data to be found (Denmark, US, Mars etc.), that give the cases and solutions, like Safe Practices, although these would be very valuable to all, particularly to the seamen on board when conducting the risk assessments and determining the safeguards to take any task on board, but also to the companies for the improvement of the ISM systems and administrations for proactive regulatory work.

Imo has issued Guidance on Near-Miss reporting to promote a no-blame culture and to encourage reporting of near-misses so that remedial measures can be taken to avoid recurrences13, trying to initiate not only reporting, but also the continuous improvement in safety management systems by implementing remedial measures and sharing such experiences and findings between all parties in the maritime industry.

It is not possible to conduct proper risk assessment if it is based only on personal experience, or only on cases that have happened within one company, even within one flag fleet.

There was one master that had no cases in all his sailing history, until ..

Was the master of Costa Concordia another?

Importance of Near-Miss reporting can be better understood if we analyze the Heinrich triangle ratio14:

If we take a Near-Miss as an accident without consequences, there could have been up to 600 missed opportunities to implement the safeguards against the accident occurrence that remained unreported.

This is the area of improvement available at relatively small extra cost, but not yet made mandatory, other then within company. This is the knowledge and experience wasted unless used.

Could the Costa Concordia case be avoided if it was reported as a non-conformity or near-miss:-Unauthorized deviation from voyage plan?

-Approaching dangerously close to the shore with one of the largest passenger ships in the world?2.3. Emergency preparednessThe company15 is obliged by the ISM Code to:

".2 assess all identified risks to its ships, personnel and the environment and establish appropriate safeguards; and

.3 continuously improve safety management skills of personnel ashore and aboard ships, including preparing for emergencies related both to safety and environmental protection."

Also16:

".5 procedures to prepare for and respond to emergency situations;"

And finally:

"8 EMERGENCY PREPAREDNESS

8.1 The Company should identify potential emergency shipboard situations, and establish procedures to respond to them.

8.2 The Company should establish programs for drills and exercises to prepare for emergency actions.

8.3 The safety management system should provide for measures ensuring that the Company's organization can respond at any time to hazards, accidents and emergency situations involving its ships."

On paper, Costa Concordia had all these requirements fulfilled.

Why the response action was not successful?

Can we expect from the man that has just made one of the greatest errors in maritime history to properly command and coordinate the rescue operations?

The main point is that the crew did well even without command and coordination, and that is the best indicator that no technical invention will replace the human element drills and training. Evacuation of 4000 souls has never been tried before. This time there was not so much panic between passengers, they could see the shore, there was no wind or sea. The crew has done theirs duties as well as could be expected, and there was plenty of time, the vessel never sank.

If we divert ourselves from actions of the master, those will be investigated thoroughly by all administrations and the court, one of the main problems was the damage sustained that was greater then it was assumed probable, and the vessel could not be saved as there was no redundancy left.I don't like to think what could have happened if...., but the problem remains: too much people in too little space in emergency, even if all LSA equipment is in perfect order as it was on Costa Concordia.

After saving people, then next step is saving the ship and environment.

What could be done by coastal state in such a case?

The ship is too big and there is no possibility to even try to do any salvage operations.

Even now when the ship is grounded, there is no ready solution to salvage the ship, and it may eventually prove that it will be more economic to break the ship on site then to try to salvage her.

These extra large ships leave no possibilities of salvage, and even if someone try, like it was the Napoli case, it may prove to be more costly then ship and cargo loss. So we may ask our self how big is too big?

Emergency preparedness may be the final barrier against the consequences, but in cases like Costa Concordia damage there was no response action available to prevent the catastrophic consequences, other then abandon ship, as all system redundancy has been lost:

Once that the barriers are breached, but also that the system redundancy is lost, all the consequences may fall far beyond ALARP range, actually the costs in lives and damages can be unlimited and catastrophic, as indicated by the angle of arrow.

Organizationally the system had enough redundancy so the crew were able to evacuate the passengers, even if the error occurred in the command system.

But, hardware redundancy was lost completely by the damage sustained.

We don't have enough information to speculate if any of the regulations was not complied with, and how many compartments were flooded, but the ships will never be built strong enough to sustain any damage, only probable damages.

If we look at statistical data only, this damage may be extremely remote, even less likely to occur once in the lifetime (20 years) of a

world fleet of 5000 ships, and in the Risk Matrix17, such risk may be classified as "Negligible" or "As Low As Reasonably Practicable (ALARP)" and no safeguards are normally required.

Unfortunately, in history many kinds of damages were not assumed as probable, and yet they happened. Titanic, Andrea Doria to name the most famous cases.

In cases of the low probability risks we should not ignore catastrophic consequence regardless of the probability, as it is suggested in most of the Maritime Risk Assessment Guidelines18, such as ABS, GL and others, particularly in case of large passenger ships, and the Risk Acceptance Criteria19 should be based more on the consequences.

We have new rules for new passenger ships already in place. Are they effective against such damage?2.2. Ship size and consequencesThere is an old saying between seamen that said it all: "Big ship - Big problem".When we consider the consequences of an accident with the big ship we can not avoid the size and number of passengers as a factor.

In order to safety evacuate thousands of passengers the emergency preparedness must be almost prefect, and we know that nobody and nothing can be perfect and the value of crew competence in this matter can be achieved only by education, drills and training.

But in order to assist the biggest ships in trouble there is no stand-by arrangements. Even the towing of these extra large ships is not a simple and safe operation.

"Napoli", "Rena" and now "Costa Concordia" size makes re-floating after grounding a mission impossible and extremely costly.

We have already the case of "VALE" bulkers, one suffered damage in loading port, others are denied permission to enter Chinese ports on the ground of the their size.

Every port has its limits and every coastal state has its own limited capabilities to intervene and assist in case of accident, and that is another factor to consider when conducting the risk assessment, because the part of emergency response is the available help in case of error and accident that may significantly reduce the consequences.

Are we close to the day we have to ask ourselves "How big is too big"?

The final diagram of the Costa Concordia case could look like this:

We can see that all cost may be much higher then ALARP assumed. Every item can have its own scale, this is only to indicate how the failure in one level can increase the risk of error and accident, and how the failures in emergency preparedness and inadequate redundancy can increase the costs in human lives, in ecological damage, in clean-up and salvage operation, and finally others costs like claims by passengers.So the Risk Matrix, indicating that the ultimately catastrophic costs should be taken into account, no matter how unlikely to happen, would look like this:

When we make the risk assessment we have to look on the other side, what happens after an error occurs, and after an accident happened, in order to estimate the possible consequences of the given risk and determine the measures that could prevent the error at the first place.

If the costs of salvage are to big due to ships size, even if system has enough redundancy there is no way to keep this costs in ALARP zone other then error prevention. The data that could be collected and analyzed from Near-Misses Reports and shared Best Practice solutions is one of the most effective ways of error prevention and the means to improve risk assessment and Safety Culture in maritime industry.The only way to achieve this is to make the maritime industry an "Open Industry" in which all data, not only from accidents, are published and shared, and "Just Culture" is implemented at all levels.

.3. CONCLUSIONSTo improve the Safety Culture in maritime transportation system it is necessary to replace the "Closed Industry System" and "Blame Culture" with an "Open Industry System" in which "Just Culture" is implemented in order to improve reporting at all levels, ensuring that all information about accidents, near-misses and Safe Practices are reported and shared among all interested sides, starting from seamen to Administrations, and then it will be possible to carry out continuous assessment of current practices and risk assessments with more accuracy, resulting in improvement of safety and proactive regulatory process. Such data should be published, categorized and easily searched.REFERENCES

1.IMO: Resolution A.849(20), Resolution A.884(21), Resolution A.1029(26);, 2.IMO: MSC-MEPC.3_Circ.3, MSC-MEPC.3_Circ.2;3.DIRECTIVE 2009/18/EC OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 23 April 2009, Official Journal of the European Union L 131/114;4.SOLAS 74 Convention, Part C Casualties [Chapter 1 / Reg. 21, Chapter XI-1]; MARPOL 73/78, 84 amend., [Reg. 8, Reg. 12]; Load Line Convention 1966, Casualties [Reg. 23]; United Nations Convention on the Law of the Sea (UNCLOS 1982) [Article 94 - Duties of the flag State]; Maritime Labour Convention, 2006 (MLC 2006) - [Regulation 5.1.6 - Marine casualties, Guideline B4.3.6 Investigations;];5.Pomorski zakonik (NN 181/04, izmjene NN 76/07, 146/08, NN 61/11) [lanak 49], Pravilnik o istraivanju pomorskih nesrea (NN 09/07);

6.International Safety Management (ISM) Code 2008, (MSC.273(85));

7.IMO MSC/Circ.1023/MEPC/Circ.392;

8.IMO web site: http://www.imo.org/OurWork/Safety/SafetyTopics/Pages/FormalSafetyAssessment.aspx;

9.J. Reason, "Managing the Risks of Organizational Accidents", Ashgate Publishing, Hampshire, England;

10.International Safety Management (ISM) Code 2008, article 9.1, (MSC.273(85));11.IMO MSC-MEPC.7/Circ.7, Annex 1.3;

12.Jack Devanney: "Uses and Abuses of Ship Casualty Data" , Center for Tankship Excellence, USA;13.IMO MSC-MEPC.7/Circ.7, MSC/Circ.1015;14.Herbert W Heinrich: "Industrial Accident Prevention, A Scientific Approach";15.International Safety Management (ISM) Code 2008, article 1.2;16.International Safety Management (ISM) Code 2008, article 1.4.;

17.IMO GUIDELINES FOR FORMAL SAFETY ASSESSMENT (FSA), MSC/Circ.1023 - MEPC/Circ.392;

18.Germanicher Lloyd 2010: ISM Guidelines, RABASKA 2005 - DNV LNG Terminal Study.19.Rolf Skjong: "Risk Acceptance Criteria: Current proposal and IMO Position, 2002;BiographieCapt. Davor Vidan is a Master Mariner, lecturing "maritime accident investigation and risk assessment" at Maritime University in Split, Croatia, with the experience of 20 years at sea and 10 years in maritime administration.