Technical Session 1 – Maritime Accidents and near misses
Chair:    Captain Duncan Glass (UK)
Vice Chair    Mr Lu Yongqiang (China)
Introduction by Chair
Captain Glass welcomed delegates to the first technical session of the Conference which would look at the causes of maritime accidents, the extent to which the maritime industry was learning from mistakes and what changes can be made in the future to reduce their occurrence.

The M/V COSCO BUSAN mishap in San Francisco Bay and potential impact to IALA, Mr Jorge Arroyo, United States Coast Guard

Presented by Mr Jorge Arroyo.
In the early morning fog of November 7, 2007, the 810-foot-long container ship COSCO BUSAN struck the centre tower of the San Francisco Bay Bridge, spilling 58,000 gallons of fuel which caused considerable damage to wildlife and the environment, but, fortunately no injury or loss of life was sustained by those aboard nor by motorists transiting the bridge.  As with most maritime accidents, no one action or inaction was identified as the sole cause of this accidents; but, there were certainly many factors that could have contributed to it—shortcomings in bridge resource management, electronic charts, vessel traffic services, radio communications, health and well being, language, personal responsibility.  Subsequent to the accident various initiatives and policies were considered, debated, and many are now in place—clear guidance for VTS control and restricted visibility clearances, medical reporting procedures, personal piloting units, etc.  The presentation provided a synopsis of this mishap, the lessons learned, and the role of digital information (radar, AIS and VDR) in the investigation and its potential impact to IALA and its members.
The key points of the presentation were:
1    A synopsis of the COSCO BUSAN allision & subsequent oil spill in San Francisco Bay.
2    An outline of the causes of the accident, as found by the USCG Report of Inquiry, included: pilot performance, poor pre-departure and in-transit master/pilot exchange and oversight, inadequate crew training and the pilotage regulator’s failure to adequately oversight the pilot’s medical fitness.  The role of the VTS and AtoN in the mishap was insignificant,
3    The role of digital information in the investigation.  In particular post-2000 SOLAS requirements for standardised digital sentences across multiple on-board navigation systems were important in ensuring multiple data options were available to assist the investigation including AIS and radar.  IALA’s role is important, as it is the only source of such data standards.
4    The potential issues that this and future mishaps will pose to IALA and its members.  Many will rely upon IALA Recommendations and Guidelines to use and display this data and the impact on authorities’ resources needs to planned for.

Collision avoidance in the e-Navigation environment, Dr Nick Ward, General Lighthouse Authorities of the United Kingdom and Ireland

Presented by Dr Nick Ward.
This presentation showed the results of a study carried out by Helios for the General Lighthouse Authorities of the UK & Ireland into developments in collision avoidance systems, how they will influence the future development of marine aids to navigation and how they fit into the concept of e-Navigation.
Collision avoidance is considered in the wider sense of preventing groundings and striking fixed obstacles, as well as ships colliding with other ships.  A survey of the market was carried out to consider the scope and functionality of collision avoidance equipment, including the automatic identification system (AIS), as well as to consider the way in which available equipment operates in the coastal and harbour waters of the UK and Ireland.
The presentation considered existing technology of relevance to collision avoidance, including Class A and B AIS equipment, manufacturer specific aids to collision avoidance (e.g. non-standardised techniques and functions that aid detection or resolution of potential collision scenarios).
The implementation of current automated collision avoidance alarming was studied, for example whether alarms are triggered by zones or through greater algorithmic intelligence.
The key points of the presentation were:
1    Influence of e-Navigation on collision avoidance, including provision of a definition for, and the objectives of e-Navigation.
5    Existing technology for collision avoidance including GNSS, radar, AIS, VTS and lights & buoys.
6    New technologies and the need for a common information structure for both mariners and shore users.
7    Implementation of collision avoidance systems.  Collision risks comprised other vessels, fixed objects (e.g. structures) and floating debris (e.g. containers).  New technology for collision avoidance included new technology radars, eLoran, data fusion and synchronised lights
8    The benefits of e-Navigation for collision avoidance including improved situational awareness, clear, uncluttered information presentation, avoiding information overload and supporting decision making.

Do we ever really learn from our mistakes? Mrs Jillian Carson-Jackson & Captain Michael Squires, Australian Maritime Safety Authority

Presented by Captain Terry Hughes (Trinity House).
Title of presentation: VTS and VTM - when will we ever learn?
Captain Hughes advised that he would be presenting a replacement presentation for Jillian Carson-Jackson’s and Michael Squires’ paper but that he strongly recommended that delegates read the paper which is provided in the proceedings.
In the VTS world, do we ever learn from our mistakes?  Case studies show that we could be doing much better.  We continually seem to be making similar mistakes linked to similar issues – communications (clear, concise, timely); operating procedures (general, poor visibility, heightened awareness); expectations (level of service offered); etc.  Why is it that we don’t seem to able to learn from these mistakes?  There are a number of existing mechanisms that could be adapted, for example, IALA has produced an internationally accepted standard of training and certification of VTS personnel.  The V-103 Model Courses cover all aspects of the duties required by VTS Operators and Supervisors.
Finally, we must not forget training.  IALA has produced an internationally accepted standard of training and certification of VTS personnel.  The V-103 Model Courses cover all aspects of the duties required by VTS Operators and Supervisors.  Training should be carried out by organisations accredited specifically for this specialised training.  On the Job Training and continual professional development are equally important and the progress of all operational personnel should be continually monitored and assessed.
The key points of the presentation were:
1    The cause of accidents.  Causes of accidents can be attributable to mariner-related issues such as inadequate procedures, confusion and a lack of decision making skills; VTS issues such as poor communications (which features in 90% of accidents) and a lack of training including lack of access to simulation; proposal that mariners need VTS awareness training.
2    The lack of consistency in VTS and information globally; IMO Resolution A.918(22), the IMO standard for marine communication phrases.
9    The need for sharing of learning from incidents / near misses globally.
10    The need for improved communications between VTS, masters and pilots.

Enhanced radar conspicuity of small craft, Mr Peter Douglas, Northern Lighthouse Board, Scotland

Presented by Mr Peter Douglas.
The sinking of the yacht ‘Ouzo’ in the English Channel in 2007, with the loss of 3 lives, highlighted once again the vulnerability of small craft in close quarters situations with larger vessels.  This incident was subject to a major investigation, which included an assessment of a number of proprietary brand radar reflectors.  None of these were found to adequately meet the ISO standard for radar reflectors, and some could be considered hazardously misleading by encouraging the user to consider themselves more conspicuous than they are.
This presentation examined a number of means of both enhancing the radar conspicuity of small targets, and of other means by which small craft can reduce the likelihood of fatal interactions with large vessels.  This leads onto other areas of potential benefit to National Administrations, in that buoyage and other small aids to navigation may also be given enhanced conspicuity, reducing the likelihood of accidents to vessels or damage to Aids to Navigation.
The key points of the presentation were:
1    Limited functionality of commercially available passive radar reflectors with none meeting international quality management standards.
11    Scope for improved design of reflectors such as incorporation of trihedrals & dipoles.  Active radar reflectors are also an option but these currently only perform at X Band, and require power supply.  There is also a need for better installation.
12    Lack of observance of standard rules, in particular safe speed.
13    Scope for design improvements to small craft.  Small craft generally have very poor radar reflectivity due to wood or GRP construction.  One area in need of improvement is the conspicuity of yacht masthead lights.
14    Scope for incorporation of radar reflection within small craft hull construction; the benefits of new technology radars – low power, improved clutter performance.
15    Other potential aids to avoiding collision

MAIIF Investigations, liabilities and lessons learned, Cdre David Squire, Marine Accident Investigators International Forum (MAIIF) and editor of the Nautical Institute’s ‘Alert!’ bulletin, which aims to improve the awareness of the human element in the maritime industry

Presented by Cdre David Squire.
The objective of the IMO’s Casualty Investigation Code is to provide a common approach for Flag States to adopt in the conduct of marine safety investigations into marine casualties and marine incidents.  A marine safety investigation is an investigation conducted with the objective of preventing marine casualties and marine incidents in the future, without apportioning blame or determining liability
The impact of people in the maritime safety system has been with us since time immemorial but the people, systems and machines have changed, not only through increasing technology, but also because of the need for operators to maintain the competitive edge by reducing running costs.  The introduction of new technology and computer-based systems has changed the way in which mariners are presented with information but some operators are reluctant to train their seafarers properly in the operation of these systems.
Most accidents result from operator error, the root causes of which can manifest themselves in a variety of ways, and many of which can be attributed to the human element.  Recent investigations, carried out by MAIIF members, indicate that not all of the industry is heeding the lessons from these investigations.
The key points of the presentation were:
1    Role of the MAIIF and the Nautical Institute in relation to the topic;
2    The purpose of the Code of the International Standards and Recommended Practices for a Safety Investigation into a Marine Casualty or Marine Incident
3    Marine accident investigation.
16    Human element - Most accidents result from operator error, the root causes of which can manifest themselves in a variety of ways, and many of which can be attributed to the human element
17    Human/operator error. Human error is the cause of most accidents.  Human input to design and operation of a system are a key contributory factor.
18    Maritime accidents – contributory factors include poor ship/system design, equipment failure through poor maintenance and seafarer fatigue and complacency and ineffective communication
19    Grounding incidents – contributory factors include poor bridge resource management, lack of effective passage plan, poor master/pilot communication and poor navigation.  This was supported by a number of case studies from around the world, featuring one or more of the causes.
20    Evidence shows that we are not leaning from our mistakes.
Discussion – Technical Session 1 – Part 1 (papers 1 - 5)
It was asked of all speakers: What is the role for automation given the key involvement of human error in accidents?
Cdre Squire responded that technology should take on the tasks that humans are not good at e.g. monitoring and analysis.  Humans should do what they are good at e.g. interpreting information and decision-making.  Captain Squire added that the problem with automation is that it turns the operator into a monitor who can then be distracted.  Referenced incorrect setup of automatic pilot as a contributing factor to the problem and an example of how greater automation could be problematic.
There was no response when it was then asked if the speakers would be happy for greater use of automation in the operation of vessels?
It was observed that in the aviation sector the pilot is thoroughly trained in the use of instrumentation and so is there a need for more standardisation and training in maritime sector?
Nick Ward responded that training is critical of course but also that there is great scope for standardisation, including in relation to information displays.  Terry Hughes agreed that training was very important, noting that standardisation is harder to achieve in shipping than in aviation due to greater variation in vessel characteristics / equipment.
In response to the question ‘Should commanded values e.g. rudder be included in the Voyage Data Recorder, as it would greatly assist accident investigations’.  Cdre Squire advised that the UK MAIB have developed a suite of elements to be taken into account in an investigation and that it was technically possible to achieve.  He agreed that it would assist investigations.