Wen | Mo Qingyan
Editor|Mo Qingyan
preface
The number of accidents at sea due to technical problems has been decreasing year by year due to the development and implementation of international maritime conventions and regulations governing the safe operation of ships, but despite many efforts, accidents at sea continue to occur from time to time.
Because accidents are not only caused by technical factors, but also by human and natural factors, these factors are also interrelated due to the large-scale automation of modern ships.
Therefore, in order to prevent the recurrence of accidents at sea, it is necessary to systematically analyze the causes of accidents.
We all know that maritime accidents are characterized by large-scale destruction of property and the environment, as well as threats to human life, and since the occurrence of maritime accidents is mainly caused by human error, lack of technical skills and organizational factors, it is necessary for the relevant departments to develop some practical countermeasures.
With the fourth industrial revolution, people have integrated intelligent information technology into the navigation, freight and engine systems of ships, improving the level of ship informatization and intelligence, but also increasing the complexity of ship system design and operation.
Therefore, even when ship automation systems are operating normally, unpredictable accidents can occur internally due to the interaction between these factors.
Since the occurrence of large-scale ship accidents is mostly the result of the superposition of various causes, rather than the occurrence of specific causes in a complex way, it is very one-sided to view maritime accidents from the perspective of one-to-one causal relationship.
So from what point of view should accidents at sea be viewed?
Case study
Although the technical level of various types such as shipbuilding informatization and automation continues to improve, our systematic causal analysis technology for maritime accidents is still in the preliminary stage.
For this matter, scientists have studied and analyzed the systematic causal relationship between human error factors in various maritime accidents that may occur during the arrival and departure of giant container ships in the peak period of growth and ship expansion.
This study reviews the accident case of the Busan Singang motor ship Milan Bridge, which has become the top priority for the port due to the increase in the number of docks at the hub port of large container ships.
Since ports and port service workers lack the corresponding knowledge, and therefore the treatment plan for unintentional marine accidents is insufficient, it is particularly important to analyze the causal system that leads to maritime accidents.
In 2020, the contact accident of the MV Milan Bridge crane of the giant container ship Busan Singang was selected as a representative case of this study.
The scientists used an analysis method called functional resonance, which is an appropriate technique for accident cause analysis and risk assessment, and is used to logically explore the causes of the accident.
The study aims to improve navigation safety and prevent accidents at sea by proposing improvement plans, and it also promotes the development of systematic maritime accident investigation and safety management systems.
The safety management system focuses on identifying basic safety issues rather than relying on reactive measures, and the main contribution of this research is the analysis of the MV Milano Bridge accident using FRAM.
Revealing the technology involved in the system, the intricate interplay of human and organizational factors, using FRAM, provides the basis for reducing the risk of future maritime accidents during pilotage and berthing operations.
It is worth noting that this study has gone beyond the traditional approach to accident analysis, as FRAM allows for a comprehensive explanation of maritime accidents by considering the interactions between system functions, which enhances the applicability of this research in the maritime industry.
Literature review
In this study, the scientists identified the limitations of linear accident analysis and compared trends in maritime accident investigation methods and accident analysis research, and also investigated FRAM's research.
First, based on previous research results, scientists have studied the limitations of the simple linear accident analysis method, and in order to consider the limitations of this method, it is necessary to analyze the causes of accidents to prevent similar accidents and reduce repeated losses of capital.
The need to combine domino models with Bayesian networks or machine learning algorithms to discover potential patterns of thought evolution has also been emphasized, and fault tree analysis is a representative method in systems safety engineering.
Theory and methodology
FRAM, which originated in the 1950s and 1960s, was developed for resiliency engineering, and FRAM is a systematic method for determining how individual parts of a task should occur.
FRAM models can be used to interpret selected events or performance in terms of the functions required to perform the activity, the potential coupling between functions, and the general variability of the functions.
The scientists analyzed the 2020 Milan overhead crane contact accident in Busan Sinport by modeling the nonlinear interaction of the system function using FRAM.
Since FRAM is a functional modeling technology that can systematically analyze the causes of complex maritime accidents, it can be used in the future to develop autonomous offshore surface ships, intelligent ship management, and maritime accident investigation and judgment.
The identification and description of the system functions related to FRAM modeling, namely the MV Milan overhead crane contact accident in Busan Sinhav, was involved in this study.
The scientists examined the functions that represent the interaction between various systems related to the accident, and determined the interconnections between the functions that must be performed to achieve the actual purpose, and the relevant functions were determined by dividing the functions into six areas based on the results of the accident.
Scientists speculate that this may occur due to differences in the accuracy of each element and the timing of the application, and Hall Negel exhibits variability that occurs due to differences in time and accuracy of each element.
The scientists also used FRAM to analyze the potential variability of each function in the cause of the Busan accident, and the individual functional resonance accidents analyzed, which they found to be based on the variability after each function was connected.
By analyzing the Busan accident using the FRAM model, the variability of the function and ripple path was determined, so we can understand from here that there is a causal relationship between the cause and impact of the marine accident.
When conducting risk assessments, we can logically develop technical, managerial and organizational improvement plans, and plan future improvements by anticipating the likelihood of multiple potential accidents based on variability and ripple paths.
In order to analyze the Milan Bridge accident using FRAM, the scientists first determined the system and its characteristic functions, classifying the functions and characteristics of the physical elements of the ship, port and natural environment of the Milan Bridge accident according to the guiding question of each element proposed by Hall Nagel.
Scientists analysed the arrival trajectory of the Milan Bridge at the time of the accident, and the port entered the port slightly faster than other conditions near the island of "To".
But near "To" Island, a change of course at a large angle is inevitable, usually the change of course on the starboard side begins after passing "To" Island, and most large ships slow down to about 3 knots until they enter the sea area before Pier 3.
The angular velocity of rotation increased with speed when the ship turned diagonally, and when the Bridge Milano began to change its course to starboard at a high speed of 9.5 knots, its maneuverability was significantly reduced due to the exposure of its propellers.
When the course begins to change, the increase in the angular velocity of the turning is delayed, and the propulsion of the rudder force on the ship is extended, which leads to an increase in the turning diameter.
Especially when the ship stops changing course at a large angle of about 3°, the remaining distance from Pier 0 to the expected berth is about 45.90 miles, and under normal berthing conditions, the ship needs to slow down sufficiently before deploying the tug and bow thrusters.
However, the Valle Milano's deceleration was not enough to support its safe mooring, and in order to avoid the risk of collision with ships moored in port, it had to re-try acceleration to increase the speed of ships turning on the starboard side.
Therefore, when the ship accelerates to avoid a collision, it is difficult to use backup maneuvering devices, such as tugboats or bow thrusters, and emergency measures such as emergency anchoring cannot be used.
So by the time the Bridge Milano approached Pier 3, several attempts had been made to increase the ship's speed and turn to starboard side, a move that increased the risk of collision with the moored vessel.
When faced with such a situation, the captain should evaluate all information related to the planned voyage or route, develop a detailed voyage plan, and execute the established voyage plan while monitoring all such processes, which should include the entire navigation process between the two berths.
And when a ship enters and exits port with the assistance of the pilot on board the pilotage area, the master and the pilot on board should communicate effectively and exchange information to ensure that the ship operates safely in accordance with the navigation plan made using mutual information, including the condition of the vessel, maneuverability, and pilotage plan.
Although we all know that the Milan Bridge has had its propellers exposed due to low draft since it left the Zhejiang repair plant in China, the captain of the ship did not pay attention to it, so there was no plan to safely enter the port of Busan.
After the pilot on board boarded the ship, a list of pilot information on the exchange was provided, but there was no exchange of information on the passage plan or the condition and maneuverability of the ship moored at Busan New Port.
And the pilot on board was aware of the problem of propeller exposure caused by low draft before piloting the boat, and worried that the exposed propeller would cause a decrease in maneuverability, but the captain did not actively intervene or provide sufficient guidance on this matter.
The pilot did not establish any communication or seek any advice from the captain, and the ship failed to slow down and turn in the right instant, leaving the ship without enough time and space to deal with emergency measures such as tugboats, thrusters and emergency anchoring.
The time-series analysis of the Milan Bridge accident was carried out in the order in which the ship occurred after it was built at a Japanese shipyard, passed through a Chinese repair plant, and then entered Busan New Port.
After completing ship repairs in China, supplying fuel and ballast water, the Milan Bridge sailed the Yellow Sea, entered the coast of Busan, and entered the Busan New Port area through port services such as pilotage, tugboat and VTS, but when the ship entered the port, a collision occurred.
During the aspect activation of FRAM, the number of activations between accident-related functions increased, with weighting factors applied to all six aspects of each activity.
And using open-source network analysis and visualization packages written in programming programs, the scientists conducted semantic network analysis to understand the meaning of meaningful words in language text.
discuss
Through this study, we found that the Milano Bridge accident, caused by factors related to human error, remains the main concern of maritime safety management and berthing operations of large vessels, although the technical causes are decreasing with the introduction of ship safety management and technological developments.
The results obtained by analyzing the Milan Bridge accident using FRAM identified the importance of technical, human and organizational factors in maritime accidents and linked them to the accident results.
From this, we can see that the factors related to human error based on maritime accident risk assessment have an important impact on large container ships in ports.
This study differs from existing academic research on maritime accidents and proposes a new method of systematic analysis of accidents from a preventive perspective, with the aim of reducing human error and improving maritime safety in pilotage and port operations.
In order to reduce human error and prevent future maritime accidents, including pilotage and port accidents, in the event of future port accidents, this study categorizes various complex factors and analyzes the causal relationship system by classifying various complex factors and using the port contact accident that occurred during the MV Milano Bridge entering Busan New Port as a reference.
conclusion
This study is significant because FRAM is a systematic accident analysis technique that complements the limitations of traditional accident analysis, and its applicability in the maritime industry has been confirmed when applied to actual maritime accident cases.
As a result of this study, the functional relationships between organization and technology, people and technology, and organization and people are visually represented in FRAM during pilotage to prevent possible accidents and respond appropriately to emergencies, which is expected to contribute to the formation of a governance structure for maintaining and actively utilizing communication systems.
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