Accidents related to ISM Code failures: What we have learned so far

In the following table, we have compiled a list of accidents related to ISM Code failures to highlight lessons learned. Besides, by learning lessons, safety procedures can be reviewed and amended to reduce risk of occurrence.

#	Date	Ship	Place	Brief Description	ISM Relation
1	6 March 1987	Herald Of Free Enterprise Ro-Ro Passenger vessel	Zeebrugge – Belgium . Just outside the harbor	The Ro-Ro vessel during good weather and day light, when sailed just outside the harbor took a side list and touched bottom. 150 passenger and 38 crew members died. The accident occurred because the bow door was left open when the ship left port allowing water to enter and flood the car deck.	The accident initiated a series of changes in SOLAS due investigation outcome and drove IMO to set International Safety Management Code as a mandatory standard for industry (1994 - Resolution A.741(18) as part of SOLAS Chapter IX). The Code requires a safety management system (SMS) to be established by the shipowner or manager to ensure compliance with all mandatory regulations and that codes, guidelines and standards recommended by IMO and others are taken into account.
2	24 March 1989	Exxon Valdez Oil Tanker	Near Valdez Alaska	The tanker grounded on a small reef near the TSS lanes after passing on the opposite side of the lane. No injuries but excessive oil spill (252 831 barrels of crude oil) occurred.	Investigation results included items involving Company’s Policies implementation, inadequate manning levels, Drug & alcohol procedures, Personnel competence and training, managing company’s involvement to vessel’s operations.
3	28 February 2004	Bow Mariner Chemical tanker	45 nm east of Virginia USA	The vessel caught fire and exploded while crew was engaged in cleaning tanks. The cause was the ignition of fuel/air mixture either on deck or in cargo tank sourced by unknown reason. 21 crew members died while 3188711 gallons of ethyl alcohol and 192904 gallons of HFO and 48266 gallons of DO were spilled.	That was the first time that an investigation indicated that a “Contributing factor to this casualty was the failure of the operator and senior officer to properly implement the company and vessel Safety,Quality and environmental protection management System.''
4	24 July 2006	Cougar Ace Car carrier	Coast of Alaska near Canada	Vessel experienced severe listing to its port side and transmitted the distress signal, requesting for immediate assistance, while en route from Japan to Canada. At the time of the incident, the ship was carrying out ballast water exchange (BWE) operations. All the 23 crew members on board were rescued safely USCG. There was no pollution as a result of the incident. On 8^th August 2006 vessel towed and secured at Unalaska Island	In accident’s findings, it was mentioned that the assignment of duties and responsibilities should be clearly defined and documented in the vessel’s Safety Management System (SMS), within the context of ballast water exchange operations
5	31^st October 2006	Harvest Caroline General cargo	Tanera More, Summer Isles, Scotland	The vessel started to drag her anchor in strong northerly winds and was blown about eight cables until she grounded. There was no pollution and no injuries. Damage to the vessel was limited to indentations to the hull plating in way of the engine room.	Investigation revealed that the SMS of the ship did not meet the objectives of the ISM Code, the ship manager had very little experience or expertise in ship management and operations and the SMS had not been properly established when the Interim Safety Management Certificate was issued and was tailored to the ship’s operation.
6	12 April 2007	Bourbon Dolphin Offshore support Tug	85 miles west of Shetland islands, North of Scotland	The ship was pulling a heavy anchor chain, which suddenly slid across the deck and dragged the vessel over. The main engines stopped and moments later, the vessel capsizes. 8 crew members lost their lives.	The Company had not examined whether the vessel was suitable for the operation. The ISM Code demands procedures for key operations. Despite anchor handling being the main function there was no vessel-specific anchor handling procedure. The Company did not follow the ISM Code requirements that all risks are identified and the Company did not make sufficient requirements for the crew’s qualifications for demanding operations.
7	7 June 2007	Pasha Bulker Bulk carrier	Anchorage off the coast near Newcastle, New South Wales, Australia	Due to adverse weather conditions vessel grounded to the near beach while trying to be put to sea by Master. No casualties or pollution reported.	The ship’s SMS did not provide Master with any specific guidance with regard to safely putting to sea in adverse weather or general guidance about the risks at a weather exposed anchorage. The master’s standing orders posted on the bridge, in a standard format copied from the ship’s SMS, made no mention of BRM and nothing in the orders encouraged the use of recognized BRM techniques such as challenge and response.
8	29 September 2007	Viking Islay Emergency Response Rescue Vessel	North Sea	Three seamen on board lost their lives as a consequence of entering an enclosed space. Two of the vessel’s seamen went forward with the intention of securing a rattling anchor chain within the chain locker. One of the seamen entered the chain locker and collapsed. It is probable that the other seaman, realizing that help was urgently required, raised the alarm with the duty watchkeeping rating on the bridge before he, too, entered the chain locker in an attempt to help his companion. He also collapsed. During the consequent rescue efforts, the first rescuer found he was unable to enter the chain locker wearing a BA, and he therefore donned an EEBD. He entered the space, but at some point the hood of the EEBD was removed, or became dislodged and this rating also collapsed. All three seamen died as a result of an oxygen deficient atmosphere within the chain locker.	The crew of Viking Islay failed to recognize the chain locker was a potentially dangerous enclosed/confined space, or the likelihood that the atmosphere within the space could become oxygen deficient over time. Consequently, well established permit to work measures as per SMS were not considered before the space was entered. Moreover, the ship manager’s company policy on entry into enclosed spaces (as per SMS) was not clear and did not take into account scenarios that could require crews to enter confined spaces while at sea. Finally, the audit regime employed by the ship’s managers to ensure compliance with its SMS, failed to detect deficiencies in training, equipment and safety culture on board
9	7 November 2007	Cosco Busan Container	Port of Oakland California, USA	The ship was outbound from berth 56 in the Port of Oakland, California, and was destined for Busan, South Korea. Vessel was under pilotage in dense fog. While navigated through the “Delta–Echo” span (the 2,200-foot-long span between bridge towers/piers D and E) of the Bay Bridge an allision occurred with the Delta Tower pier. Resulted in damage to the pier fendering and the breaching of three port wings tanks of the ship releasing approximately 54 000 gallons of oil into San Francisco Bay.	The investigation revealed inadequate or non SMS familiarization for the key officers on board. The Safety Board also concluded that the master had not implemented several procedures found in the company SMS related to safe vessel operations, which placed the vessel, the crew, and the environment at risk. In addition, Company had not successfully instilled in the Cosco Busan master and crew the importance of following all company safety management system procedures. Furthermore, most crew members had limited knowledge of English language factor which limited their abilities to read and understand SMS
10	23 January 2008	PADRE Bulk carrier	Immingham, UK	During a PSC Inspection, 64 deficiencies were found in total (8 detainable), including the following: the compass was not aligned to the ships head and the compass card was badly worn and unreadable on some headings; embarkation ladders for the lifeboats were badly worn and connection eyes defective; the vessels' sick bay was dirty and unhygienic with the bathroom floor broken and holed and the bath full of liquid that could not be drained; the securing bolts were missing from the access hatch from the bridge deck; numerous fire dampers were unable to be closed and secured in a closed position the engine room workshop vent was holed and the internal damper missing. No Injuries or pollution was reported; however the ISM Certification was withdrawn.	The number and nature of the defects identified on board indicated a major failure of the vessels' Safety Management System (SMS).
11	16 March 2011	Oliva Bulk carrier	Nightingale Island in the Tristan Da Cunha Group	The vessel was following a great circle route that took the vessel directly over Nightingale Island. One of the navigational officers of the watch had made an error in plotting one of the way points the vessel had to follow. This resulted in a course line, which indicated that the vessel would clear the group of islands by about 10 nautical miles. The navigational officers of the watch (OOWs) was not using an appropriate large scale chart for that area and the plotting sheets in use did not show the islands ahead. No crew injuries were reported but a wide spread of pollution near the islands.	The passage plan did not comply with the company’s instructions of clearing distances when a vessel was in open waters. Although the company had provided comprehensive guidance and procedures in its SMS to prevent this accident, these were not followed on board. Therefore, Company was instructed to perform unscheduled navigational audits at sea, so as to verify compliance of its operational procedures while the vessel is underway.
12	5 October 2011	Rena Container	Astrolabe Reef, Bay of Plenty, New Zealand	The vessel while approaching the area, was delayed by currents. Master had authorized the watch keepers to deviate from the planned course lines on the chart to shorten the distance, and to search for the least unfavorable currents. While the vessel was scheduled to pass two nautical miles north of Astrolabe Reef, OOW decided to reduce the distance to one mile in order to save time. OOW then made a series of small course adjustments towards Astrolabe Reef to make the shortcut. In doing so, he altered the course 5 degrees past the required track and did not make an allowance for any compass error or sideways “drift”, and as a consequence the Rena was making a ground track directly for Astrolabe Reef. Vessel ran aground at full speed on Astrolabe Reef. The ship remained stuck fast on the reef and in the ensuing months it broke in two. The aft section moved off the reef and sank. About 200 tonnes of heavy fuel oil were lost to the sea. A substantial amount of cargo in the containers was lost but no injuries were reported.	One of the investigation results was that the safety management system of the Company was not sufficient to prevent a high number of port state control deficiencies identified during two port state control “initial” inspections about three months prior to the grounding, and routine violations of some company procedures for voyage planning and navigation.
13	13 January 2012	Costa Concordia Passenger ship	“Scole Rocks” at the Giglio Island, Italy	The ship was sailing too close to the coastline, in a poorly lit shore area, under the Master’s command who had planned to pass at an unsafe distance at night time and at high speed (15.5 kts). The danger was considered so late that the attempt to avoid the grounding was useless, and everyone on board realized that something very serious was happening, because the ship violently heeled and the speed immediately decreased. The vessel immediately lost propulsion and was consequently effected by a black-out. The ship turned starboard by herself and finally grounded. 26 passengers and 4 crewmembers died. No pollution was reported.	Analyzing the cause factors of the accident related to ISM there are reference to Master’s performance, Inadequate passage planning, inadequate SMS procedures related to : “Management of the Emergency Instruction for Passengers; Decision Support System for Master and Passage Planning''
14	18 September 2013	Ovit Oil/Chemical tanker	Dover straight	The vessel was on passage from Rotterdam, Netherlands, to Brindisi, Italy carrying a cargo of vegetable oil. Ovit was following an autopilot controlled heading at a speed of between 12 and 13 (kts). The OOW navigated using ECDIS. As Ovit approached the Varne Bank, the deck cadet, who was standing on the starboard side of the bridge and using binoculars, became aware of flashing white lights ahead. He did not identify the lights or report the sighting to the OOW. Ovit passed close by the Varne Light Float. After few minutes ship’s speed slowly reduced until the vessel stopped when it grounded on the Varne Bank. No injuries or pollution were reported.	The passage plan was prepared by an inexperienced and unsupervised junior officer and was not properly checked. The deck officers were unable to safely navigate using the vessel’s ECDIS. Master and deck officers did not implement the ship manager’s policies for safe navigation and bridge watchkeeping. The serious shortcomings with the navigation on board had not been identified during the vessel’s recent audits and inspections.