Chain-breakers - a survey of fatal ship accidents with the event-chain method

Journal article, 2008

The ship research project DESSO (Design for Survival Onboard) aims at improving the safety of RO/RO (roll-on/roll-off) ferries. The project was organized in the autumn of 2003 in order to use the research and development resources existing in Sweden, combined with international expertise, for a radical RO/RO concept with a focus on safety. One part in the early stages of this project was to identify chain breakers from previous accidents, that is, something that would have prevented, stopped, or reduced the consequences of the Incident event, in order to obtain a realistic basis of "working on the right problem." A systematic and in-depth analysis of a few selected significant and well-documented disasters was made using the event-chain method. The identified chain breakers were further categorized and analyzed to find ideas and concepts that would prevent these events from occurring. These efforts were further developed into a method where the graphics of event chains with chain breakers are used in workshops with experts in two stages. In general, it was found that "Management" in most cases was the initial cause of the events. Often, "Management" was also the reason for the continuing or worsening of the events. As such, education/training and stricter routines were found to be the most effective methods for reducing accidents and are at the same time an inexpensive measure to take. This, together with online stability calculations and decision-support systems, would have prevented most of the accidents analyzed in this work.