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Attilio Ievoli Accident and Human Errors Case Study


Vessels running aground have occurred many times since the history of navigation. The incident in 2004 when the 4,450 tonne chemical tanker, Attilio Ievoli, ran aground on Lymington Banks in the West Solent. Adopting an explicit reflection, this analytical treatise offers an informed review of the events leading to this accident thorough investigation of human activities in the 4,450 tonnes Attilio Ievoli just a few moments before the accident.

Besides, the treatise offers recommendations to ship steers to avoid the occurrence of the same incident in the future. Specifically, the main event that led to the chemical tanker Attilio Ievoli running aground on Lymington Banks in the west Solent can be located in the miscommunication between the Master and the relieving officer who continued with the change of course without accurate consultation of the previous plan for navigating and manoeuvring between the two vessels in a relatively high tide environment.

Basically, this reflective treatise attempts to expound on events that led to the occurrence of this incident when the vessel hit the buoy despite clear visibility and full functioning of the ship radar. In addition, the report offers practical solutions for avoiding the occurrence of such an accident in the busy traffic seaways in the future. The aim of this report is to present actual finding on the probable cause of the accident in which the 4,450 chemical tanker to run aground just some few moments after the change of guard between the ship Master and the relieving officer.

This aim is represented in a report finding a module for the causes of the accident, distribution of liability, what could have been done to avoid the accident occurrence and recommendations in future navigation within the same environment and conditions that led to the accident. The recommendations made to avoid the occurrence of this incident include a complete avoidance of small alterations in the bearing, especially when the same has not been aligned with the radar report and previous analysis when crews change the guard.

Specification of the vessel and accident scenario

The Attilio Levoli was an Italian registered chemical tanker. The ship was made of steel and had an overall length of 115.5 meters and loaded draft of 6.5 meters. The gross tonnage of the ship was 4,450, and it had a service speed of 14 knots. The unfortunate events that led to the 4,450 tonne chemical tanker to hit the South Ridge Buoy and run aground was an accident that occurred in 2004 and were however recorded as very minor since there were no injuries or serious damages on the vessel.

The events leading to the occurrence of the accident can be traced to the interaction between the master and the relieving officer of the vessel on a fateful day. Specifically, the Master had left the vessel with the relieving officer after setting the course of the ship and making accurate calculations on future alterations. Before changing command to the relieving officer, the master steer had made it clear to the officer to keep constant communication in case of any alterations or changes to the vessel (Olsen & Gluver 2008).

Noting that the vessel with a service speed of 14 knots, the relieving officer had doubts on his bearing and had alternated the same twice within a relatively shorter time without much consideration of the tidal speed and previous measure to correct the off course cruise. As a matter of fact, steering a modern ship like the coaster vessel is very demanding in terms of skills and accuracy of operation in order to correspond to the radar reading and external environmental circumstance of the ship (Olufen, Spouge, & Hovem 2003).

Reflectively, the relieving officer was aware of his error upon making the first alteration and did not coordinate with the bridge watch team to assist in accurate positioning of the ship to pass between the vessels along the narrow pass. As a result of overestimation of the course location and expected alteration, the relieving officer panicked and forgot the essence of constant communication (Olufen, Spouge, & Hovem 2003). The aspect of human error, in terms of inaccuracy and communication was the main cause of the accident. In fact, the relieving officer should accept partial liability to the accident since he failed his part of communicating with the Master upon the initial panic (Montewka et al. 2011; Olsen & Gluver 2008).

How accident causation has changed over time from domino to Swiss-Cheese model

Accident causation has changed over time from domino theory to the Swiss-Cheese model, which highlights the circumstances surrounding the causal aspects from human, environmental, and technical perspectives. Unlike the simple domino theory that examines the causal factors from a restricted perspective, the Swiss-Cheese model identifies all circumstances that might have propelled occurrence of an accident in order to create systematic solutions for avoidance of the same, as a policy initiative (Mazaheri et al. 2009).

Four levels of analysis in HFACS

The four levels of HFACS classification are unsafe acts, preconditions for unsafe acts, unsafe supervision, and organizational influences. The first level comprises of errors and violations. The errors consist of decision, perceptual, and skill oriented mistakes committed by the person entrusted with responsibly of making rational decisions in piloting a ship. The violations consist of exceptional and routine mistakes as a result of habitual actions and decision making without consulting the person in charge in piloting a ship (Olufen, Spouge, & Hovem 2003).

The second level consist of environmental, personnel, and prevailing operations conditions that might catalyse occurrence of unsafe actions on the side of those responsible for piloting a ship. For instance, weather, interface, stress, fatigue, and visual limitation among other factors might create ideal preconditions for actions that are unsafe in piloting a ship (Olufen, Spouge, & Hovem 2003). The third level called unsafe condition occurs as a result of inadequate supervision, failure to rectify known problem, violation in supervision, and inappropriate operation planning in piloting a ship (Olufen, Spouge, & Hovem 2003).

The last stage is the organizational influences such as operational process, organization climate, and resource management (Olufen, Spouge, & Hovem 2003). For instance, limited human resource, poor work culture, and improper organization oversight might result in poor decisions among pilots steering a ship.

HFACS classification for Attilio Ievoli

Following the alteration of the course of the vessel, the immediate action that should have been taken by the relieving officer was initiating communication with the bridge watch team and the Master in order to confirm his calculations on the position of the vessel and expected position following alteration on the course. Moreover, the relieving master should have set on the bridge alarm system that would have alerted the crew of an off course cruise.

Considering the tidal speed of 1.5 knots, the inaccurate adaptation of 175 (T) created marginal error of about ten metres and the relieving officer did not imitate a corrective response on time (Montewka et al. 2011; Olsen & Gluver 2008). Thus, had the aspect of human operations activity on the vessel been accurate, the accident would have not occurred. These aspects are classified below within the four levels of HFACS classification for the chemical tanker that run aground.

Unsafe acts

The decision to not follow protocol, which is to use East Solent route was responsible for the accident. This decision created the stage for occurrence of the accident since it went against the standard protocol created by the shipping company.

Preconditions for unsafe acts

The weather was not very clear and visibility was limited. Being in the evening, the master might have suffered from limited visibility as the dull weather sets in.

Unsafe supervision

Engagement of automatic steering close to the Lymington Banks was an irrational decision. The engagement of automatic steering at this point was unnecessary and simply a sign of fatigue on the part of the master. Interestingly, the master was alone and did not have a co-pilot to make his work easier through duty alternation.

Organizational influences

The shipping company did not have structures to monitor the actions of the master in line of duty. Since the master was alone, it is possible that the shipping company did not have enough human resource to steer the ship since shipping standards require presence of at least two captains.

Results of HFACS classification

Despite relatively clear visibility and full functioning of the support systems, the chemical tanker ran aground at low, despite frequently operating in the same route. The collision led to minor damages on the vessel with no human injury recorded. Due to risen sea traffic as a result of increase in the number of vessels over the years, instances of vessels running aground have been on the rise, however, the magnitude is very low.

From reviewing the events leading to the collision accident, the primary cause of the chemical tanker running aground was human error on the part of master and series of assumptions on the probable alternation course during the short moment before running aground (Mazaheri et al. 2009).

As a result of the assumptions, the master did not initiate a clear tracking of the Electronic Chart Display Information system that maps and pinpoints location of the bank, its speed and course over specific duration of time. In fact, the master did not establish the location of the bank through its GPRS system despite having located the docking bay minutes before the accident. On the other hand, the bridge team were ignorant of the direction to be taken by the master and his manoeuvring team of the chemical tanker since the master initiated off course alternations on the tanker with the assumption that the approaching vessels would not perform any alternations (Montewka et al. 2011; Olsen & Gluver 2008).

Due to the lacking communication of this unwritten rule, there was general confusing in the chemical tanker coupled with poor visibility. An interesting aspect to note before the accident was the chemical tanker’s warning system that would initiate a report to the crew of a possible collision within a range of 450 metres to the bank. Despite the green button signal, the chemical tanker did not slow down but assumed that its alternation course would steer it of the possible collision route (Praetorius, 2012).

The same event occurred for the master who made alternations in the direction that made the collision unavoidable. Too sum it all, the shore personnel did not communicate these alterations they are supposed to track to avoid the collision (Olufen, Spouge, & Hovem 2003).

Thus, poor visibility and relatively high speed near the docking bay made the collision unavoidable (Praetorius 2012). In fact, the master of the Chemical tanker did not initiate any official communication of the situation at hand to avoid running aground on time (Olufen, Spouge, & Hovem 2003). From the above reflection, lack of systematic reporting and track keeping of location, speed and position of the chemical vessel, as a result of human negligence, was the cause of the collision between the chemical vessel and the docking bank (Montewka et al. 2011; Olsen & Gluver 2008).

Human error was the sole cause of the accident. There was no communication coordination among the crew members of the vessel and this resulted into repeated inaccurate alterations of the course of the vessel within a narrow pass despite presence of very clear visibility of up to 10 miles (Mazaheri et al. 2009). Being in the evening, the accident can also be blames on visibility misjudgement by the master and negligence of the bridge watch team who were caught unaware when the accident occurred (Lin 2009).

Lessons to be applied to navigation and safety management

Thus, improvement of coordination among the crew is necessary in order to avoid occurrence of the same incident in the future. In order to avoid running aground, the immediate action that should have been taken by the master of the chemical vessel is to communicate the course alteration bearings and speed simultaneously to ensure that the vessel was not in the course to run aground (AASHTO 2011; Fujii et al. 2004). Besides, the shore personnel team ought to have coordinated the location of the bank to the master of the chemical tanker by advising him on the probable course of movement to limit through their systematic reporting and track keeping of location systems.

The informal assumption by the master of the chemical vessel to alter course without tracking communication should have be cancelled and the vessel guided by communication response from the offshore personnel to avoid occurrence of such accidents. The accident should be blame on poor communication coordination between the shore personnel and the crew of the chemical tanker, which resulted in the Attilio Ievoli running aground.


Human error, environmental factors, and fatigue can be blamed for the accident in which the chemical tanker was run aground. The master failure to following the direction protocol and might have been influenced by usual knowledge and past experience to steer the ship. In order to avoid occurrence of the same incident in the future, there is need to formalise the company protocol as the primary piloting guideline to avoid instance of masters making decisions based on their assumptions. The guideline is likely to promote real-time communication on any alterations and subsequent actions that might result in accident.

Reference List

AASHTO 2011, Guide specifications and commentary for vessel collision design of highway bridges, AASHTO, London, UK.

Fujii,Y, Oshima, R, Yamanouchi, H & Mizuki, N 2004, “Some factors affecting the frequency of accidents in marine traffic: I- The diameter of evasion for crossing encounters, II- The probability of stranding, III- The effect of darkness of the probability of collision and stranding,” The Journal of Navigation, vol. 27, no. 2, pp. 239-247.

Lin, S 2009, Physical risk analysis of ship grounding, AASHTO, London, UK.

Mazaheri, A, Kotilainen, P, Sormunen, O, Montewka, J & Kujala, P 2009, “Dependency of ship grounding accident frequency on the ship traffic and the waterway complexity,” Shipping management Journal, vol. 3, no. 5, pp. 34-76.

Montewka, J, Krata, P, Goerlandt, F, Mazaheri, A & Kujala, P 2011, “Marine traffic risk modeling – an innovative approach and a case study,” Journal of Risk and Reliability, vol. 225, no. 3, pp.307-322.

Olsen, D & Gluver, H 2008, Ship collision analysis: proceedings of the International Symposium on Advances in Ship Collision Analysis, Taylor and Francis, Copenhagen, Denmark.

Olufen, O, Spouge, J & Hovem, L 2003, The forman safety assessment methodology applied to the survival capability of passenger ships, RINA Passenger Ship Safety, London, UK.

Praetorius, G 2012, Safety within the Vessel Traffic Service (VTS) Domain – Understanding the role of the VTS for safety within maritime traffic management, McGraw Hill, London, UK.

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