The aim of this assignment is to assess your ability to gather testable data, to analyse this data using structured methodology, draw conclusions on the root cause(s) that created this incident, and to detail recommendations on how to prevent such an incident from happening again.
Collision of Vessels near Lamma Island, Hong Kong, on 1 October 2012
Two local passenger ferries collided on 1 October 2012 off Lamma Island, Hong Kong, which killed 39 people while another 92 were injured. The two ships involved were “Sea Smooth”, a passenger ferry operated by Hong Kong and Kowloon Ferry, and “Lamma IV” owned by the Hongkong Electric Company. Lamma IV was carrying 3 crew members, 124 employees and their families on a company event, heading to observe the fireworks display commemorating China’s National Day. Sea Smooth had 4 crew members and 95 passengers.
At 8:20pm, the larger Sea Smooth crashed into Lamma IV on the port side and the impact ruptured Lamma IV’s two watertight compartments at the rear. Water quickly filled up Lamma IV and the ship sank rapidly within two minutes after collision. Many passengers were trapped inside the vessel and had not enough time to put on lifejackets.
A distress call was made by Lamma IV to a sister ship Lamma II that was travelling several minutes behind. Lamma II arrived at the scene and helped rescue survivors. The first emergency service vessel to arrive was a Marine Police vessel at 8:39 pm followed by a Fire Services vessel shortly thereafter.
Meanwhile, Sea Smooth which sustained damage and lost part of her forward compartment was able to remain afloat even though some water had flooded in. She remained in the vicinity of the collision for a few minutes before resuming her way to Lamma Island where all her passengers disembarked.
Of the 39 fatalities from Lamma IV, 8 were children aged 10 years and below. This accident was Hong Kong’s deadliest maritime disaster in four decades.
You are tasked to conduct an Accident Investigation on what caused these losses using evidence that has already been established. You are not expected to uncover new evidence, but should use sources already in existence and discoverable to the public.
Question 1 – Evidence and Timeline
(a)Examine the collected evidence for this incident and present this using the structure of the Swiss Cheese Model.
(b)You should present the layers of Organisational Influence, Unsafe Supervision, Preconditions and Unsafe Acts independently and highlight your reasons for placing each item within the layer. You should also state where there are shortcomings in the evidence, the reasons why these shortcomings are so, and how they might be overcome (if possible).
(c)For all evidence that you use, you should present actual and/or potential scientific verification, and you should formally cite the source(s).
(d)From this evidence, create a timeline of events that led up to the collision and the subsequent loss of Lamma IV and the lives. Each element of the timeline should identify the evidences and from which layer of the Swiss Cheese Model these come from.
(e)You are free to use other additional tools to support your analysis, but if so you should state your reason(s) for doing so.
Question 2 – Root Cause Analysis
(a)From the evidence gathered and your timeline, construct a Root Cause Analysis (RCA) using the Swiss Cheese Model created in Question 1.
(b)Identify the Root Cause(s) of the incident using a Causal Tree.
(c)From this Causal Tree and using the Hierarchy of Controls, compose your conclusion and recommendations to ensure that this incident does not happen again.
(d)Analyse the likelihood of success for each recommendation, presenting reasoning for this.
(e)You are free to choose the format of the recommendations; however, the format chosen should support the earlier assessment methodologies that you employed.
Question 3 – Incident Report
(a)Create a detailed report of this incident using the structure studied in this course i.e.
(ii)What caused it to happen?
(iii)What you recommend should happen next.