A STAMP and HFACS-MA Analysis of the Sanchi Oil Tanker Disaster: Lessons Learned and Ways Forward

Abstract

The merchant shipping industry – carrying around 90% of the world’s trade – has been considered as one of the most international and important industries of the world. It has also been considered as a high-risk industry where a small error has the potential to lead to losses of human lives, cargos, properties as well as environmental damage. Studies have shown that 75-96% of maritime causalities are related to human factors, and 89-96% of ship collisions are human-related. Safety policies and rules with regard to ship operations are made by the International Maritime Organization, flags and port states as well as the ship-owning companies. These policies and rules are all with the goal of improving vessel safety and reducing risks, but still, accidents happen with deadly consequences.

On January 6, 2018, the tragic accident involving the collision of Sanchi, and CF Crystal happened. The accident caused 32 fatalities and a total of 113,000 tons of oil spilled into the sea, making it the largest incident since ABT Summer in the early 90s. To understand what lies behind the Sanchi disaster and causation of the accident, this study has applied two models to analyse this accident. Firstly, Human Factors Analysis and Classification System Maritime Accidents (HFACS-MA), a linear event-based accident analysis built on James Reason’s Swiss cheese model are applied to analyse the accident. Furthermore, a dedicated Systems-Theoretic Accident Model and Processes (STAMP) based accident analysis (CAST) has been further applied to analyse inadequate control actions, inappropriate interactions between systems components and external disturbances. These two methods have individually generated findings, which are compared, and causal factors for the Sanchi accident are identified. Furthermore, the study identifies in what ways the system theory-based STAMP differs in conclusion compared to the human-orientated HFACS-MA. Finally, recommendations for the maritime industry are developed, and the areas for further research studies are also suggested for preventing similar accidents from occurring in the future.

The merchant shipping industry – carrying around 90% of the world’s trade – has been considered as one of the most international and important industries of the world. It has also been considered as a high-risk industry where a small error has the potential to lead to losses of human lives, cargos, properties as well as environmental damage. Studies have shown that 75-96% of maritime causalities are related to human factors, and 89-96% of ship collisions are human-related. Safety policies and rules with regard to ship operations are made by the International Maritime Organization, flags and port states as well as the ship-owning companies. These policies and rules are all with the goal of improving vessel safety and reducing risks, but still, accidents happen with deadly consequences.

On January 6, 2018, the tragic accident involving the collision of Sanchi, and CF Crystal happened. The accident caused 32 fatalities and a total of 113,000 tons of oil spilled into the sea, making it the largest incident since ABT Summer in the early 90s. To understand what lies behind the Sanchi disaster and causation of the accident, this study has applied two models to analyse this accident. Firstly, Human Factors Analysis and Classification System Maritime Accidents (HFACS-MA), a linear event-based accident analysis built on James Reason’s Swiss cheese model are applied to analyse the accident. Furthermore, a dedicated Systems-Theoretic Accident Model and Processes (STAMP) based accident analysis (CAST) has been further applied to analyse inadequate control actions, inappropriate interactions between systems components and external disturbances. These two methods have individually generated findings, which are compared, and causal factors for the Sanchi accident are identified. Furthermore, the study identifies in what ways the system theory-based STAMP differs in conclusion compared to the human-orientated HFACS-MA. Finally, recommendations for the maritime industry are developed, and the areas for further research studies are also suggested for preventing similar accidents from occurring in the future.