Beware of human error

The Marine Accident Investigation Branch, a UK government organization authorized to investigate all maritime accidents in UK waters and accidents involving UK registered ships worldwide, published their findings when a the 300-meter container ship lost cargo overboard while 700 miles east of Japan in the North Pacific Ocean:

Summary
On October 30, 2017, the UK registered container ship Ever Smart suffered a container stow collapse while on passage between Taipei, Taiwan and Los Angeles, USA. The master had changed the ship’s passage plan to avoid severe weather caused by a developing depression east of Japan, but the ship continued in heavy seas; rolling and pitching heavily with frequent bow flare slamming.

Once the weather had abated, the crew discovered that the container stacks on the aft most bay had collapsed and toppled to port. Of the 151 containers in the stow, 42 were lost overboard and 34 were damaged. Superficial damage was caused to the ship.

Safety issues
• The loss of the containers most likely occurred during a period of heavy pitching and hull vibration in the early morning of 30 October.
• Combination of factors resulted in a loss of integrity for the whole deck cargo bay; in particular, the containers were not stowed or secured in accordance with the cargo securing manual.
• The container lashings might not have been secured correctly.

Safety recommendations
Recommendations have been made to Evergreen Marine Corp. (Taiwan) Ltd to improve standards of stowage plans produced ashore, knowledge of the dangers of bow flare slamming, and lashing gear maintenance management.

After 78 pages and nearly three years, the conclusion is that humans continue to be a source of human error.