PORTFOLIO – 2(MÆRSK BUTTLER)

A tragedy occurred for “MÆRSK” shipping company in 2016 where “Mærsk

Searcher” and “Mærsk Shipper”, two Danish offshore supply ships were capsized
and sank in the “Bay of Biscay” which towed to Aliaga, Turkey for recycling by
another offshore ship named “Mærsk Buttler”. It was considered as a significant
accident in the history of this shipping company because of releasing tons of oil
into the ocean though there were no lives at risk during the accident. The “Danish
Maritime Accident Investigation Board(DMAIB)” therefore investigated the
whole calamity in the company of a French authorities to signify the happenings
to lead the foundering of two ships.
PART - 1 :
This accident occurred due to several rationales, e.g. choosing the wrong towing
method, providing incomplete documents, lengthy organizational changing
procedure, failed to handover the documents to the new organization, loss of
fenders and so on and there was some organizational factors that lead to this
casualty. Reviewing this case, I found two organizational factors, for instance,
active role of top management and evaluation of occupational safety hazards.
Towing Procedure :
The towing setup was watermarked as draft and it was not handed over to the new
master of “Buttler”. Hence,choosing the wrong towing method led to the severe
accident which raise the question about the role of top management. DMAIB
report also highlighted that the towing procedure was unconventional. The
purpose of safety management and the generic structure was not addressed. It was
mostly focused on the towage preparation and the voyage carried out operation.
(DMAIB, 2017). Therefor, it was the most significant organizational factor.
Risk Assessment :
This was also another important organizational factor that contributed extensively
to this fatal disaster. Poor risk assessment and initiative of ineffective risk
mitigation process were completely accountable for this catastrophe. The
operational management failed to evaluate the hazards accurately. The DMAIB
concluded its report by highlighting the absence of strategies for this acute
incident. Hence, this evaluation factor was considered an important circumstance.
(DMAIB, 2017)

PART – 2 :
After evaluating this case, I found some human errors behind occurring this
tragedy. According to the definition of human errors in health & safety
management, it is termed as “intended action”.

Figure 1 Human errors type (Self Figure)

Knowledge-based mistakes had occurred because they failed to do their intended

acts due to knowledge deficits and also there situational violations happened due
to the master’s noncompliance where he tried to complete his job carelessly. To
overcome and avoid this type of error we can follow the predictive human error
analysis(PHEA) strategy since it covers almost all the tasks to elude the
maximum errors. The PHEA covers problem definition, task analysis, human
error analysis, consequence analysis, develop error reduction strategies.
According to the case of this accident, some attitudes can also be an influencer to
prevent this kind of incident. Management safety commitment, Safety evaluation,
Safety control, and Safety responsibility could be the concerned attitudes that led
to avoid these circumstances. Besides, some integrated approaches to manage the
human risks, for instance, training, targeted human resources like behavior
modification and attitude change, and technical intervention could be the
significant strategies.

References:
• Marine accident report on MAERSK BATTLER’s loss of tow and the
foundering of MÆRSK SEARCHER and MÆRSK SHIPPER on 21 and
22 December 2016, DMAIB. https://dmaib.dk/media/9092/maersk-battler-
loss-of-tow-on-22-december-2016.pdf

• Human Safety and Risk Management (second edition)- A. Ian Glendon,

Sharon G Clarke, Eugene F. Mckenna