III 9-WP.3 - Report of The Working Group (Secretariat)

E
SUB-COMMITTEE ON IMPLEMENTATION III 9/WP.3

OF IMO INSTRUMENTS 4 August 2023
9th session Original: ENGLISH
Agenda item 4
DISCLAIMER
As at its date of issue, this document, in whole or in part, is subject to consideration by the IMO organ
to which it has been submitted. Accordingly, its contents are subject to approval and amendment
of a substantive and drafting nature, which may be agreed after that date.
LESSONS LEARNED AND SAFETY ISSUES IDENTIFIED FROM THE ANALYSIS OF

MARINE SAFETY INVESTIGATION REPORTS
Report of the Working Group
General
1 The Working Group on Lessons Learned and Safety Issues Identified From the
Analysis of Marine Safety Investigation Reports (the Group) met from 31 July to 3 August 2023
under the chairmanship of Capt. Kunal Nakra (Singapore).
2 The Group was attended by representatives from the following Member

Governments:
ANTIGUA AND BARBUDA MEXICO

ARGENTINA NETHERLANDS (KINGDOM OF THE)
AUSTRALIA NEW ZEALAND
BAHAMAS NIGERIA
BELGIUM NORWAY
BRAZIL PANAMA
CANADA PAPUA NEW GUINEA
CHILE PHILIPPINES
CHINA POLAND
DENMARK PORTUGAL
FRANCE REPUBLIC OF KOREA
GERMANY RUSSIAN FEDERATION
INDONESIA SAUDI ARABIA
JAMAICA SINGAPORE
JAPAN SPAIN
KENYA SWEDEN
LIBERIA TÜRKİYE
MALAYSIA UNITED ARAB EMIRATES
MALTA UNITED KINGDOM
MARSHALL ISLANDS UNITED STATES
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III 9/WP.3
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by representatives from the following Associate Member of IMO:
HONG KONG, CHINA
by observers from the following intergovernmental organizations:
EUROPEAN COMMISSION (EC)

MARINE ACCIDENT INVESTIGATORS' INTERNATIONAL FORUM (MAIIF)
by observers from the following non-governmental organizations in consultative status:
INTERNATIONAL CHAMBER OF SHIPPING (ICS)

OIL COMPANIES INTERNATIONAL MARINE FORUM (OCIMF)
INTERNATIONAL MARITIME PILOTS' ASSOCIATION (IMPA)
INTERNATIONAL FEDERATION OF SHIPMASTERS' ASSOCIATIONS (IFSMA)
INTERNATIONAL ASSOCIATION OF DRY CARGO SHIPOWNERS
(INTERCARGO)
INTERNATIONAL TRANSPORT WORKERS' FEDERATION (ITF)
WORLD SHIPPING COUNCIL (WSC)
NAUTICAL INSTITUTE (NI)
and by the following IMO training institute:
WORLD MARITIME UNIVERSITY (WMU)
Terms of reference
3 Taking into account comments made, relevant decision taken in plenary and
documents III 9/4; III 9/4/1; III 9/4/2, III 9/4/3, III 9/4/4, III 9/4/5, III 9/4/6, III 9/4/7, III 9/4/8,
III 9/4/9, III 9/INF.10, III 9/INF.11, III 9/INF.12, III 9/INF.13 and III 9/INF.33, the Group was
instructed to:
.1 confirm or otherwise, the findings of the Correspondence Group based on

the analysis of individual marine safety investigation reports and GISIS, for
the Sub-Committee's approval and authorization of their release to the public
on GISIS (III 9/4, paragraph 28.8);
.2 confirm the reviewed text of lessons learned from marine casualties, for the
Sub-Committee's approval and authorization of release in accordance with
the agreed procedure and examine the observation regarding lessons
learned for evaluation (III 9/4, paragraphs 28.1 and 28.2);
.3 consider the proposal for a new output for the development of guidelines
addressing risks of falls from height, and make recommendations as
appropriate (III 9/4, paragraph 28.3);
.4 complete the questionnaire for collecting data for the work for preventing
collisions with fishing vessels and suggest a way forward to continue the
work of further analysing these casualties (III 9/4, paragraph 28.4);
.5 consider the result of the analysis on ISM Code related concern on

unsatisfactory implementation of safety management systems with
recommendations as appropriate, taking into account outcome of MSC 107
(III 9/4, paragraph 28.5);
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.6 confirm the result of the test of the updated Procedure for identifying and
forwarding safety issues, taking into account that MSC 106 had approved the
updated procedure (III 9/4, paragraph 28.7);
.7 consider the observations on the quality of marine safety investigation

reports and make recommendations, as appropriate, taking into
consideration the consolidated report of previous analyses of observations
on the quality of the reports in document III 9/4/2, and provide feedback
(III 9/4, paragraph 28.9);
.8 consider the views expressed by NCSR 10, on the safety issues resulting in
man overboard from fishing vessels for feedbacks and make
recommendations as appropriate (III 9/2/2/Add.1 (Secretariat));
.9 consider the testing result of the MCI2 and the way forward and provide
recommendation as appropriate (III 9/4/3 (Secretariat));
.10 consider documents III 9/4/4 (China) and III 9/4/6 (Republic of Korea) and in
particular, the proposals contained in paragraph 14 of document III 9/4/4 and
paragraph 10 of document III 9/4/6;
.11 consider documents III 9/4/7(European Commission), III 9/4/9 (Secretariat),

III 9/INF.10 (INTERCARGO), III 9/INF.11 (InterManager), III 9/INF.12
(InterManager), III 9/INF.13 (InterManager) and III 9/INF.33 (Secretariat) in
particular the findings identified in data analyses for recommendations on the
way forward, as appropriate;
.12 advise on the re-establishment of the Correspondence Group, at this

session, and the Working/Drafting Group on Analysis of Marine Safety
Investigation Reports, at the next session, which could start their work on the
morning of the first day of III 10, in accordance with paragraph 5.19 of
MSC-MEPC.1/Circ.5/Rev.4 on Organization and method of work of the
Maritime Safety Committee and the Marine Environment Protection
Committee and their subsidiary bodies. If so, prepare draft terms of reference
for those Groups under agenda item 4, as appropriate; and
.13 submit a written report to the plenary on Friday, 4 August 2023.
Report of the Correspondence Group
Analysis of individual marine safety investigation reports and observation on the quality
of the report
4 The Group, in considering the analyses of individual marine safety investigation

reports, emphasized that the work of the Correspondence Group on Analysis of Marine Safety
Investigation Reports (CG), was not focused on the analysis or quality of the investigation, but
only on the marine safety investigation reports themselves.
5 The Group agreed to the consolidated text of analyses available in electronic form on
IMODOCS (referred in III 9/4/1), taking into consideration the input from the discussion during
the session, and invited the Sub-Committee to approve and authorize the release of the
analyses to the public on the GISIS Marine Casualties and Incidents (MCI) module.
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6 The Group noted the observations made by the Correspondence Group on the
feedback on the quality of marine safety investigation reports analysed and agreed with the
observations made by the Correspondence Group on the quality of 28 reports analysed (III 9/4,
paragraph 26).
7 The Group noted that, although the quality criteria were not fully met in 12 of the 28
investigation reports, valuable lessons could be learned on account of the nature of the marine
casualty or the safety investigation and accordingly these 28 reports could be retained in the
summary of the analysis (III 9/4, paragraph 26.3).
8 The Group recommended that the Sub-Committee bring the observations referred to
in paragraph 26 of the Correspondence Group report to the attention of Administrations by
means of an III.3 circular, to complement III.3/Circ.9, to be processed by the Secretariat with
the objective of improving future marine safety investigation reports.
9 The Group considered document III 9/4/2 containing the consolidated report prepared
by the Secretariat of previous analyses of observations on the quality of the reports. The Group
deliberated on whether the questions expected of the analysts are representative of the
problem at hand and agreed that the scope of the questions could be improved.
10 While noting the lessons learned prepared by Member States, the Group:
.1 noted that the limited availability of the analyst need not be restricted to the
expertise for the casualty analysis process so as to allow the outstanding
reports to be cleared;
.2 agreed that the analysts could direct their effort in identifying safety issues
from the investigation reports; and
.3 assessed that the Analysis of Marine Safety Investigation Reports can be

improved and done in a calibrated and targeted manner.
11 Thus the Group expressed the views that the Correspondence Group, if established,
could work on improving the questions from the observations on the quality of the report which
an analyst answers with a view to provide more feedback for the Member State to improve the
quality of their investigation report in the future. The Group also expressed a desire for such
feedback to be more dynamic for greater efficiency. In view of this, the Group agreed that a
change to the GISIS module on the feedback on observation of the quality of the report can be
considered in order to improve the existing questions posed to an analyst.
12 The Group, therefore agreed to recommend the Sub-Committee to approve the

Group's view on the observations on the quality of marine safety investigation reports and to
instruct the Correspondence Group, if established, to review the method by which analysts
provide information in GISIS regarding potential safety issues and to recommend changes in
the MCI 2 module as appropriate.
Safety issues that need further consideration
13 The Group noted that there were no safety issues related to the reports considered
by Correspondence Group (III 9/4, paragraphs 10 to 12).
III 9/WP.3
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Lessons learned from marine casualties for release on the IMO website
14 The Group considered 13 cases of Lessons learned from marine casualties reported
and compiled by the Member States and Correspondence Group. The Group agreed that three
cases of Lessons learned could be improved for better clarity and finally agreed to invite the
Sub-Committee to approve the 13 Lessons learned for release on IMO website, as set out in
annex 1, following a review to be carried out by the Secretariat.
15 In noting the Correspondence Group's observation on the Lessons learned to be less

than the number of reported occurrences, the Group evaluated the possible reason. The Group
noted that submitting a Lessons learned was currently not a mandatory field when a marine
safety investigation report is submitted to MCI 2 module in GISIS. As a result, an investigating
State may submit the investigation report and leave the Lessons learned field empty.
The Group further noted that consequent to a change of procedure by III 5 (as identified in
III 5/15), Member States may not be aware of the expectation to fill the field on the Lessons
learned, along with a marine safety investigation.
16 As such a circular reminding Member States to fill in the Lessons learned field using
the style guide and format for Lessons learned may be useful. The Group also suggested that
a pop-up dialogue box at each relevant field of the Lessons Learned could be prepared using
the style guide to make the submission more user-friendly so that the quality of the Lessons
learned could also be improved. In this regard, the Group recommended the Sub-Committee
to request the Secretariat to issue a relevant circular covering the aforementioned areas and
to take appropriate measures in the MCI 2 module to reflect a pop-up dialogue box at each
relevant field of the Lessons learned as per III 5/15, annex 4.
Proposal for a new output on guidelines addressing risks of falls from height
17 The Group considered the proposal developed by the Correspondence Group for a
new output on guidelines addressing the identified safety issues of seafarers exposed to risk
of falls from height (including, but not limited to, access to and egress from the location where
the work will be conducted, working from height and work over the side) (III 9/4, annex 2).
Considering that no IMO guidelines addressing the issue currently exist and that there was no
single source that could be used as a basis when developing safe work procedures for working
from height or over the side, the Group agreed with the proposal developed by the
Correspondence Group.
18 Accordingly, the Group recommends the Sub-Committee to invite MSC to consider

the proposal at annex 2, with the HTW Sub-Committee as the coordinating body of the work
for this output and take further action as appropriate.
Work on preventing collisions with fishing vessels
19 Regarding the safety issue related to collisions with fishing vessels, the Group
considered the results from the report of the Correspondence Group:
.1 one reason for collisions with fishing vessels may be different prerequisites
and conditions based on different and/or unequal national legislation. Hence,
a way forward would be to strive for equating those differences;
.2 a comparison of the technical equipment used for preventing collisions would

be useful (e.g. Automatic Identification Systems (AIS) and Very High
Frequency (VHF) radio) to find out to what extent this equipment is used on
fishing vessels; and
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.3 a specially designed questionnaire developed by the Correspondence Group

for that purpose (III 9/4, annex 3) may be useful to gather information from
Member States for analysing the matter in detail.
20 In considering the above views, the Group discussed further improvements to the
questionnaire drafted by the Correspondence Group (III 9/4, annex 3) and agreed on a revised
questionnaire, as set out in annex 3.
21 In this regard, the Group agreed to invite the Sub-Committee to approve the revised
questionnaire contained in annex 3, and to advise the Secretariat to gather information from
Member States using the revised questionnaire. The information gathered from Member States
may be provided to the Correspondence Group, if established, for a further analysis of the
safety issue.
Analysis on ISM Code related concern on unsatisfactory implementation of safety

management systems
22 The Group discussed the conclusions drawn and the recommendations made by the
Correspondence Group based on the analysis of ISM Code related concern on unsatisfactory
implementation of safety management systems. The Group noted that the analysis was mainly
aimed at finding common safety issues and whether ISM Code/SMS has not been fully
implemented. The Group noted the following outcome of the analysis provided by the
Correspondence Group:
.1 a common safety issue was lack of risk assessment;
.2 a majority of the cases indicated ISM Code/SMS had not been fully
implemented;
.3 in many cases the ISM related deficiency could have been detected during
an inspection/audit; and
.4 the problem was how the ISM Code is implemented; not with the ISM Code
itself.
23 In this regard, the Group noted that a comprehensive review of the ISM Code and
related guidelines was discussed by MSC 107 and the Committee agreed to keep the proposal
in document MSC 107/17/5 in abeyance until after the results of relevant studies, including the
Secretariat's study on the ISM Code and related instruments, and the outcome of the ILO/IMO
Joint Tripartite Working Group (JTWG) were available (MSC 107/20, paragraph 17.21).
24 After discussions, the Group opined that it was appropriate to apprise the ILO/IMO
JTWG about the findings of the Correspondence Group and agreed to recommend the
Sub-Committee to bring the content of paragraph 22 to the attention of the Committee for
consideration by the ILO/IMO JTWG.
Result of the test of the updated Procedure for identifying and forwarding safety issues
25 The Group considered the result of the test of the updated Procedure for identifying and
forwarding safety issues carried out by the Correspondence Group and the experience from the
development of the proposed new outputs addressing falls from height and loss of containers
as well as the safety issue defined in document III 8/4/3. The Group also noted that the
Procedure had been compared with other relevant national procedures and the result had been
satisfactory.
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26 Taking into account that MSC 106 had approved the updated Procedure
(MSC 106/19, paragraph 14.6) and based on the report received from the Correspondence
Group, the Group confirmed the results of the test of the updated Procedure for identifying and
forwarding safety issues.
Safety issues resulting in man overboard from fishing vessels
27 On safety issues resulting in man overboard from fishing vessels in relation to the use
of personal flotation devices (PFDs), the Group noted that HTW 9 encouraged fishing vessel
companies and skippers to ensure that fishing vessel personnel wore PFDs on the upper decks
of all fishing vessels while at sea.
28 The Group also noted that the invitation of III 8 to the SSE Sub-Committee to discuss
this matter could not be taken up during SSE 9.
29 The Group further noted the views of NCSR 10 as contained in NCSR 10/WP.7
paragraph 58 on the possible application of existing technology such as SART to locate a
person falling overboard from fishing vessels and the upcoming consideration by the ICAO/ILO
Joint Working Group on Harmonization of Aeronautical and Maritime Search and Rescue
(JWG 30).
30 Recognizing that various options had been indicated in NCSR 10/WP.7 paragraph 58,
the Group invited the Sub-Committee to invite the NCSR Sub-Committee to recommend the
JWG 30 to determine the most effective and appropriate means for locating a person falling
into the water from fishing vessels and take further action to address the safety issue.
Testing results of the MCI 2 module and the way forward
31 In noting document III 9/4/3 (Secretariat), regarding refinement status of the Marine
Casualty and Incidents (MCI) 2, the Group recalled that III 6, III 7 and III 8, having taken into
consideration of the current limitations of the GISIS MCI 2 module, requested the Secretariat
to take action on further developing some functionalities of the MCI2 module as highlighted in
document III 9/4/3.
32 Some members of the Group expressed their views related to difficulties in general
on working with the MCI 2 module.
33 In this regard, the Group was updated by the Secretariat on the status of the current
development.
34 The Group noted the effort made by the Secretariat to refine the MCI 2 module, taking
into consideration the testing as well as the proposed way forward covering enhancement of the
module.
Lessons learned from the marine accidents
35 The Group considered documents III 9/4/4 (China), III 9/4/6 (Republic of Korea),
related to the Lessons learned from marine accidents.
36 The Group discussed document III 9/4/4, related to the cases involving bulk carrier
Theresa Aries, bulk carrier Blue Bosporus and bulk carrier Da Dan Xia and re-analysed the
safety risks concerning lifeboat slings, presenting countermeasures against repetition of
certain similar accidents related to lifeboat slings. There was broad support in the Group to
request the Sub-Committee to invite the SSE Sub-Committee to consider the information
provided in the document, while progressing the work on the existing output 2.16 on "Revision
of SOLAS chapter III and the International Life-Saving Appliance (LSA) Code", as appropriate.
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37 The Group discussed document III 9/4/6 highlighting analysis of the causes of a very
serious marine casualty involving mineral concentrates and the necessity to consider
amending the IMSBC Code to explicitly and directly indicate in the Code the hazards and
precautions of mineral concentrates by official shipping name (BCSN) written on the cargo
declaration. After deliberations, the Group agreed to request the Sub-Committee to invite the
CCC Sub-Committee to consider the information provided in the document, while progressing
the work on the existing output 7.13 on "Amendments to the IMSBC Code and supplements",
as appropriate.
38 The Group used this opportunity to highlight that the proposed way forward for the
above identified safety issues did not have an impact on the existing process for identifying
and forwarding safety issues under the III Sub-Committee.
Findings identified in data analyses of marine casualties and incidents
39 The Group considered documents III 9/4/7 (European Commission), III 9/4/9
(Secretariat), III 9/INF.10 (INTERCARGO), III 9/INF.11 (InterManager), III 9/INF.12
(InterManager), III 9/INF.13 (InterManager) and III 9/INF.33 (Secretariat).
40 The Group noted that III 9/4/7 reported on the analyses conducted by the European
Maritime Safety Agency (EMSA) of marine casualties and incidents reported in the European
Marine Casualty Information Platform (EMCIP) concerning Ro-Ro ferries, container ships and
navigation accidents, and provided overviews of the potential safety issues and their remedial
actions.
41 The Group further noted that III 9/4/9 and III 9/INF.33 provided preliminary results of
the pilot study of selected passenger ship casualties, as a pilot model/example, and provided
qualitative and in-depth data statistics and trend analysis from selected marine safety
investigation reports involving passenger ships on the basis of the taxonomy specified in
MSC-MEPC.3/Circ.4/Rev.1.
42 The Group noted with appreciation the information on bulk carrier casualty statistics
and analysis between the years 2012-2023 from INTERCARGO, the information on analysis
of enclosed space asphyxiation accidents, on analysis of lifeboat and rescue boats accidents
as well as on the action to prevent marine casualties caused by cargoes from InterManager.
43 In this context, the Group discussed the possible way forward in relation to the
analysis results received by the Group, such as those provided in III 9/4/7 and III 9/4/9 as well
as the above information documents. In general, the Group was in support of considering the
results of such analyses to support the existing regulatory work of various IMO organs
effectively, and as a possible part of a process to support data-based decision-making and
policy development at IMO. During ensuing discussions, some of the views expressed by the
members of the Group were:
.1 reports of these analyses should be examined by the Correspondence Group

in detail before considering application of the updated Procedure (approved
by MSC 106);
.2 the work of the Group may be more complex since the analysis reports may
come from different sources in different formats and have been developed
using different analysis methodology;
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.3 the role of the Correspondence Group is to deal with safety issues

intersessionally and take it forward for further action, and such analyses
results/reports could be an additional source of data;
.4 different streams of data may not be in a uniform template;
.5 Member States may forward relevant analyses of casualty data to other IMO
organs with specific areas of interest, if that IMO organ has an existing output
on the same subject;
.6 would this new process mean that the Correspondence Group is to become:
.1 the body to confirm acceptance or not of safety issues identified and

forwarded by other sources; or
.2 a body which should accept the safety issues identified as submitted

by the other sources.
44 In this regard, the Group suggested that the Correspondence Group, if established,
may be requested to examine the documents as listed in paragraph 39 of this document in
detail as an example, and develop a process to support data-driven decision-making and policy
development at IMO based on apparent safety issues identified from casualty data analysis
reports and studies.
Correspondence Group on Lessons Learned and Safety Issues Identified from the
Analysis of Marine Safety Investigation Reports and terms of reference
45 The Group, taking into account the work completed at this session, recommended
that the Correspondence Group on Lessons Learned and Safety Issues Identified from the
Analysis of Marine Safety Investigation Reports be re-established, under the coordination of
Sweden,* to continue its work intersessionally under the following terms of reference, using
IMO Space facilities:
.1 conduct a review of the marine safety investigation reports on investigations

into casualties submitted by Administrations, in the five years preceding the
current session, prioritizing very serious marine casualties involving SOLAS
ships; additionally those that have occurred in the 10 years preceding the
current session for which reports are available will be prioritized in
consultation with the Secretariat. A summary list of draft Lessons learned
from marine casualties, where appropriate, will be prepared;
.2 review the draft text of Lessons learned from marine casualties, for the
Sub-Committee's consideration prior to release in accordance with the
agreed procedure;
.3 identify safety issues that need further consideration by the Sub-Committee,

and make recommendations taking into consideration the discussion at the
Working Group;
*
Coordinator: Capt. Jörgen Zachau
Swedish Accident Investigation Authority
P.O. Box 12538, SE- 102 29 Stockholm, Sweden
Phone: +46 8 508 862 13 | Fax: + 46 8 508 862 90
Email: jorgen.zachau@shk.se
III 9/WP.3
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.4 review the method by which analysts provide information in GISIS regarding

potential safety issues and recommend changes under observations on the
quality of the report as necessary;
.5 analyse the information gathered from Member States through the specially
designed questionnaire, and provide recommendation on preventing
collisions with fishing vessels;
.6 develop a process to support data-driven decision-making and policy

development at IMO based on apparent safety issues identified from casualty
data analysis reports and studies, such as that provided in documents
III 9/4/7 (European Commission), III 9/4/9 (Secretariat), III 9/INF.10
(INTERCARGO), III 9/INF.11 (InterManager), III 9/INF.12 (InterManager),
III 9/INF.13 (InterManager) and III 9/INF.33 (Secretariat), recognizing that
similar casualty analysis reports may be expected in the future; and
.7 submit a report to III 10.
Working/Drafting Group on Lessons Learned and Safety Issues Identified from the
Analysis of Marine Safety Investigation Reports
46 In this context, the Group also recommended the Sub-Committee to consider that the
Working Group on Lessons Learned and Safety Issues Identified from the Analysis of Marine
Safety Investigation Reports , if re-established, should start its work on the morning of the first
day of III 10, in accordance with MSC-MEPC.1/Circ.5/Rev.4 on Organization and method of
work of the Maritime Safety Committee and the Marine Environment Protection Committee and
their subsidiary bodies, under the following provisional terms of reference, subject to further
instructions to be received from plenary:
.1 confirm or otherwise, the findings of the Correspondence Group based on

the analysis of individual marine safety investigation reports and GISIS, for
the Sub-Committee's approval and authorization of their release to the public
on GISIS;
.2 confirm the reviewed text of Lessons learned from marine casualties, for the
Sub-Committee's approval and authorization of release in accordance with
the agreed procedure;
.3 consider and advise whether those reports with safety issues reviewed by
the analysts indicating potential safety deficiencies should be referred to the
relevant committees and sub-committees. In doing so, the Working Group
should submit supporting information derived from the Casualty Analysis
Procedure, used to develop recommendations for consideration by the
committees and sub-committees according to agreed procedures;
.4 consider the recommendation provided by the Correspondence Group

related to the method used by analysts to provide information in GISIS
regarding potential safety issues;
.5 consider the summary provided by the Correspondence Group related to

collisions with fishing vessels;
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.6 consider the proposal by the Correspondence Group related to the

development of a process to support data-based decision-making and policy
development at IMO; and
.7 consider the analysis made by the Correspondence Group on the feedback

on the observation on the quality of the report.
Action requested of the Sub-Committee
47 The Sub-Committee is invited to approve the report in general and, in particular, to:
.1 approve the findings of the Correspondence Group based on the analysis of

individual marine safety investigation reports and GISIS, as reviewed by the
Group, including the changes to the text of casualty analyses; and authorize
their release to the public on the GISIS MCI2 module (paragraphs 4 and 5);
.2 bring the observations referred to in paragraph 9 to the attention of

Administrations, by means of an III.3 circular; to complement III.3/Circ.8 to
be processed by the Secretariat, with the objective of improving future marine
safety investigation reports (paragraph 8);
.3 agree to the recommendation of the Group on the observations on the quality

of marine safety investigation reports and for the correspondence group, if
established, to review the method by which analysts provide information in
GISIS regarding potential safety issues and to recommend changes in the
MCI 2 module, as appropriate (paragraph 12);
.4 approve the draft text of Lessons learned from marine casualties and their
release on the IMO website in accordance with the agreed procedure
(paragraph 14 and annex 1);
.5 request the Secretariat to issue a relevant circular and to take appropriate

measure in the MCI module to reflect a pop-up dialogue box at each relevant
field of the Lessons learned (paragraph 16);
.6 agree with the views of the Group on the development of guidelines

addressing risks of falls from height and invite MSC to consider the proposal
for a new output for development of guidelines addressing risks of falls from
height with the Sub-Committee on Human Element, Training and
Watchkeeping (HTW) as the coordinating body (paragraphs 17, 18 and
annex 2);
.7 approve the revised questionnaire on fishing vessel collisions contained in

annex 3, and advise the Secretariat to gather information from Member
States using this questionnaire (paragraph 21 and annex 3);
.8 endorse the recommendation of the Group for the correspondence group, if

established, to analyse the information gathered from Member States related
to the work for preventing collisions with fishing vessels and recommend
further actions (paragraph 21);
III 9/WP.3
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.9 approve the recommendation of the Group on the result of the analysis on

ISM Code related concern on unsatisfactory implementation of safety
management systems and invite MSC to bring the content of paragraph 22
to the attention of the Committee for consideration by the Joint ILO/IMO
JTWG (paragraph 24);
.10 note the confirmation by the Group of the updated Procedure for identifying
and forwarding safety issues (paragraph 26);
.11 agree to the views of the Group on the safety issues resulting in man
overboard from fishing vessels and invite MSC to bring the views of the
Group to the attention of the Sub-Committee on Navigation,
Communications, Search and Rescue (NCSR) (paragraphs 29 and 30);
.12 note the views of the Group regarding the result of the testing of the MCI 2
module (paragraphs 33 and 34);
.13 endorse the views of the Group on the proposals contained in III 9/4/4
(China) and invite the SSE Sub-Committee to consider the information
provided in the document, while progressing the existing output 2.16 on
"Revision of SOLAS chapter III and the International Life-Saving Appliance
(LSA) Code", as appropriate (paragraph 36);
.14 endorse the views of the Group on the proposals contained in III 9/4/6
(Republic of Korea) and invite CCC Sub-Committee to consider the
information provided in the document, while progressing the existing
output 7.13 on "Amendments to the IMSBC Code and supplements", as
appropriate (paragraph 37);
.15 agree to the views of the Group regarding data analysis as identified by EC,
WMU, INTERCARGO and InterManager and instruct the correspondence
group, if established, to examine the documents in detail and develop a
process to support data-driven decision-making and policy development at
IMO based on apparent safety issues identified from casualty data analysis
reports and studies (paragraphs 43 and 44);
.16 re-establish the Correspondence Group on Lessons Learned and Safety

Issues identified from the Analysis of Marine Safety Investigation Reports
under the proposed terms of reference (paragraph 45); and
.17 agree to the early establishment of the Working/Drafting Group on Lessons

Learned and Safety Issues Identified from the Analysis of Marine Safety
Investigation Reports at III 10 under the proposed terms of reference
(paragraph 46).
***
III 9/WP.3
Annex 1, page 1
ANNEX 1
LESSONS LEARNED FROM MARINE CASUALITIES
1 OCCUPATIONAL ACCIDENT
Very serious marine casualty: Fatality under fallen load
What happened:
A ship berthed to commence unloading operation. While the carbon anode cargo was being
unloaded, a row of cargo in the hold fell over, and the stevedore who was unlashing the sling
of steel plate at that time perished under the fallen load.
Why did it happen:
It was concluded that the factors that contributed to the accident were leaving the stacking
level of the load units over the tolerable level during the unloading procedure, not taking into
account the balancing considerations produced by the non-standard sizes of load units, and
the way the job was done, with no effective monitoring and decision-making mechanisms.
What can we learn:
• Shipping companies should review the SMS procedures to clearly identify risks
involved in different tasks and provide clear guidance to its fleet of ships accordingly.
• The Terminal representatives/Stevedoring Companies engaged with

loading/unloading operations on board should carry out a risk assessment effectively
prior to the commencement of the tasks.
Who may benefit:
Ship Operators/Managers/Owners, Terminal Representatives, Stevedores.
Very serious marine casualty: Fatal strike by mooring line
What happened:
A general cargo vessel was moored alongside an anchored bulk carrier to load a cargo of grain
using the bulk carrier's cranes. Towards the end of the loading process, it was identified that
the smaller general cargo vessel needed to move two to three meters forward to allow the bulk
carrier's forward crane to reach part of the cargo hold that was being loaded. The general
cargo vessel's master decided to warp the vessel ahead using the mooring lines and tasked
the watch crew and the chief officer. No additional crew members were assigned to the task,
as the off watch crew was resting, while the master acknowledged that the chief officer was
tired. An AB and the chief officer were posted on the general cargo vessel's aft mooring station,
with the 3/O and bosun on the forward mooring deck. The SMS required an officer-led team of
three crew at each mooring station for mooring operations, with the chief officer supervising.
It was dark by the time the warping operation commenced and the bulk carrier's deck was
about eight meters higher than the general cargo vessel, despite the vessels having had similar
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freeboards at the start of the loading operation, 22 hours earlier. As the bosun slackened the
forward springs, the AB began to haul in one of the aft spring lines, with the chief officer
standing close to the vessel's side and the aft springs. Both of these lines led through the same
open design fairlead and as the tension increased on the spring, it skipped over the fairlead
and struck the head of the chief officer, who collapsed unconscious. Although the alarm was
raised immediately, it took two hours until a medical professional could treat the injured chief
officer, who was declared deceased.
Why did it happen:
• The mooring line sprang free because the fairlead in use was open and the lines had
adopted a hazardous upward lead caused by the difference between the vessels'
freeboards that had developed while the during cargo operations.
• Leading two lines through the same fairlead restricted the space available and almost
certainly contributed to the mooring line springing out of the fairlead and snapping
tight.
• The chief officer was struck on the head and fatally injured while standing in the
danger zone close to the tensioned spring lines when the warping operation
commenced.
• An insufficient amount of crew were allocated to the warping operation, as the off
watch crew were resting and the master didn't want to disrupt their hours of rest.
• Both the mooring and warping operations were insufficiently planned due to a lack of
time available and the crew's lack of familiarity with ship-to-ship dry cargo operations.
• The crew of the general cargo vessel was unfamiliar with the ship-to-ship transfer
operation and there was no guidance for the activity in the SMS.
What can we learn:
• This accident highlights the importance of assigning sufficient crew to shipboard

operations. In this case, two crew at the aft mooring station were not sufficient to
safely conduct the warping manoeuvre, resulting in the chief officer placing themself
in a position of danger.
• There is well documented industry guidance for the ship-to-ship transfer of liquid
cargoes, but the guidance for transfer of bulk cargoes was limited. There was no
procedure in the SMS for the ship-to-ship transfer of dry cargo, nor for warping the
vessel using the mooring lines. It is important that an SMS is comprehensive and
provides guidance on the appropriate conduct of all operations that may be carried
out on a vessel.
• Operations need to be properly planned, risks assessed and the subject of a safety
brief before they begin so that all hazards involved can be identified and appropriate
control measures put in place. In this instance, the risk of the spring line jumping out
of the fairlead had not been appreciated and the warping operation not sufficiently
planned. Furthermore, the effect of the change in relative freeboard that had
developed during the time the cargo operation had been under way had not been
considered.
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• It is important to ensure that equipment is suitable for the intended operation and that
crew have a good understanding of the limitations of the equipment.
Who may benefit:
All deck officers and ratings.
3 MAN-OVER-BOARD
Very serious marine casualty: Fatality when crew member fell over-board from ladder
What happened:
In June, a gas carrier was transiting in the South Atlantic Ocean, bound for a Brazilian port.
In the morning after handing over the navigational watch to the Third Officer, the Chief Officer
tasked two crew members to carry out painting work for the undersides of two separate
stairway landings from the boat-deck.
After the crew members collected the required tools, they began the painting work using
telescopic rods connected to roller-brushes. About an hour into the painting work, one of the
crew members saw the other carrying a portable A-frame ladder to the boat-deck.
Shortly after, the crew member who collected the ladder was seen sitting on top of the ladder
carrying out the painting and then losing his balance when the ladder tilted, while the vessel
was altering course. The crew member and the ladder fell overboard.
Man Over-board (MOB) procedure was carried out and with the assistance of a nearby fishing
vessel. The lifeless body of the lost crew was brought onboard the vessel, and attempts to
resuscitate the crew were unsuccessful.
Why did it happen:
The investigation revealed that the use of the portable ladder was not considered necessary
for the painting work, when the crew members were assigned and briefed for the work in the
bridge. The use of the portable ladder, as stated in the Safety Management System (SMS),
required a risk assessment and a permit-to-work to be carried out before approved by the
Master.
However, the crew member had used the portable ladder without consulting anybody. Although
provided with a stop-work authority card, the other crew member did not execute this authority,
missing the opportunity to stop the use of the portable ladder.
The investigation also revealed that there was a difference in the understanding of the SMS
requirement for the type of work activities to be entered in the "Change of Bridge Watch"
checklist by the watchkeeping officers (the CO and 3O), resulting in the 3O not being aware of
the painting work on the open-deck.
What can we learn:
• The importance of carrying out toolbox meeting and information highlighting the task
that would be undertaken by the crew onboard to be made available to the Officer on
watch, in particular, where the duty crew was involved with the task.
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Annex 1, page 4
• The importance of crew members exercising "stop work" authority when they see a
dangerous situation or unsafe act.
Who may benefit:
Officers, Crew, and Ship Managers
Very serious marine casualty: Fatality when crew member disassembled valve under
pressure
What happened:
In the early hours of September, while transiting south-westerly in the Indian Ocean for a
Brazilian port, an Ore carrier experienced an exhaust temperature anomaly from the main
engine.
The engine crew subsequently assembled in the engine-room and emergency replacement of
a fuel oil injector valve (FOIV) was initiated.
After the fuel oil high-pressure pipe had been removed from the engine cylinder cover, the
Fourth Engineer and supervising engineer (Second Engineer) left the main engine to the spare
parts room, while the Third Engineer (3E) was alone on the cylinder head platform.
Shortly after, a loud bang was heard and the 3E collapsed on the platform with the fuel
oil injector valve (FOIV) and its securing nuts nearby. The 3E was bleeding from the right-side
of his face with fainting pulses. Immediate first aid was given on board and the vessel
deviated to the nearest port for shore medical assistance, but the 3E succumbed to the injuries
before medical treatment could be provided.
Why did it happen:
The investigation revealed that the securing nuts of the FOIV were removed by the 3E while
the engine RPM had not attained zero. The FOIV expelled from the cylinder cover with
substantial force on to the 3E's face.
While the investigation team could not establish the reasons for the 3E's removal of the FOIV
without waiting for the RPM to be zero, the investigation revealed that the engine crew relied
on memory and observations on how the FOIVs were removed previously and with varied
interpretations of the safety precautions stipulated in the engine manual.
There was also an absence of supervision in terms of task assignment(s) to the engine crew.
The engine's data records retrieved from the main engine revealed that certain safety
precautions were not carried out.
What can we learn:
• This incident iterates the importance of compliance to safety precautions, especially

for ship engine where the omission of any steps can result in undesired outcome for
both the engine and personnel.
• The purpose of each safety precaution should be well comprehended, and verification
processes be established to ensure that work is safe to commence.
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Annex 1, page 5
• These can be achieved through appropriate checklist(s) as part of a permit-to-work

system with enhance scope in training encompassing these safety precautions.
Who may benefit:
Shipping community, Officers, Crew, Ship Managers, Shore Technicians
5 DANGEROUS SPACE / FALL FROM HEIGHT
Very serious marine casualty: Fatality and injury when crew entered cargo hold
What happened:
A bulk carrier, alongside discharging coal, was requested by stevedores to provide additional
lighting. The officer of the watch tasked two crew to complete the task. While entering the hold
via the enclosed Australian ladder, crew 1 collapsed and fell to the bottom of the ladder.
Crew 2, on witnessing this, entered the ladder trunking to provide assistance. He also
collapsed and fell to the bottom of the ladder. A rescue operation was initiated and both crew
were recovered alive and, after a delay, transferred to hospital. Crew 2 recovered some time
later but crew 1 succumbed – a post-mortem identified exposure to hydrogen sulphide as the
cause of death.
Why did it happen:
Neither crew considered themselves at risk of exposure to harmful or toxic gases when they
started the task as the hold was open and almost empty of cargo. The officer of the watch did
not foresee entry into a dangerous space, and was not present, so the atmosphere was not
tested in line with the company's enclosed space entry procedures. Although the hold was
open, the design of the Australian ladder's trunking meant that there was no natural ventilation
of the space as cargo blocked the lower exit.
Despite delays in their recovery, both casualties were breathing when they were recovered to
the deck but no medical assistance arrived to assist. They were eventually taken to hospital
by car, significantly delaying access to medical care.
What can we learn:
Cargo holds are dangerous spaces and each cargo presents its own hazards. The importance
of effectively communicating these hazards and conducting a thorough risk assessment cannot
be overstated. Realistic drills can improve speed of casualty recovery from dangerous spaces,
as assistance from shore may take time.
Who may benefit:
The shipping community.
Very serious marine casualty: Fatality when crew was lost over-board
What happened:
In September a container ship was under way from a port the North Pacific Ocean enroute to
Mexico.
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Annex 1, page 6
Early in the morning, the Bosun came to the bridge to take job orders from the Chief Officer
who was keeping the 0400H-0800H navigational watch. The Bosun could not find the Chief
Officer and informed the Master, who turned the ship around on a reciprocal course.
Nearby Coast Guard was alerted for search and rescue efforts, which spanned till the next day
to no avail.
Why did it happen:
Why it happened could not be determined with certainty. However, the marine safety
investigation revealed that the Company's SMS on bridge watchkeeping was not implemented
as there was no lookout on the bridge with the Chief Officer. In addition, the established
procedures for mitigating the risk of a single watchkeeper were not complied with, as the Bridge
Navigational Watch Alarm System (BNWAS) had been switched off and the lookout had been
rostered by the Chief Officer not to report for the watch.
What can we learn:
• The importance of BNWAS activated for the safety of navigation.
• The bridge to be manned appropriately at all times.
• The availability of a convenient avenue for the fleet personnel to report unsafe
practices on board including solo watch during hours of darkness.
Who may benefit:
Shipping Community.
7 FIRE
Very serious marine casualty: Fatalities when crew fought fire and abandoned the ship
What happened:
While on route, a 150,000 GT Container Carrier encountered a severe fire in one of the cargo
holds. Self-sustaining decomposition of a Class 9 cargo caused smoke and fire to spread in
the cargo hold. The cargo was carried in block stowage exacerbating and accelerating the
decomposition process. The crew responded to the fire by cooling and subsequent release of
CO2. The response was however not successful, and the crew eventually abandoned the
vessel. Four of the crew were not accounted for and declared missing, and another was
deceased while being transported ashore.
Why did it happen:
As most of the evidence were destroyed by fire, it was not possible to conclusively determine
the cause of the fire. However, one or more containers in the cargo hold containing Sodium
Dichloroisocyanurate Dihydrate (SDID) were compromised by self-decomposition of the SDID.
The block stowage of the SDID further exacerbated the rate of reaction and heat production
which resulted in an uncontrollable spread of the fire. The actual temperature at which
exothermic decomposition is initiated is much lower than the values typically declared by the
shipper, and the presence of free water and/ or stowage of the SDID in large packages or
consignments leads to further substantial depression of the onset temperature.
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Given the susceptibility of SDID to exothermic decomposition in the presence of free water or
impurities, serious consideration must be given to the prospect that the decomposition could
be initiated as a direct result of the inherent properties of the cargo itself.
What can we learn:
Special Provisions (SP135) within the IMDG Code allows for the classification and carriage of
SDID under Class 9 (UN no.3077), thus not recognizing the potential thermal instability of this
material, possibly as a result of legacy carriage requirements recognized nearly 40 years prior.
As a result, despite these secondary hazards, SDID was stowed under deck where the main
fixed firefighting means in this area was CO2, which is ineffective to tackle fires associated
with such materials.
Noting the secondary hazards presented by SDID, which are not captured in the current
provisions of the IMDG Code, the provisions in the IMDG Code would need to be reviewed.
Firefighting response for SDID, an oxidiser, required the use of abundant water, which could
not have been achieved promptly, given the existing statutory requirements for firefighting
measures for container fires under deck.
Adoption of standards/ guidance like those prepared by American Bureau of Shipping (ABS)
and DNV-GL, as a risk-mitigating measure, should be considered. Regardless of when the
amendments to the statutory requirements take place, dangerous goods with oxidising
properties such as SDID should be considered for stowage on-deck, away from direct sunlight,
where water could be used more effectively.
There was a delay in decision-making to allocate resources better for the abandoning of ship
while attempting to fight the fire.
Who may benefit:
Seafarers, Flag Administrations, Recognized Organisations, Shipowners, Ship operators,

Charterers, Shippers, Consignees, Salvors, Container terminals. SAR authorities, HAZMAT
agencies.
8 FIRE
Very serious marine accident: ship total loss due to fire
What happened:
In June during cargo discharge operations while alongside a fire broke out in the internal cargo
handling spaces of a self-unloading (SUL) bulk carrier.
The ship's crew initiated an emergency response but shipboard efforts to control the fire were
ineffective. The fire soon established itself and spread to the exterior of the ship, setting the
discharge boom on deck alight. The ship's crew were evacuated and shore firefighting services
from ashore took charge of the response to the fire. The fire was contained and eventually
extinguished about five days after it started.
The ship sustained substantial structural damage, including breaches of two fuel oil tanks, and
key components of the SUL system were largely destroyed. The ship was declared a
constructive total loss and subsequently dispatched to be recycled. There were no serious
injuries or pollution of the sea reported.
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Annex 1, page 8
Why did it happen:
The investigation concluded that the fire originated in vessel's C-Loop space and was likely
the result of a failed bearing in the ship's conveyor system which created the heat necessary
to ignite the rubber conveyor belt. The investigation also determined that the ship did not have
an emergency contingency plan for responding to fire in the ship's SUL spaces and that there
were technical failures of the ship's alarm systems during the emergency response to the fire.
Furthermore, some aspects of the shipboard response likely aided the fire's development while
others increased risk by removing shipboard capability.
The investigation found that the risk of fire in the vessel's C-Loop space was identified and
documented by the ship's operators as being unacceptable about five years before the fire.
This risk rating was primarily due to the absence of an effective means of fire detection and
fire suppression for the SUL system spaces. However, measures taken to address the risk
were either inadequate or ineffective. Furthermore, the lack of adequate regulatory
requirements or standards related specifically to the fire safety of SUL ships have been a factor
in several fires, including the ship. The investigation also identified that the regulatory oversight
of the vessel did not identify any deficiencies related to the safety factors identified by this
investigation, or to the ship's inherent high fire safety risk and management of that risk.
In addition, the investigation identified a safety issue related to the marine firefighting capability
of the shore-based fire fighters as well as other safety factors related to the inconsistent
conduct of ship's drills and the port's emergency response plans.
What can we learn:
The investigation into the fire has highlighted the inadequacy of fire safety regulations and
standards for the cargo handling spaces on board self-unloading bulk carriers.
The effectiveness of a shipboard response to a fire depends primarily on the ability to detect
the fire at an early stage and quickly extinguish it at the source. Where it has been identified
that the lack of such systems has resulted in the risk of a fire in a space being unacceptable,
suitable control measures need to be implemented in order to reduce the risk to an acceptable
level.
The introduction of mandatory minimum standards for suitable fire detection and extinguishing
systems, to address the known high fire risk spaces of self-unloading bulk carriers, can
significantly reduce the risk of major fires in these spaces. Additionally, the introduction of
standards governing the fire resistance properties of conveyor belts used in shipboard systems
can help reduce the likelihood of ignition in the first place.
Who may benefit:
Operators and crew of self-unloading bulk carriers and other vessels exposed to similar risks,
State firefighting agencies, National maritime regulators, Classification societies.
9 COLLISION
Very serious marine accident: Vessel sinking after collision
What happened:
A bunker tanker was under way at night within port limits after completing bunkering operations
with another vessel. As the bunker tanker was proceeding, the vessel's Master sighted an unlit
wooden coaster that was approaching on the bunker tanker's starboard bow. The bunker
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Annex 1, page 9
tanker's Master sounded one long blast on the vessel's whistle just before the bunker tanker
and wooden coaster collided. Neither vessel took any apparent action to avoid collision. At the
time of the collision, the bunker tanker's Master was in charge of the vessel's navigation and
radio communications. He was also serving as the vessel's helmsman. The Chief Officer was
on the bridge making entries in the logbook. A dedicated lookout was not posted. The wooden
coaster's Skipper was alone on the vessel's bridge. The bunker tanker's Master immediately
reported the collision to the port authority as the vessel continued enroute the anchorage.
The wooden coaster's hull was seriously damaged. After some period of time, the wooden
coaster broke up and sank. All nine crewmembers on board the wooden coaster were rescued
by a passing tug soon after. The bunker tanker suffered only scratches. There were no reported
injuries.
The incident occurred in fair weather with partly cloudy sky and good visibility. The sea state
was calm and easterly wind was light less than five knots.
Why did it happen:
The investigation revealed that the wooden coaster was not manned by qualified crew, was
equipped with non-standard navigational lights, did not have a radar reflector, and had not
maintained a proper lookout.
The bunker tanker's Master was navigating the vessel, serving as the helmsman, and
conducting radio communications by himself. Further, a designated lookout was not posted
and the Master did not notice the presence of the wooden coaster until very near to the time
of collision.
What can we learn:
• The importance of all vessels maintaining a proper lookout by sight and hearing.
• The importance of Masters determining if a vessel involved in a collision may require

assistance before continuing on a planned voyage.
• The need for all vessels to display required navigation lights from sunset to sunrise
and between sunrise to sunset in restricted visibility.
• The importance of wooden vessels using radar reflectors to improve detection by

other vessels.
• The importance of vessels being manned by properly qualified crewmembers.
Who may benefit:
Ship managers, watchkeepers, fishing vessel owners, seafarer training institutions.
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10 MAN-OVER-BOARD
Very serious marine casualty: Crew washed overboard
What happened:
A capsize bulk carrier, loaded to its summer draught marks, was on passage around the
southern tip of Africa in May. In marginal conditions, the bosun and second officer were
repairing a leak on the deck's fire main. Having completed the task, both crew members went
for a coffee break. Shortly thereafter, work on deck was suspended due the increased wave
and swell height. After their break, the bosun and second officer went back on deck to collect
their tools when an unusually large wave struck on the vessel's starboard beam and washed
the bosun overboard. A search and rescue operation was initiated, but the bosun was not
recovered.
Why did it happen:
A heavy weather warning had been received that morning but had not been incorporated into
the work plan - tasks on deck continued as conditions deteriorated. Guidance on heavy
weather was not robust and did not include a threshold for what constituted heavy weather.
The decision to stop work on deck was made in time but no additional protection was afforded
to the crew who went on deck to secure the loose items in line with the heavy weather checklist.
The vessel was loaded to its summer draught but was in relatively high latitudes in winter, just
13 nautical miles from the winter zone load line.
What can we learn:
When expecting heavy weather, a timely termination of all operations on deck is vital to ensure
the safety of the crew. If the crew are required to go on deck during deteriorating weather
conditions, a thorough risk assessment should be performed and effective risk reduction
measures, such as adjusting course and speed, implemented. Personal Protective Equipment
(PPE) such as a harness, safety line and a floatation device should be worn as a minimum.
Who may benefit:
The shipping community.
11 COLLISION BETWEEN GENERAL CARGO SHIP AND FISHING VESSEL
Very serious marine casualty: Fishing vessel lost
What happened:
In the afternoon, while navigating close to the coast, a coastal general cargo ship collided with
a wooden hulled fishing vessel in restricted visibility. The fishing vessel was severely damaged
and sank while being towed to port. The cargo ship suffered minor damage. There were no
injuries.
Why did it happen:
The vessels collided in fog because neither watchkeeper was keeping an effective lookout: the
wheelhouse on board the fishing vessel had been left unattended and the officer of the watch
onboard the cargo vessel was distracted from lookout duties with administrative work.
The general cargo ship did detect the fishing vessel on radar but, as it did not have a correlating
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Annex 1, page 11
Automatic Identification System (AIS) transmission, the bridge team tried to confirm the echo's
validity visually, delaying the decision to alter course until it was too late. At the time of the
collision, both were power driven vessels as defined by COLREGs, neither was making the
required sound signals.
What can we learn:
Navigation in restricted visibility requires heightened vigilance. Proper use of bridge equipment
is crucial to provide an early warning of potential dangers with radar becoming the "eyes" of
the watchkeeper. Reliance on AIS for ship detection can result in smaller vessels going
unseen. Properly mounted radar reflectors help ensure wooden-hulled boats give good radar
echoes on other ships' radar screens. Sounding of fog signals provides an additional means
for detection in restricted visibility.
Who may benefit:
Ship managers, watchkeepers, fishing vessel owners, seafarer training institutions.
12 COLLISION CONTAINERSHIP AND FISHING VESSEL
Very serious marine casualty: Crew missing and fishing vessel sank
What happened:
An almost 2,000 (twenty-foot equivalent units ) TEU container ship collided with a 31 meter
fishing vessel on the high seas. The collision occurred during daylight hours in good weather
with visibility of more than 5 NM as the container ship was passing through a group of fishing
vessels that were all drifting. None of the fishing vessels were engaged in fishing. The fishing
vessel capsized and sank. Two of the fishing vessel's crew members are missing.
The container ship had minor damage. At the time of the collision, only the Officer on Watch
(OOW) was on the bridge of the container ship and there was not a watchstander on duty on
the fishing vessel.
Why did it happen:
• Neither the container ship nor the fishing vessel were maintaining an effective lookout
as required by the COLREGs.
• Ineffective navigational watchstanding on board the container ship due to the OOW
prioritizing other watchkeeping tasks over maintaining an effective lookout and
collision avoidance.
• The fishing vessel did not have a watchstander on duty.
• Both of the container ship's radars were in standby and were not being used for vessel
detection and collision avoidance even though both were operational.
• Over reliance by the container ship's OOW on AIS information for vessel detection
and collision avoidance.
• The container ship's OOW was alone on the bridge had not called the duty ASD to
the bridge to provide assistance.
What can we learn:
• The importance for all vessels to maintain an effective lookout at all times.
• The importance of making use of radar, if fitted and operational, for vessel detection
and collision avoidance.
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Annex 1, page 12
• The danger of over reliance on AIS information for vessel detection and collision
avoidance.
• The dangers of prioritizing other watch keeping duties over collision avoidance.
• The hazards of one person watch standing.
Who may benefit:
Ship managers, seafarers, fishing vessel owners, seafarer training institutions.
13 MAN-OVER-BOARD
Very serious marine casualty: Crew fell over-board when rigging pilot ladder
What happened:
Prior to sunrise, a 51,500 deadweight (DWT) chemical/oil products tanker was preparing for
arrival. At approximately 0515, the Bosun and an ASD started rigging the combination pilot
ladder on the ship's port side in order to embark a pilot. After they lowered the accommodation
ladder over the side, they noticed that the lower platform was not parallel to the water and
needed adjusting. The ASD went down the ladder without wearing a lifejacket and safety
harness with a lifeline attached to the ship as required by the shipboard safety management
system. The Bosun did not tell the ASD to return to the ship's deck when he saw him start
down the accommodation ladder. In addition, the Bosun did not inform the Master or OOW
that the ASD was going down the ladder. The ASD fell overboard while he was adjusting the
lower platform of the accommodation ladder.
The Bosun immediately informed the Master and OOW that the ASD had fallen overboard.
He then threw a lifebuoy overboard. Neither the Master nor the OOW released the MOB
lifebuoy from the bridge wing when the MOB was reported. The Master then ordered the turned
to starboard rather than to port, which increased the possibility that the ASD being struck by
or forced under the ship's hull. The SAR operation did not find the ASD.
Why did it happen:
• Ineffective pre-task planning due to it being rushed and the attention of both the
Master (who was conducting the pre-task Toolbox Talk) and the OOW (who was the
officer responsible for the planned task) being divided between navigating the ship
and reviewing the procedures, required PPE, and relevant risk assessments with the
crew members assigned to rig the combination pilot ladder.
• Not wearing a lifejacket and a safety harness with lifeline attached to the ship while
working over the side.
• Ineffective supervision by the OOW of the Bosun and the ASD while they were rigging
the combination pilot ladder.
• Lack of communication between the Master, OOW, Bosun, and ASD.
• Multiple crew members not identifying an unsafe condition.
• Inadequate preparedness of the Bridge Team for a MOB emergency.
What can we learn:
• To be effective, the attention of crew members participating in a pre-task Toolbox Talk

cannot be divided.
• The importance of wearing appropriate PPE (e.g. lifejacket and safety harness with a
lifeline attached to the ship) when working over the side.
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• The importance of effective supervision by the officer or another crew member who is
responsible for planned job or task and the crew members who are conducting it.
• The need timely and effective communications.
• The importance of crew members being able to identify an unsafe condition and then
taking action (e.g. exercising stop work authority) so that the situation can be
addressed.
Who may benefit:
Ship managers, Masters, seafarers
***
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Annex 2, page 1
ANNEX 2
PROPOSAL FOR A NEW OUTPUT FOR THE DEVELOPMENT OF GUIDELINES

ADDRESSING RISKS OF FALLS FROM HEIGHT
Introduction
1 This proposal is submitted in accordance with the Organization and method of work
for the Maritime Safety Committee and the Marine Environmental Protection Committee and
their subsidiary bodies (MSC-MEPC.1/Circ.5/Rev.4), taking into account resolution A.1111(30)
on Application of the Strategic Plan of the Organization.
2 III 7 reviewed data obtained from the GISIS module on Marine Casualties and
Incidents (MCI) for occupational accidents and determined that falls from height occurred more
commonly than other type of occupational accidents. Based on this, the Sub-Committee
directed the intersessional Correspondence Group on Analysis of Marine Safety Investigation
Reports (Casualty Analysis Correspondence Group) that was formed following III 7 to conduct
further analysis of available marine safety investigation reports and to make recommendations
for addressing this safety issue.
3 III 8 noted the analysis of the intersessional Casualty Analysis Correspondence Group
(III 8/4, annex 6) and endorsed the recommendation of the Working Group on Analysis of
Marine Safety Investigation Reports (Casualty Analysis Working Group) to develop a proposal
for a new output on guidelines addressing the risk of falls from height (including, but not limited
to, access to and egress from the location where the work will be conducted, working at height
and work over the side) with the HTW Sub-Committee as the coordinating body.
4 MSC 106 noted the III Sub-Committee's analysis of this safety issue and its
instructions for the intersessional Casualty Analysis Working Group formed after III 8 to
develop a proposed new output for the development of guidelines addressing this safety issue
(MSC 106/19, paragraph 4).
Background
5 The Casualty Analysis Correspondence Group formed after III 7 reviewed 70 marine
safety investigation reports involving falls from height, including falls overboard, that occurred
during the 5-year period between 2016 and 2021. Details of this review and the
recommendations that were made for consideration by the III Sub-Committee are found in
document III 8/4, paragraphs 20 to 22 and annex 6.
6 At III 8, the Sub-Committee reviewed the work that was conducted by the Casualty
Analysis Correspondence Group and approved the development of a proposed new output for
the development of guidelines addressing risks of falls from height (including, but not limited
to, access to and egress from the location where the work will be conducted, working at height
and work over the side) to reduce the number of these occupational fatalities by providing
practical guidance to ship operators and seafarers.
IMO objectives
7 The proposal is directly related to strategic direction 6 (addressing the human
element) of the Organization's Revised strategic plan of the Organization for the six-year period
2018-2023 (resolution A.1149(43)) through the development of guidelines intended to improve
the safety of seafarers by providing clear, practical guidance addressing safety issues
associated with the risk of falls (including, but not limited to, access to and egress from the
location where the work will be conducted, working at height and work over the side).
III 9/WP.3
Annex 2, page 2
Need
8 Of the 70 marine safety investigation reports reviewed between 2016 and 2021 by the
Casualty Analysis Correspondence Group after III 7, 69 reports identified that the person who
fell was fatally injured. This is a clear indication that the consequences of falls from height or
falls overboard are likely to be severe.
9 Of the persons who were fatally injured due to falls from height, 97% were ship crew
members. This is a rate of approximately 14 persons (of whom 13 are seafarers) per year who
are being fatally injured as a result of falls from height or falls overboard.
10 The fact that between 2016 and 2021 almost 14 persons a year were fatally injured
on board ships worldwide when they fell while working at height, either accessing or egressing
from the location where the work was conducted, or working over the side clearly indicates
that there a need for the Organization to issue clear, practical guidance addressing the safety
issues associated with the risk of falls. Such guidance will assist ISM managers and flag States
by providing a common approach for improving the safety of seafarers by controlling the
hazards associated with working from height or over the side on board ships worldwide.
Analysis of the issue
11 Although the specific circumstances of each of the falls from height or over the side
between 2016 and 2021 that were investigated differed, the review of these 70 marine safety
investigation reports identified the following safety issues:
.1 the procedures in vessel manager's safety management systems for working

from height or over the side are not always being implemented and are not
always achieving their intended purpose;
.2 pre-task risk assessments and safety meetings or toolbox talks appear to be

ineffective and most were based on generic risk assessments rather than on
a task specific risk assessment that took existing conditions into account;
.3 tasks that involve the risk of falling from height are not always considered as
"working from/at height" so that no control measures to avoid falls or
minimize their consequences were identified or implemented;
.4 personal protective equipment (PPE) intended to reduce the risk of falls while
working from height or over the side was not used or was not appropriate for
the planned work;
.5 on board safety training did not appear to be achieving its intended purpose;
and
.6 on board management supervision and control of seafarers performing

shipboard tasks that require working from height or over the side is ineffective
and needs to be improved.
Additional details are set out in document III 8/4, annex 6.
12 No IMO guidelines or recommendations addressing falls from height (including, but

not limited to, access to and egress from the location where the work will be conducted,
working at height and work over the side) currently exist. Although some flag and coastal
States have issued guidance or recommendations regarding safe work practices for working
III 9/WP.3
Annex 2, page 3
from height or over the side, these do not address all of the safety issues associated with such
work. The implication is that there is not a single source that ISM managers can use as a basis
when developing safe work procedures for working from height or over the side.
Analysis of implications
13 It is considered that the proposed new output will not lead to any additional
administrative requirements or burdens an in this regard, the completed administrative
checklist, as set out in annex 6 to the Organization and method of work of the Maritime Safety
Committee and the Marine Environment Protection Committee and their subsidiary bodies
(MSC-MEPC.1/Circ.5/Rev.4), is set out in annex 1.
Benefits
14 Addressing the safety issues associated with falls form height (including, but not
limited to, access to and egress from the location where the work will be conducted, working
at height and work over the side) will directly contribute to improving seafarer safety in much
the same way that Assembly resolution A.1050(27) on Revised recommendations for entering
enclosed spaces aboard ships has done.
Industry standards
15 While there is some guidance available addressing safe work practices for working
from height on board ships, the guidance that is available does not address all of the safety
issues associated with such work.
Proposed output
16 The proposed output title is "Guidelines addressing the risk of falls from height."
As discussed in paragraph 3, such guidelines would include, but not be limited to, falls that
may occur not only while a seafarer is working at height or over the side, but also while
accessing or egressing from the worksite. Under this output the III Sub-Committee proposes
the development of guidelines that address each of the safety issues identified in paragraph 11.
17 The Sub-Committee on Human element, Training and Watchkeeping (HTW)

Sub-Committee would be the coordinating body for the work on this output.
18 The proposed output in SMART terms (specific, measurable, achievable, realistic,

and time-bound) is as follows:
.1 Specific – the output, as described in paragraph 16, is clear and specific;
.2 Measurable – the output consists of one specific result: guidelines

addressing the safety issues identified in paragraph 11;
.3 Achievable and realistic – the output should be both achievable and

realistic given the Organization's experience developing resolution
A.1050(27) on Revised recommendations for entering enclosed spaces
aboard ships;
.4 Time-bound – the completion of the work is envisaged to take [four]

sessions of the HTW Sub-Committee with a target year of completion [2028].
III 9/WP.3
Annex 2, page 4
Human element
19 The completed checklist for considering human element issues by IMO bodies as set
out in annex 5 of to the Organization and method of work of the Maritime Safety Committee
and the Marine Environment Protection Committee and their subsidiary bodies
(MSC-MEPC.1/Circ.5/Rev.4), is set out in appendix 1. The proposal is not considered to have
negative implications for the human element. Rather, the guidelines, if used by ISM managers,
will improve seafarer safety.
Urgency
20 Given the fact that an average of 14 persons were fatally injured due to falls from
height or over the side each year between 2016 and 2021, the III Sub-Committee proposes
that the output should be addressed as a matter of priority and as soon as practicable. In this
regard, the proposed output, if approved, should be included in the Strategic Plan of the
Organization and priorities for the [next] biennium.
Action requested of the Committee
21 The Committee is invited to consider the proposal in paragraphs 16 to 18 and take

action as appropriate.
III 9/WP.3
Annex 2, page 5
APPENDIX 1
CHECKLIST FOR CONSIDERING AND ADDRESSING THE HUMAN ELEMENT
This checklist consists of five questions as follows:
.1 questions 1 to 4 are risk-based questions intended to identify risks from the

implementation and operation of new outputs; and
.2 question 5 is a list of measures for addressing the human element.
The Correspondence Group has considered that there is no additional administrative

requirements or burdens, nor is there any negative implications for the human element.
III 9/WP.3
Annex 2, page 6
1 2 3 4 5
Question Yes/ IMO References Considerations Instructions
No
Other relevant references may If answer to question is "yes" Identify how human element
be added identify considerations. If answer considerations should be
Workload is "no" make proper justification addressed in the output
Strike out references that are
not relevant
1 Does the "output" affect
workload?
1.1 On board, especially in the Revised guidelines for the

already intensive phases of operational implementation of
the voyage and port the International Safety
operations to: Management (ISM) Code by
Companies
(MSC-MEPC.7/Circ.8)
Guidelines on fatigue
(MSC.1/Circ.1598)
Principles of minimum safe

manning
(resolution A.1047(27))
Guidelines for the investigation

of accidents where fatigue may
have been an issue
(MSC/Circ.621)
1.1.1 Operations including navigation,
cargo and engineering
1.1.2 Maintenance of the ships
structure and its equipment
1.1.3 Onboard administration in
support of the ships'
management systems
III 9/WP.3
Annex 2, page 7
1 2 3 4 5
No
1.1.4 Onboard administration related
to regulation involving flag
States, classification societies,
port State and other bodies such
as charterers and port
authorities
1.1.5 Increased workload or time
pressure on personnel if
involved in implementation of
changes prior to the
implementation date
1.2 Ashore, in a manner that
would affect the ships
operation to:
1.2.1 Companies' administration
1.2.2 Flag State, port State and
classification societies
administration such that
certification and other processes
are compromised or delayed
III 9/WP.3
Annex 2, page 8
1 2 3 4 5
No
Decision-making is "no" make proper justification addressed in the output
not relevant
2 Does the "output" impact
decision-making on board
the ship?
2.1 By confusion with existing

requirements and regulations
2.2 By changing responsibilities as
laid out in the ISM Code
2.3 By creating complexity in its
implementation and/or in the
safety management systems
2.4 By requiring increased mental
effort, such as the need to find,
transform and analyse data or
result in the need to make
judgements based on
incomplete information
2.5 By limiting the time available to
establish situational
awareness, decide,
communicate (possibly across
time zones) or check
2.6 By increasing reliance on
judgement and administrative
controls to manage major risks
such as oil spills and collisions
III 9/WP.3
Annex 2, page 9
1 2 3 4 5
No
Living and Working Environment is "no" make proper justification addressed in the output
not relevant
3 Does the "output" affect the living Guidelines on the basic elements
and working environment? of a shipboard occupational
health and safety programme
(MSC-MEPC.2/Circ.3)
Guidelines on fatigue
(MSC.1/Circ.1598)
3.1 By interfering with existing
arrangements for abandonment, fire-
fighting and other emergency plans or
procedures
3.2 By introducing new materials that
could create an explosion, fire,
environmental or occupational health
risk
3.3 By introducing new high energy
sources such as high-voltage, high
pressure fluids
3.4 By affecting access or egress and
causing lack of ventilation in working
spaces
3.5 By affecting the habitability of
accommodation spaces due to
noise, vibration, temperatures, dust
and other contaminants
III 9/WP.3
Annex 2, page 10
1 2 3 4 5
No
Operation and Maintenance is "no" make proper justification addressed in the output
not relevant
4 Does the "output" affect Revised guidelines for the operational implementation of the
the operation and International Safety Management (ISM) Code by Companies
maintenance of the ship, (MSC-MEPC.7/Circ.8)
its structure or systems
and equipment? Guidelines for bridge equipment and systems, their arrangement and
integration (BES) (SN.1/Circ.288)
Principles of minimum safe manning (resolution A.1047(27))
Issues to be considered when introducing new technology on board

ships (MSC/Circ.1091)
Guideline on software quality assurance and human-centred design

for e-navigation (MSC.1/Circ.1512)
Guidelines for the standardization of user interface design for

navigation equipment (MSC.1/Circ.1609)
4.1 By introducing equipment

that the user may find
difficult to operate or
maintain or may be
unreliable
4.2 By introducing new and/or
novel technology, or
technology that changes the
role of the person
III 9/WP.3
Annex 2, page 11
1 2 3 4 5
No
4.3 By introducing requirements
for new competencies and
roles
4.4 By overloading existing
infrastructure such as power
generation and ventilation
systems
4.5 By poor integration with
existing systems and
controls
4.6 By introducing new and
unfamiliar
operations/procedures
4.7 By introducing new and
unfamiliar operating
interfaces?
4.8 By introducing risks to the
ship during any modifications
required prior to the
implementation date of the
output
III 9/WP.3
Annex 2, page 0
1 2 3 4 5
No
Measures to address the human element is "no" make proper justification addressed in the output
not relevant
5 Does the "output" require Shipboard technical operating
changes to: and maintenance manuals
(MSC.1/Circ.1253)
Revised guidelines for the

operational implementation of
the International Safety
Management (ISM) Code by
Companies
(MSC-MEPC.7/Circ.8)
5.1 Training
5.2 Practical skill development and
competences
5.3 Operating, management and/or
maintenance procedures
5.4 Information/manuals for
operation and maintenance
5.5 Spares outfit
5.6 Occupational safety
requirements including
guarding and PPE
5.7 Shore support
III 9/WP.3
Annex 2, page 16
APPENDIX 2
CHECKLIST FOR IDENTIFYING ADMINISTRATIVE REQUIREMENTS

This checklist should be used when preparing the analysis of implications required in
submissions of proposals for inclusion of outputs. For the purpose of this analysis, the term
"administrative requirement" is defined in accordance with resolution A.1043(27), as an
obligation arising from a mandatory IMO instrument to provide or retain information or
data.
Instructions:
(A) If the answer to any of the questions below is YES, the Member State proposing an
output should provide supporting details on whether the requirements are likely to
involve start-up and/or ongoing costs. The Member State should also give a brief
description of the requirement and, if possible, provide recommendations for further
work, e.g. would it be possible to combine the activity with an existing requirement?
(B) If the proposal for the output does not contain such an activity, answer NR
(Not required).
(C) For any administrative requirement, full consideration should be given to electronic
means of fulfilling the requirement in order to alleviate administrative burdens.
1. Notification and reporting? NR Yes

Reporting certain events before or after the event has taken place, □ Start-up
e.g. notification of voyage, statistical reporting for IMO Members x □ Ongoing
Description of administrative requirement(s) and method of fulfilling it: (if the answer is yes)
2. Record-keeping? NR Yes
Keeping statutory documents up to date, e.g. records of accidents, □ Start-up
records of cargo, records of inspections, records of education x □ Ongoing
3. Publication and documentation? NR Yes

Producing documents for third parties, e.g. warning signs, □ Start-up
registration displays, publication of results of testing x □ Ongoing
4. Permits or applications? NR Yes

Applying for and maintaining permission to operate, e.g. certificates, □ Start-up
classification society costs x □ Ongoing
5. Other identified requirements? NR Yes

□ Start-up
x □ Ongoing
***
III 9/WP.3
Annex 3, page 1
ANNEX 3
III CORRESPONDENCE GROUP ON LESSONS LEARNED AND SAFETY ISSUES

IDENTIFIED FROM THE ANALYSIS OF MARINE SAFETY INVESTIGATION REPORTS
Questionnaire on fishing vessel collisions
The III Sub-Committee is seeking information about collisions and near misses involving
fishing vessels to better understand the prevalence of this type of occurrence. Your
cooperation is appreciated to provide this data for the period 2018-2022 (5 years). In order to
ensure that there is sufficient time for data analysis, please complete your responses and
submit to the Secretariat.
1) Does your State gather/have casualty data regarding collisions between merchant
and fishing vessels?
a) If yes, please complete the table following these questions.
2) Does your State gather/have near-misses reported between merchant and fishing
vessels?
a) If yes, please complete the table following these questions.
3) Are fishing vessels registered in your State required to carry?

a) AIS Yes / No / [If yes, fill in free text…]
b) VHF Yes / No / [If yes, fill in free text…]
III 9/WP.3
Annex 3, page 2
Table 1: Collisions with fishing vessel
Date Time Locat Vessel Vessel V1 nav Vessel Vessel V2 nav Occurre No. of No. of Fishing Link to report Remarks (may
(local ion* 1 flag 1 type* status* 2 flag 2 type* status* nce perso person vessel fitted (if available) include
) severity ns s with additional
* killed injured AIS* VHF information
such as
summary of
occurrence,
etc.)
Examp [05- [20:0 (drop [Baham (drop (drop [None] (dropdo (drop (dropdo [1] [0] (dropd Y N [www.maritime
le Apr- 5] down as] down) down) wn) down) wn) own) authority.com/]
22] )
Key:
* to be selected from drop down list (see annex 3, page 3, table 2)
III 9/WP.3
Annex 3, page 3
Table 2: Dropdown tables
Navigation status dropdown

Location Vessel type dropdown (from AIS table) Severity drop down AIS
Fishing vessel Under way using engine Near miss/marine incident Fitted, transmitting
Internal waters - Fitted, not
port area High speed transmitting
At anchor Marine casualty
Internal waters - Not fitted
other Livestock carrier
Not under command Very serious marine casualty
Traffic Separation Unknown
Scheme MODU / drilling rig
Restricted manoeuvrability
Open sea
Offshore support / construction
Constrained by draught
Territorial sea
Passenger
Moored
Passenger - Ro Ro Aground
Refrigerated Cargo Engaged in Fishing
Research / survey Under way sailing
Power-driven vessel towing
Tanker - chemical
astern
Power-driven vessel pushing
Tanker - LNG
ahead or towing alongside
Tanker - LPG
Tanker - oil
Tug
Yacht
Other
___________

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E

SUB-COMMITTEE ON IMPLEMENTATION III 9/WP.3

LESSONS LEARNED AND SAFETY ISSUES IDENTIFIED FROM THE ANALYSIS OF

Report of the Working Group

2 The Group was attended by representatives from the following Member

ANTIGUA AND BARBUDA MEXICO

by representatives from the following Associate Member of IMO:

HONG KONG, CHINA

by observers from the following intergovernmental organizations:

EUROPEAN COMMISSION (EC)

by observers from the following non-governmental organizations in consultative status:

INTERNATIONAL CHAMBER OF SHIPPING (ICS)

and by the following IMO training institute:

WORLD MARITIME UNIVERSITY (WMU)

.1 confirm or otherwise, the findings of the Correspondence Group based on

.5 consider the result of the analysis on ISM Code related concern on

.7 consider the observations on the quality of marine safety investigation

.11 consider documents III 9/4/7(European Commission), III 9/4/9 (Secretariat),

.12 advise on the re-establishment of the Correspondence Group, at this

.13 submit a written report to the plenary on Friday, 4 August 2023.

Report of the Correspondence Group

4 The Group, in considering the analyses of individual marine safety investigation

.3 assessed that the Analysis of Marine Safety Investigation Reports can be

12 The Group, therefore agreed to recommend the Sub-Committee to approve the

Safety issues that need further consideration

15 In noting the Correspondence Group's observation on the Lessons learned to be less

18 Accordingly, the Group recommends the Sub-Committee to invite MSC to consider

Work on preventing collisions with fishing vessels

.2 a comparison of the technical equipment used for preventing collisions would

.3 a specially designed questionnaire developed by the Correspondence Group

Analysis on ISM Code related concern on unsatisfactory implementation of safety

.1 a common safety issue was lack of risk assessment;

Findings identified in data analyses of marine casualties and incidents

.1 reports of these analyses should be examined by the Correspondence Group

.3 the role of the Correspondence Group is to deal with safety issues

.4 different streams of data may not be in a uniform template;

.1 the body to confirm acceptance or not of safety issues identified and

.2 a body which should accept the safety issues identified as submitted

.1 conduct a review of the marine safety investigation reports on investigations

.3 identify safety issues that need further consideration by the Sub-Committee,

.4 review the method by which analysts provide information in GISIS regarding

.6 develop a process to support data-driven decision-making and policy

.7 submit a report to III 10.

.1 confirm or otherwise, the findings of the Correspondence Group based on

.4 consider the recommendation provided by the Correspondence Group

.5 consider the summary provided by the Correspondence Group related to

.6 consider the proposal by the Correspondence Group related to the

.7 consider the analysis made by the Correspondence Group on the feedback

Action requested of the Sub-Committee

.1 approve the findings of the Correspondence Group based on the analysis of

.2 bring the observations referred to in paragraph 9 to the attention of

.3 agree to the recommendation of the Group on the observations on the quality

.5 request the Secretariat to issue a relevant circular and to take appropriate

.6 agree with the views of the Group on the development of guidelines

.7 approve the revised questionnaire on fishing vessel collisions contained in

.8 endorse the recommendation of the Group for the correspondence group, if

.9 approve the recommendation of the Group on the result of the analysis on

.16 re-establish the Correspondence Group on Lessons Learned and Safety

.17 agree to the early establishment of the Working/Drafting Group on Lessons

LESSONS LEARNED FROM MARINE CASUALITIES

Very serious marine casualty: Fatality under fallen load

Why did it happen:

What can we learn: