BSafe Case Studies
Using case studies as a way of analysing previous incidents and identifying lessons learned which can be shared with others, is an important part of improving safety performance
Reflecting on past events is recognised as an effective way of learning from experience in order to positively influence future behaviours.
Reflection is not just about reading an accident report or watching a case study video. It’s about examining the content and reviewing the sequence of events. It’s about analysing why it happened and “what it means to me” (Energy Institute), then relating the identified learning points to an individual’s personal situation and considering whether things can be done differently.
Encouraging reflective learning is a key element of BSafe. Each month we will be issuing a new BSafe Incident Case Study on this page. These will be based on a real accident or claim, appropriately anonymised , with a summary of the key lessons learned.
We believe the true power of reflective learning lies in considering and discussing an incident with colleagues, which generates a richer and more valuable dialogue. In order to encourage this, we will also provide dedicated training materials for each BSafe Incident Case Study. This will include presentation material and a reflective learning form which can be used as training materials as Members or their crew see fit. For example, these could be used to support onboard safety meetings, crew seminars, or just for individual reflection.
Finally, a Britannia commentary will be provided for each incident which explores the key issues in more detail to help develop the reflective learning. This will include some suggestions for possible controls that could have helped mitigate the risk by using our interpretation of a Hierarchy of Risk Controls (based on ISO 45001 and the National Institute for Occupational Safety and Health (NIOSH)).
Links to our monthly BSafe Incident Case Studies are provided below. In addition, we have also included some other previously published Britannia case studies. Although these don’t include the reflective training material provided with the full BSafe Incident Case Studies, they do still offer some valuable insights for consideration.
BSAFE INCIDENT CASE STUDY 01: DEATH OF THIRD ENGINEER DUE TO BURN INJURIES
Published: November 12, 2020
View ArticleThe Third Engineer (3/E) on board an anchored capesize bulk carrier was splashed by hot sludge while opening the manhole cover of a settling tank and subsequently died from a septic shock having sustained 2nd degree burns to a large part of his body.
CASE STUDY: COLLISION IN DENSE FOG AND TRAFFIC
Published: August 1, 2019
View ArticleAn investigation report published by the Transport Safety Investigation Bureau (TSIB) of Singapore has highlighted some sadly all too familiar lessons regarding the appropriate actions to be taken both before and after a collision
CASE STUDY: COMPLACENCY CAUSES GROUNDING?
Published: August 1, 2016
View ArticleThe UK Marine Accident Investigation Branch (UK MAIB) has recently published its report on the HOEGH OSAKA, a pure car and truck carrier (PCTC) which grounded on Bramble Bank in the Solent shortly after departing Southampton in January 2015
COLLISION CASE STUDY: USE SOUND SIGNALS AND LOOK OUT TO AVOID COLLISION
Published: August 1, 2015
View ArticleNOCC OCEANIC, a 12 deck car carrier, left Keihin Port, Japan on 22 June, bound for Balboa, Panama.
COLLISION CASE STUDY: THE IMPORTANCE OF PROPER BRIDGE TEAM MANAGEMENT IN BUSY TRAFFIC LANES
Published: November 1, 2014
View ArticleOn 10 December 2013 at 2245 the general cargo ship PAULA C was heading south-west in the Dover Strait traffic separation scheme. It was a dark, clear night with good visibility. She was in ballast, heading for Poole, England.