299
1 INTRODUCTION
It is very important to prevent marine accidents
becauseofhugeimpactonthewholesociety,suchas
physical damage, loss of life, economic loss, and
environmental pollution. However, accidents caused
by marine activities are very complex, and it is not
possible to simply explain why accidents occur
and
how to prevent accidents[1]. Especially, accidents
relatedtopilotagearedirectlyorindirectlyrelatedto
pilotswhoareplacedatthe forefrontofsafety,soit
hasasignificantimpactonrelatedindustriesandcan
causeenormousportcosts[2].
In South Korea, an accident occurred in which a
pilot
collided with a pier and an oil pipeline and
spilledcrudeoilwhileberthingacrudeoilcarrierin
2014.Thiswasthesecond‐largestaccidentinthecase
ofoilspillinmarineaccidentsfrom2000to2022,and
environmentaldamagewasserious[3].Inaddition,in
2020, a 13,900 TEU
large container ship, the Milano
Bridge,whichwasapproachingthepierforberthing
with a pilot on board at Busan New Port, collided
with a gantry crane and the other ship that was
berthing.Inthisaccident,itisestimatedthatatotalof
about25millioneurosofdamage
occurredonlyinthe
repairandrestorationcostsofgantrycranes[4].
Although the frequency of pilotage accidents is
mostlylowcomparedtoothermaritimeaccidents,itis
very important to identify the cause of pilotage
accidents and prepare safety measures because the
scaleofdamageissignificant[2].However,according
to the
pilotage accident investigations from 1978 to
2017, it can be confirmed that the accident
investigationwascompletedmostlybypunishingthe
shipoperatorsandpilotswhomainlyparticipatedin
themanoeuvringoftheshipsattheKMST[5].
Therefore,itwasrecognizedthatitwasnecessary
toanalysethepilotageaccident
fromtheperspective
of the social system rather than simply the existing
cause‐and‐effect method of accident investigation
Analysis of Pier Contact Accident in Busan New Port
of South Korea by System-Theoretic Accident Model
and Processes (STAMP)
S.R.Kim,W.J.Wangui,G.Camliyurt,D.W.Kim&Y.S.Park
KoreaMaritimeandOceanUniversity,Busan,SouthKorea
ABSTRACT:Marineaccidentsarecausedbycomplexanddiversecauses.Therefore,itisnecessarytoanalyse
accidentsfromtheperspectiveofthewholesystemratherthantheexistinganalysismodelsthatfocusoncause‐
effect.TheSTAMPanalysisisaconstraint‐basedmodel
thatfocusesonimpropermanagementorenforcement
of safety‐related constraints in system operation. Thus, as a case study of the application of the STAMP
techniqueinmarineaccidentanalysis,theMilanoBridgepiercontactaccidentthatoccurredonApril6,2020in
BusanNewPortofSouthKoreawas
analysedbytheSTAMPtechniqueinthisstudy.Throughthisstudy,itwas
proposedtobreakawayfromthedomesticaccidentinvestigation,whichfocusedonlyonthepunishmentofthe
shipoperator,andtosuggestimprovementsthatenableorganizationsrelatedtothemarineaccidentstotake
initiativetotakeeffortsfor
safety.
http://www.transnav.eu
the International Journal
on Marine Navigation
and Safety of Sea Transportation
Volume 17
Number 2
June 2023
DOI:10.12716/1001.17.02.05
300
analysis. This study intends to reveal more diverse
causesoftheaccidentanddrawlessonsbyapplyinga
systematicanalysismodeltothepiercontactaccident
oftheMILANOBRIDGE.
2 MILANOBRIDGEPIERCONTACTACCIDENT
2.1 SpecialreportofKoreaMaritimeSafetyTribunal[4]
OnApril6,2020,the
MilanoBridge,alargecontainer
ship,collidedwitha gantrycraneintheNewportof
Busan, South Korea. This huge incident caused
significant damage to the crane, the ship, and the
surroundinginfrastructureresultinginatremendous
operatingloss.
Figure1.M/VMilanoBridge(MarineTraffic)
Table1.Ship’sparticularofM/VMILANOBRIDGE
________________________________________________
MMSI371076000
ShipnameMILANOBRIDGE
Ship’stypeFullcontainership
DateofLaunch 18thJuly2017
FlagstatePanama
LXBXHXD(m) 365.94X51.20X71.33X29.9
Grosstonnage(t)150,706
DesignSpeed(kn) 21.85
________________________________________________
Figure2. Berthing arrangement and collision when the
accidentoccurred(KMST,2021)
According to the official reports by KMST, the
explicit cause of the accident was excessive speed
during manoeuvring and the underestimated effects
oftheshipinballast.Theshipenteredtheportwith
about one‐third of its propeller exposed above the
waterʹssurfacebecauseitwasnotcarryingsufficient
ballastwater.
Figure3. Track of MILANO BRIDGE at the time of the
accident(KMST,2021)
Inordertosearchthecauseoftheaccident,KMST
conducted a various ship maneuvering simulations
based on the operation records at the time of the
accidentstoredintheVDRoftheMilanoBridge.
Trajectory of ship Propeller fully immersed
No wind effect
Low speed (5 knot)
Figure4.Shipmanoeuvringsimulationresults(KMST,2021)
The results of the simulation confirmed that the
possibilityofanaccidentwassignificantlyreducedif
the propellers were immersed 100% in the water to
improve manoeuvring ability and ship entered the
port at a lower speed. In addition, it was confirmed
thatthehullwaspushedtowardthepierdue
tothe
wind blowing from the south at the time of the
accident.However, since the extentof wind andthe
change in wind speed during pilotage was
insignificant,itisdifficulttosaythattheinfluenceof
windactedasamajorfactorintheoccurrenceofthis
accident.
Furthermore, KMST pointed out the lack of
communication between the ship operator and the
marinepilotasoneofthecausesoftheaccident.
2.2 LiteratureReview
Asimilaraccidentoccurredworldwideformerlyand
afterward of Milano Bridge. In May of 2017, the
container ship CMA CGM Centaurus collided with
the
quay and two shore cranes during its arrival at
Jebel Ali, UAE, resulting in injuries and damage[6].
An investigation found that the ship was going too
fast for the intended manoeuvre and there was no
agreed plan between the bridge team and the pilot.
Therefore, the investigation emphasizes the
importance
of effective communication and
collaboration between pilots and bridge teams to
ensuresafety,especiallyascontainershipscontinueto
grow.
301
Figure5. CMA CGM Centaurus making contact with the
quay(MAIB,2018)
On 28 January 2019, the container vessel Ever
Summitwasberthingundertheconductofapilotat
Vantermin the Port ofVancouver, British Columbia
(BC),with2tugsassistingwhenthevesselstruckthe
berthandanearbyshoregantrycrane[7].Thevessel,
berth, and crane were damaged and
there was no
injuries or pollution. The investigation determined
thattheEverSummitstrucktheberthafterthevessel
made a close approach and that the pilot
inadvertently gave the assisting tugs the opposite
instructions from what was intended during the
berthing manoeuvre. The investigation looked at
communications with tugs
during berthing, the
suitability of the berth infrastructure for large
container vessels at Vanterm, and overall risk
management of the terminal. (MARINE
TRANSPORTATION SAFETY INVESTIGATION
REPORT M19P0020, Transportation Safety Board of
Canada,2019)
Figure6.Strikingofberthandshore gantrycranewithEver
Summit(TSB,2020)
PreviousstudiesusingSTAMPinmarineaccident
analysisincludestudyofKimetal.[8]thatanalyzed
the Korean Sewol ferry accident as STAMP‐Model.
The author recognized of the vulnerability of the
safety control system in the accident of the Sewol
ferry and tried to approach it from an institutional
perspective. The analysispoints out the institutional
problemsofSewolferryaccident,highlightstheneed
forasystemapproachtodetectionandpreventionof
safety constraint violations, and asks for corrective
actionatnationalandinternationallevels.
In addition, a study that analyzed the explosion
accident at an oil company
that handles crude oil
productionworkfoundoutthatthemaincauseofthe
accident was a spark, but the organizations of oil
company also had a great influence on the accident
[9]. In particular, ineffective safety policies,
inadequate communication between and within
departments,pooroversight,andinadequateresource
allocation were
cited as contributing factors to this
tragicaccident.Itwasthensuggestedthatpoliciesand
regulationsshouldbeimplementedatoilcompanyto
ensure safety for humans, equipment and the
environment. Additionally, the authors suggest that
alleffortsatvariouslevelsofthehierarchicalstructure
must work together to design
safer systems in the
companytopreventaccidents.
3 ACCIDENTANALYSIS
3.1 STAMP(System‐TheoreticAccidentModeland
Processes)Model
Inthemodernworld,newerandmorecomplexsocio‐
technicalsystemsare inexistenceand the sequential
and epidemiological models cannot be used
effectivelyasbefore[10].Thesystematictheorysafety
approach
does not blame one single contributory
factorandisamoresuitableapproachforanalyzing
accidentsoriginatingfromsuchcomplexsystems[11].
There are numerous systemic methods, for accident
analysis of complex socio‐technical systems, such as
the Functional Resonance Accident Model (FRAM)
[12], the AcciMap model [13], and the
System‐
Theoretic Accident Model and Processes (STAMP)
model[14]
Amongthevarioussystematicmodels,theSTAMP
casualty modelis used toimpose behavioural safety
constraintsinasystem.TheSTAMPmodelprojectsa
comprehensive view of the system and investigates
thelinksbetweenevents.Notably,STAMPisusefulin
analyzingfeedback
andcontrolactionsandconsiders
thedynamic characteristic ofa system.Furthermore,
whenSTAMPisadoptedasthebasisofsafety,safety,
andriskareconsideredasafunctionoftheefficacyof
the controls to instill safe system behavior [15].
STAMP is a more comprehensive model in terms of
theidentifiedcausalfactorsaswellascoverageofthe
entiresocio‐technicalsystem[16].
Figure7.STAMPprocess(Leveson,2016)
3.2 ApplicationofSTAMPtotheMILANOBRIDGE
piercontactaccident
Thegenericsocio‐technicalhierarchicalsafetycontrol
structurefortheSTAMPmodelcomprisestwomajor
302
structures‐oneforsystemdevelopmentandtheother
for system operation. Each system within the
hierarchicalsafety controlstructure can be modelled
toincludeits specificfeaturesforboth structures. In
addition,boththesestructureshaveinterrelationships
between them. However, in this accident analysis,
only the system operational structure will
be
considered because all the main components that
were identified as having immediate control are
underthisstructure[14].
Inthisaccidentanalysis,factualdatawassourced
from the special accident investigation reports from
the Korea Maritime Safety Tribunal (KMST) as
published on 12 January 2021 as well as from
interviewswithpersonsofinterestfromothersystem
componentsidentified.
TheinitialphaseofSTAMPmodelanalysisisthe
identification of the hazards as well as the
construction of the hierarchical control structure. To
achievethis,theauthorwillbegintheanalysisofthe
Milano Bridge contact accident by establishing the
berthing process of a vessel and identifying the key
system components involved in the ship berthing
process in Busan New Port. Furthermore, the
relationships between all the identified system
components will be outlined to gain a bigger
overviewoftheentireshipberthingprocess.Infigure
8,theprocessof
berthingashipisembodiedthrough
interviews with industry praticians participating in
shiparrivalsanddeparturesatBusanPort.
VTS
Operator
During Berthing
Ship
Berthing
Before Berthing
Pilot
Ship
Information
Regional Offices
of MOF
Terminal
Shipping
company
Ship
Port
Authority
Appoint
Sailing Instruction
Cargo Info.
& Schedule
Berth Info.
Schedule
Approve
Ship Info.
Apply pilotage
Arrival report
Initia l
Arrival
report
Agent
Berth Info.
Pilot
Associations
Appoint
Figure8.ShipberthingprocessofBusanport
Asshowninfigure8,theorganizationthatmainly
participatesintheshipʹsberthingprocessisshipping
company,ship’screw,agent,terminal,portauthority,
regional office of Ministry of Oceans and fisheries,
VTS and pilot. Accordingly, if the role of each
organization and the constraints in this accident are
arranged,
the following system operation control
structurecanbecreatedasfigure9‐11.
Figure 9 shows the highest hierarchical control
structure that ensures safe arrival of cargo ships in
Busan.Thesafetycontrolstructureisinitiatedbythe
Ministry of Oceans and Fisheries (MOF), which has
guidelines and legislations to
ensure that ships can
navigatethedomesticwaterssafelywhilecomplying
with the International Maritime Organization (IMO)
Convention.MOFistheheadquartersresponsiblefor
the safety of ship navigation in Korea, so regional
administrationsare delegatedto local administrative
agencies assigned to each port. Accordingly, the
regional office of MOF will
carry out regional port
administration and the port authority will carry out
portoperations.Inaddition,theKoreaCoastGuard,
whichisinchargeofvesseltrafficservice,belongsto
theMOFandperformstaskssuchasmarinesecurity
andpollutioncontrol.
However, the Ministry of Oceans and Fisheries
only
received reports of major issues from local
administrative offices and believed that local offices
willdoingwell.TheregionalofficeofMOFentrusted
the operation of Busan Port to the Busan Port
Authority (BPA), and no consultations were held
duringtheCOVID‐19epidemic.BPAdidnotclosely
checktheship
entryreportsthataretoocommon,and
it was believed that the ship operator would safely
manoeuvre ship for berthing even the ship which is
exposed one‐third of the propeller. Those of local
institutions have also failed to prevent the accident
because they have not been able to come
up with
sufficientcountermeasuresagainstthesameaccidents
that occurred before. They had their own rules, but
they were mainly revised by civil complaints, and
therewas no changeafter the accident.VTS has not
beenreportedontheconditionofthevessel,butthe
systemhasshownthatitis
operatingatanexcessive
speed unlike other ships. However, proper control
was not carried out, and finally the vessel was
contacted with the pier at high speed by the pilot,
withoutbeingadvisedanywhere.
Figure9.Analysisofgovernmentregulatoryauthorities
303
Figure10. Analysis of industry association and ship
manager
Asshowninfigure10,forshipberthingandcargo
operations, major industry‐related agencies consult
closelybeforeshipberthing.Theshipmanagerhasthe
dutytomanagetheshipandcrewsothattheshipcan
safelycarrythecargounderthechartercontract.The
charterer or ship manager contact
the terminal for
cargoloadingandunloadingandappointanagentfor
administrative processing for entry into the port to
delegate their tasks. Terminal prepares the berths
according to the vesselʹs schedule and prepares for
safe cargo operations. The Agent conducts a ship
entry report to institutions such as
port authority
through the information received from the terminal
andtheshipmanager.
However, the ship manager did not advise the
crew to inject more ballast water, despite receiving
reports of the shipʹs condition when the Milano
BridgelefttheshipyardinChinaandwhenitarrived
inBusan.Additionally,
althoughshipmanagerswere
responsible for ensuring that adequately qualified
crew members were assigned to operational duties,
crewmembersfailedtoactinaccordancewithBridge
Resource Team Management training and
consequentlyfailedtopreventaccidents.Accordingto
the terminalʹs own regulations, the vessel foreman
mustlistentothe
transceivertocommunicatewiththe
pilot and check the speed and direction of the ship
onehourbeforeberthing.Butthepilotwasnotgiven
any advice from the vessel foreman, and no action
wastakentoadjusttheshipʹsspeedbyhim,resulting
in an accident. Agents who are
delegated with
administrativetasks for thearrival anddeparture of
ships play a role in sharing ship information.
However, the agentʹs inappropriate control actions
couldnotbefoundthroughthespecialinvestigation
reportandinterview.
Figure 11 shows human controller and vessel
operation flow. As a main human controller,
crew
members,includingcaptain,arehiredbyshipowners
and ship managers to ensure safe cargo
transportation. Since ships must live independently
once they leave port, bonding and communication
between crew members are essential and must be
trained.Asaportexpert,marinepilotsactasguides
throughskilfulmanoeuvringso
thatshipscansafely
berth andload and unload cargo.Since captains are
usually not familiar with the geography of a
particularport,theymustworkcloselywithpilotsto
safelycompletetheberthingoperation.
Despitethisheavyresponsibility,thecaptainfailed
toexchangesufficientinformationwiththepilot.The
specificinformationthatcouldbehelpfulinsteering
the ship was ignored, and he just believed that a
foreignpilotwoulddoitwell.Althoughhedelegated
manoeuvringto apilotfor berthing, but when there
was a risk of an accident, he had to manoeuvre by
himself, but it was
not carried out, and appropriate
emergency response procedures also were not
implemented. The pilot worked as a pilot in Busan
Port for more than 10 years and manoeuvred many
shipsofthesamesizeastheMilanBridge.Therefore,
hejudgedthathewouldbeabletoshipforberthing
sufficiently by increasing the horsepower of the
tugboat and drove the ship in a hurry as before.
However,hebelatedlyjudgedthattheturningofthe
shipwaslateandpanicked,failingtotakeadditional
actionsthatcouldhavepreventedtheaccident.
Figure11.Analysisofhumancontrollerandvesseloperatingprocess
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4 CONCLUSION
In April 2020, there was a pier contact accident that
caused huge economic losses at Busan New Port of
SouthKorea. The KMSTconcluded the investigation
by punishing the pilot who participated in the
operationoftheshipatthetime.However,inorderto
preventfuturemarine
accidents,thecauseshouldbe
found in a more diverse and complex social system
rather than a punishment‐oriented investigation.
Therefore, this study attempted to draw lessons by
analyzing the Milano bridge pier contact accident
with STAMP, and the recommendations for
preventing similar accidents in future were as
follows.:
1.
Each system of the safety control structure,
identifiedthroughthespecialinvestigationreport
andoperators’ interview,shouldnot postponeits
responsibility,butshouldtakeanactiveattitudeto
prevent accidents and improve proper
communicationbetweeneachsystem.
2. Vessels wishing to enter the port should be
compared with the previous database
and
reviewed to see if there are any unusual items
whenapplyingforportentry.Institutionsthatcan
check the information of the ship must carefully
observe the conditionand operationstatus ofthe
ship, and communicate with the ship to give
advicesothattheshipcanoperatemore
safely.
3. Seafarers must receive appropriate on‐the‐job
training in order to have sufficient knowledge
aboutshiphandlingandshipconditions,andmust
be continuously checked for knowledge. Even in
the case of delegation of manoeuvring authority,
proper training must be given to take
responsibility for the safety of the
ship by
communicatingcloselywithforeignpilots.
4. Evenifthepilotisaportexpert,adetailedpilotage
manualorplancustomizedforeachportmustbe
supported, and the effectiveness of pilot training
conductedonaregularbasismustbecheckedand
improved according to practice. In addition,
institutionsaroundpilotsshouldhaveaprocedure
forcheckingsafetyoncemore.
5. Lastly, the way to prevent accidents cannot be
solvedonlybypunishingoperators.Therefore,the
maritimeaccidentinvestigationandtribunalmust
clearlyidentifythecauseoftheaccidentandmake
ajudgment,but officiallydemandsafetymeasures
from
organizationsrelatedtotheaccidentthrough
techniquessuchasSTAMP.
This study is meaningful in applying the
systematictheotytotherecentpiercontactaccidentin
South Korea, and it can suggest countermeasures in
theanalysisofthecurrentmaritimeaccidentanalysis.
However, the limitation is that comparisons may be
insufficient because accident analysis models other
than system analysis techniques are not used for
accidentanalysis,whichshouldbesupplementedand
studiedinthefuture.
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