On the night between 21 and 22 December 2016, the Danish offshore supply ships MÆRSK SEARCHER and MÆRSK SHIPPER capsized and sank in the Bay of Biscay approximately 65 nm off the French coast while being towed by the offshore supply ship, MÆRSK BATTLER. The ships undertow were both unmanned during the voyage. Though no lives were at risk during the accident, the total loss of the two ships is considered a very serious accident of special concern to the potential risk of harm to the marineenvironment due to oil leakage. Therefore, the Danish Maritime Accident Investigation Board (DMAIB) in agreement with the French authorities initiated an investigation of the accident to establish the circumstances leading to the foundering of MÆRSK SEARCHER and MÆRSK SHIPPER.
The starting point for every investigation carried out by the DMAIB is that
an accident is an unwanted event for all parties, and that the persons involved in an accident strive to achieve a successful outcome and want to contribute in a professional manner. Our core objective in this investigation is to understand why the accident happened in spite of the professional efforts made by the involved parties, because this provides a nuanced understanding of the accident.
Often, accident investigations focus on a short timeframe leading up to the accident events and focus on actions taken by persons directly involved in these events. In a case like the capsizing and foundering of MÆRSK SEARCHER and MÆRSK SHIPPER, the towing operation and voyage were preceded by nearly four months’ preparation involving a large number of persons. To gain a more comprehensive understanding of the accident, the DMAIB therefore needed to broaden the investigation to include the organizational processes that took place in the shore organization months before the accident occurred, as these are tightly coupled to the events unfolding on the night between 21 and 22 December 2016.
In other words, the DMAIB regards the foundering of MÆRSK SEARCHER
and MÆRSK SHIPPER as a systemic accident. This means that local and
technical circumstances unfolding on board the MÆRSK BATTLER during
the voyage cannot be isolated from the preceding organizational events and circumstances taking place months earlier, but together constitute a complex system. The cause of accidents unfolding in such a complex system cannot be reduced to singular factors or root causes. Instead, accidents emerge from a unique conjunction of events and circumstances in which no single individual can have complete knowledge of the processes and predict future events emerging from these.
Thus, the investigation of the foundering of MÆRSK SEARCHER and
MÆRSK SHIPPER is two-fold. It focuses on the technical circumstances
leading to the foundering of the two ships and on the organizational circumstances facilitating these technical circumstances. The technical investigation describes and analyses the towing setup, the risk mitigating equipment, and the ships’ stability. The organizational investigation describes and analyses risk assessments, the decision-making process, and the flow of information within the company.
Full DMAIB Marine Accident report:
drive.google.c...
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