Module title:<\/strong> Maritime Casualty Analysis and Safety Management<\/p>\n Assessment type:<\/strong> Individual case study report<\/p>\n Weighting:<\/strong> 30\u201340 percent of module grade (as set by programme handbook)<\/p>\n Length:<\/strong> 2,500\u20133,500 words (excluding reference list, tables, figures and appendices)<\/p>\n Submission format:<\/strong> Word-processed report (DOCX or PDF) via the VLE or learning portal<\/p>\n Level:<\/strong> Final-year undergraduate or postgraduate taught (Level 6\/7 equivalent)<\/p>\n Major marine casualties continue to expose weaknesses in shipboard operations, company Safety Management Systems (SMS) and regulatory oversight, often long after technical standards have improved on paper. Casualty investigation reports from flag states, accident investigation boards and the IMO \u201cLessons Learned\u201d series show recurring patterns of organisational drift, normalisation of deviance, poor risk assessment and ineffective learning from previous incidents. This assessment asks you to conduct a structured, critical analysis of a selected casualty or serious incident in order to examine where safety management failed, how human and organisational factors interacted with technical conditions and what realistic improvements could have reduced the likelihood or severity of the event.<\/p>\n Prepare a 2,500\u20133,500 word case study report<\/strong> on a real maritime casualty or serious incident<\/strong> that demonstrates a significant failure or breakdown in safety management at ship, company or regulatory level.<\/p>\n You must:<\/p>\n Select one casualty or serious incident with sufficient publicly available documentation (for example flag state report, MAIB\/TSB\/BSU report, IMO or classification society case study, court findings)<\/p>\n<\/li>\n Obtain and use at least one official investigation or authoritative secondary analysis as a core source<\/p>\n<\/li>\n Apply a recognised human and organisational factors or safety management framework (for example HFACS, ISM Code analysis, Swiss cheese model, FSA-informed reasoning)<\/p>\n<\/li>\n<\/ul>\n Examples include, but are not limited to:<\/p>\n Collision, allision or grounding with significant damage, pollution or loss of life<\/p>\n<\/li>\n Fires, explosions or cargo-related incidents on tankers, Ro-Ro, container or passenger ships<\/p>\n<\/li>\n Fatalities during routine deck operations, mooring, pilot transfer, lifeboat drills or cargo hold work<\/p>\n<\/li>\n Loss of stability, capsizing or foundering linked to operational or loading decisions<\/p>\n<\/li>\n<\/ul>\n Your report must be structured and analytical rather than narrative, covering the following components:<\/p>\n i. Case selection and background<\/strong><\/p>\n Identify the vessel(s), date, location, casualty type and outcome (for example fatalities, pollution, total loss)<\/p>\n<\/li>\n Briefly justify why this case is suitable to illustrate safety management failure<\/p>\n<\/li>\n<\/ul>\n ii. Factual reconstruction<\/strong><\/p>\n Provide a concise, evidence-based reconstruction of the events leading up to, during and immediately after the casualty, using timelines or key phases<\/p>\n<\/li>\n Distinguish clearly between established facts, investigation findings and any necessary interpretive assumptions<\/p>\n<\/li>\n<\/ul>\n iii. Framework and analytical approach<\/strong><\/p>\n State which analytical framework you are using (for example HFACS, ISM Code clause analysis, Swiss cheese, or FSA logic for problem structuring)<\/p>\n<\/li>\n Briefly explain how the framework organises causes and contributing factors<\/p>\n<\/li>\n<\/ul>\n iv. Analysis of safety management failure<\/strong><\/p>\n Identify immediate, underlying and root causes related to ship operations, company SMS, training, supervision, maintenance, risk assessment and oversight<\/p>\n<\/li>\n Show how organisational decisions and everyday practices created conditions for the accident (for example workarounds, production pressure, informal norms)<\/p>\n<\/li>\n Link findings explicitly to specific ISM Code requirements, company procedures or recognised good practice where applicable<\/p>\n<\/li>\n<\/ul>\n v. Human and organisational factors<\/strong><\/p>\n Examine human performance issues such as fatigue, situation awareness, communication, supervision and teamwork in the context of the wider system<\/p>\n<\/li>\n Discuss organisational culture, safety climate, learning from previous incidents and the effectiveness of internal audits or external inspections<\/p>\n<\/li>\n<\/ul>\n vi. Risk assessment, barriers and controls<\/strong><\/p>\n Evaluate how risk assessment and risk control were conducted (or not) in the activities leading to the casualty<\/p>\n<\/li>\n Identify failed, missing or degraded barriers (technical, procedural, organisational) and show how they allowed the accident trajectory to progress<\/p>\n<\/li>\n<\/ul>\n vii. Lessons learned and recommendations<\/strong><\/p>\n Propose realistic, evidence-based recommendations for shipboard practice, company SMS and regulatory or oversight improvements<\/p>\n<\/li>\n Prioritise changes that address systemic contributors rather than only individual errors<\/p>\n<\/li>\n<\/ul>\n viii. Reflection on investigation and learning<\/strong><\/p>\n Critically reflect on the quality and focus of the official investigation, including strengths, gaps or biases in the way causes and lessons were presented<\/p>\n<\/li>\n Discuss what makes casualty case studies effective or ineffective as learning tools within maritime organisations<\/p>\n<\/li>\n<\/ul>\n Title page (module, student ID, word count)<\/p>\n<\/li>\n Abstract (150\u2013200 words)<\/p>\n<\/li>\n Introduction and case selection<\/p>\n<\/li>\n<\/ol>\n<\/li>\n Case background and factual reconstruction<\/p>\n<\/li>\n<\/ol>\n<\/li>\n Analytical framework and method<\/p>\n<\/li>\n<\/ol>\n<\/li>\n Safety management failures and causal analysis<\/p>\n<\/li>\n<\/ol>\n<\/li>\n Human and organisational factors<\/p>\n<\/li>\n<\/ol>\n<\/li>\n Risk assessment, barriers and controls<\/p>\n<\/li>\n<\/ol>\n<\/li>\n Lessons learned and recommendations<\/p>\n<\/li>\n<\/ol>\n<\/li>\n Reflection on investigation and organisational learning<\/p>\n<\/li>\n<\/ol>\n<\/li>\n References (Harvard style)<\/p>\n<\/li>\n Appendices (timeline, HFACS charts, barrier diagrams) as needed<\/p>\n<\/li>\n<\/ul>\n Word count: 2,500\u20133,500 words (excluding references, tables, figures and appendices), stated clearly on the title page<\/p>\n<\/li>\n Font and spacing: 11 or 12 point font, 1.5 line spacing, standard margins<\/p>\n<\/li>\n Referencing: Harvard style with consistent in-text citations and full reference list<\/p>\n<\/li>\n Sources: Minimum of 8\u201310 substantive sources, including at least one official investigation report and relevant academic or professional literature<\/p>\n<\/li>\n Confidentiality: Only use publicly available reports; do not disclose confidential company information<\/p>\n<\/li>\n Academic integrity: Individual work only; any use of AI tools must comply with institutional policy and be declared<\/p>\n<\/li>\n<\/ul>\n LO1: Critically analyse a maritime casualty using structured safety and human factors frameworks<\/p>\n<\/li>\n LO2: Identify and explain failures in safety management systems and organisational practices<\/p>\n<\/li>\n LO3: Evaluate the role of human and organisational factors in shaping accident trajectories<\/p>\n<\/li>\n LO4: Formulate evidence-based recommendations that support learning and safety improvement<\/p>\n<\/li>\n LO5: Communicate complex causal analysis clearly and professionally in written form<\/p>\n<\/li>\n<\/ul>\n The case study report is marked out of 100 and contributes 30\u201340 percent of the module grade.<\/p>\n The fatal fall from height that occurred during routine cargo hold washing on a geared bulk carrier illustrates how a superficially low-complexity task can conceal a chain of normalised deviations and unrecognised hazards within the company\u2019s SMS. Crew had become accustomed to climbing a vertical ladder without a properly secured safety harness because no fixed anchorage point had been installed and the risk assessment for hold cleaning operations failed to identify falling from height as a credible scenario, despite wet surfaces, poor lighting and time pressure to complete washing before loading. Toolbox meetings were conducted and documented, yet they functioned more as a procedural formality than as a forum to challenge implicit assumptions about the task, which meant that the absence of effective fall-arrest arrangements was never treated as a deviation requiring corrective action by ship or shore management. Viewed through an HFACS lens, the able seafarer\u2019s actions and the officer\u2019s inadequate supervision sit on top of deeper organisational factors such as incomplete risk assessment templates, lack of design feedback from ships to shore and a safety culture that tolerated workarounds in order to protect schedule and productivity.<\/p>\n Critical reflection on casualty case studies highlights that even well-documented incidents may fail to improve safety unless the lessons are actively translated into operational procedures and company culture. Case studies support organisational learning most effectively when findings are communicated clearly, when systemic contributors are emphasised over individual blame, and when regulatory and company oversight mechanisms are linked to actionable improvements (Gwebayanga, 2022).<\/p>\n Gwebayanga, N. (2022) Assessing the potential impacts of casualty incident investigation on maritime safety and security: the case of Uganda<\/em>. Master\u2019s dissertation, World Maritime University. Available at: https:\/\/commons.wmu.se\/cgi\/viewcontent.cgi?article=3075&context=all_dissertations<\/a><\/p>\n<\/li>\n International Maritime Organization (2023) Lessons learned from marine casualties \u2013 III 5<\/em>. Available at: https:\/\/wwwcdn.imo.org\/localresources\/en\/OurWork\/IIIS\/Documents\/Lessons%20learned%20English\/p%20III%205.0.pdf<\/a><\/p>\n<\/li>\n Marine Insight (2022) \u2018What is Formal Safety Assessment in shipping?\u2019. Available at: https:\/\/www.marineinsight.com\/marine-safety\/what-is-formal-safety-assessment-in-shipping\/<\/a><\/p>\n<\/li>\n IMO (2025) Model Course 3.11: Safety investigation into marine casualties and marine incidents<\/em>. Available at: https:\/\/www.scribd.com\/document\/834682789\/29-Model-Course-3-11-Safety-Investigation-Into-Marine-Casualties-and-Marine-Incident-2<\/a><\/p>\n<\/li>\nAssessment Context<\/h2>\n
Assessment Task<\/h2>\n
Task Description<\/h3>\n
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Possible Casualty Types<\/h3>\n
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Core Requirements<\/h3>\n
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Indicative Structure<\/h3>\n
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Formatting and Submission Requirements<\/h2>\n
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Learning Outcomes Assessed<\/h2>\n
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Marking Criteria and Scoring Rubric<\/h2>\n
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\n \nCriterion<\/th>\n Weight<\/th>\n Excellent (70\u2013100)<\/th>\n Good (60\u201369)<\/th>\n Satisfactory (50\u201359)<\/th>\n Fail (<50)<\/th>\n<\/tr>\n<\/thead>\n \n Case selection, background and factual reconstruction<\/td>\n 20%<\/td>\n Case is well chosen and clearly justified; factual reconstruction is concise, accurate and well-supported by investigation sources, with clear separation between facts and interpretation.<\/td>\n Case is appropriate; factual reconstruction is generally accurate with minor omissions or over-reliance on narrative detail.<\/td>\n Case is acceptable but only weakly justified; factual account is patchy, overly descriptive or unclear in distinguishing evidence from interpretation.<\/td>\n Case is poorly chosen or inadequately documented; factual reconstruction is inaccurate, confusing or largely speculative.<\/td>\n<\/tr>\n \n Use of analytical framework<\/td>\n 20%<\/td>\n Selected framework (for example HFACS, ISM analysis) is well explained and consistently applied, providing clear structure to causal analysis and insights into safety management failure.<\/td>\n Framework is appropriate and mostly well used, though some categories or links are underdeveloped.<\/td>\n Framework is named but used superficially; limited structuring of causes beyond a basic list of factors.<\/td>\n No clear framework, or framework is misapplied; analysis is unstructured and largely descriptive.<\/td>\n<\/tr>\n \n Analysis of safety management failures<\/td>\n 25%<\/td>\n Provides a deep, multi-level analysis of SMS and organisational failures, with explicit links to ISM requirements, company procedures and recognised good practice.<\/td>\n Identifies key SMS and organisational issues with reasonable depth; some links to ISM and good practice are made.<\/td>\n Highlights some SMS shortcomings, but discussion remains surface-level or focused on individual errors rather than systemic contributors.<\/td>\n Little or no analysis of SMS; focus remains on technical details or blaming individuals.<\/td>\n<\/tr>\n \n Human and organisational factors<\/td>\n 15%<\/td>\n Human and organisational factors are analysed with clear reference to relevant models and literature; interactions between people, technology and organisation are well-articulated.<\/td>\n Human and organisational contributors are discussed with some insight, though connections to wider system factors may be uneven.<\/td>\n Human factors are noted but treated generically; little integration with organisational or systemic issues.<\/td>\n Human and organisational factors are largely ignored, oversimplified or misrepresented.<\/td>\n<\/tr>\n \n Lessons learned and recommendations<\/td>\n 10%<\/td>\n Recommendations are specific, realistic and clearly derived from the analysis; they address systemic issues and show awareness of industry context and constraints.<\/td>\n Recommendations are relevant and mostly grounded in the analysis, though some remain generic or lack prioritisation.<\/td>\n Recommendations are broad, weakly justified or restate investigation conclusions without added insight.<\/td>\n Few or no practical recommendations; suggestions are vague, unrealistic or disconnected from the findings.<\/td>\n<\/tr>\n \n Critical reflection on investigation and learning<\/td>\n 5%<\/td>\n Offers thoughtful critique of the official investigation and draws clear conclusions about how casualty analyses can support organisational learning.<\/td>\n Provides some critical reflection on the investigation and learning processes, though depth is variable.<\/td>\n Reflection is brief or mainly descriptive; limited critical engagement with investigation quality or learning processes.<\/td>\n No meaningful reflection on investigation or learning; report ends at descriptive recommendations.<\/td>\n<\/tr>\n \n Use of sources, structure and academic writing<\/td>\n 5%<\/td>\n Uses appropriate official reports and academic\/professional sources; report is clearly structured, well-written and correctly referenced in Harvard style.<\/td>\n Good use of sources with minor gaps; writing and structure are clear overall; referencing mostly correct.<\/td>\n Limited or uneven source base; structure and writing show recurring issues; referencing errors are evident.<\/td>\n Very weak use of sources; structure and writing impede understanding; referencing is inadequate.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<\/div>\n \u00a0Learning Resources (Harvard Style)<\/h2>\n
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