Systemic approach to investigate tragic marine accident in Brasil

Abstract

This article presents the result of a maritime accident investigation where the systemic approach was used, in which the system as a whole is considered and the accident described as resulting from an uncontrolled relation of its constituent parts. For this, Accimap investigation method was used. The accident occurred in the state of Bahia, when a ship known as Cavalo Marinho I, which carried passengers between the maritime terminals of Salvador and Mar Grande, on the Island of Itaparica, sank and resulted in the deaths of 19 people. Being considered the worst tragedy involving shipping in the state. In the data collection phase, the crew and the owner of the ship were interviewed. There were also analyzes of documents and inspections at the maritime terminals and in vessels similar to those reported. In addition, a crossing was made between the terminals with the commander of Cavalo Marinho I. A map of the accident was constructed, containing 13 contributing factors and the interrelationship between them. Recommendations were presented with the aim of improving the safety of the maritime transport system, such as dredging of the maritime access channel to Mar Grande Beach. It is concluded that the systemic approach allowed to develop a complete picture of how and why the accident occurred and to recommend appropriate measures to prevent that similar accident occurs again.