Systems approach to accident analysis: engine room fire on cruise ship "Le Boreal"

The current explanation of accidents is derived from an analysis of proximate events and some contributing causal factors, whereas the role of a wider socio-technical context that give rise to systemic causal mechanisms is often left unexplained. The paper describes analysis results of a recent maritime incident with the purpose to illuminate the causal factors, including systemic ones, and offers a different, more comprehensive explanation of the incident causation to that which is given in the accident investigation report. The study seeks to provide valuable input for enhancements in overall maritime safety control and proactive safety management at the ship and shipping company levels. With the gained knowledge, resources committed to risk management can be better allocated, reducing associated costs and improving on business objectives.