The Exxon Valdez
Oil Spill
Marine Accident
Report
MARCH 26
Shahrukh Ahsan
N0985892
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Contents
Preamble ........................................................................................................... 4
The Incident....................................................................................................... 4
The Analysis ...................................................................................................... 5
The Human Factors ....................................................................................... 5
The Design Factor ......................................................................................... 6
The Event Tree.................................................................................................. 6
Fishbone Diagram ............................................................................................. 7
Fault Tree Analysis ............................................................................................ 8
Conclusion ...................................................................................................... 10
References ...................................................................................................... 11
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List of Figures
Figure 1: Event Tree Analysis
Figure 2: Fishbone Diagram
Figure 3: Fault Tree Analysis
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Preamble
The report aims to analyze the marine accident popularly known as the ‘Exxon
Valdez Oil Spill’. It will briefly describe that how the U.S oil tanker grounded on
the Bligh Reef and then further failure analysis is done by employing tools such
as event-tree, fault-tree and a fish bone diagram.
The Incident
A U.S oil tanker named “Exxon Valdez” embarked on a journey that would be
remembered as the biggest oil spill in the United States history. This oil spill
would be responsible in contaminating the south coast of Alaska also known as
the Prince William Sound. On 12:09 am of 24th March of 1989, the oil tanker
grounded on the Bligh reef. The grounding caused the ship to spill its contents
out into the sea. About 10.8 million gallons of oil was leaked out into the pristine
waters of the Bligh reef. The oil spill’s radius would then expand up to an area of
1750 km (Wolfe et al., 2009).
The real trouble started when the ship diverged out from its course. The
incoming and outgoing shipping lanes were mapped out in the traffic separation
scheme but there was an ice floe hindrance on the route. This made the ship’s
master to change course. He did confirm the change of route with the Coast
guard vessel traffic control to which they agreed as there was no traffic on the
other lane.
After the confirmation, the master ordered the helmsman to steer the ship
accordingly and place it on auto-pilot. It is also important to note that the speed
was not reduced and the ship was travelling on a ‘full-ahead’ speed. The master
then handed the navigation over to the third mate.
The third mate was worried of the fact that why the ship was on auto-pilot. Auto-
pilot is normally engaged when the ship is in open-sea. The third mate did not
inquire this with the master as he was off-duty and he did not want to disturb
him. The third mate decided to remain on watch while they maneuvered around
the ice floe. He used navigation tools to determine the ship’s location and also
that there was enough way to avoid Bligh reef and pass safely. The ship could
not have turned sooner because of the ice.
Now, the third mate then disengaged the auto-pilot and made his first 10o
rudder change to the right. The radar did not reflect this change and he further
instructed an additional 10o rudder change. The radar still displayed that the
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ship was following a straight course. The panicked third mate ordered a hard
right rudder and informed the master that they were in serious trouble as he felt
the ship turning but the radar did not detect this. Moments after, sharp jolts were
noticed and the Exxon Valdez had grounded. After the grounding, the strong
odor of vapors was noticed by all members present on deck. This only meant
that the oil had started leaking.(Wolfe et al., 2009)
The company tried to contain the oil spill but it was not prepared to handle a
spill of this scale. Also, a storm became the reason to extend the oil spill’s
radius and coat the nearby shores with crude oil. This spill not only affected the
economy of a nearby fishing town, Cordova, but also unsettled the ecology of
the area.
The Analysis
Any accident is a culmination of different factors that lead to failure. Similar is
the case of Exxon Valdez. The factors which influenced the most are analyzed
in the report.
The Human Factors
It has been noted that majority of the oil spills are caused due to human factors.
The human actions then cause other events which cascade down to a major
failure (Chen et al., 2020). Even in the case of Exxon Valdez, the grounding of
the ship would have been avoided if the captain or the third mate would have
been more diligent.
There was also an investigative report done on the incident by the U.S national
transportation safety board and majority of the causes were influenced by the
crew members. The following sums up the findings of the report (National
Transportation Safety Board (NTSB), 1990):
• When the captain changed course, due to the ice floe, he should not have
turned the auto-pilot on and handover his duty to the third mate. Instead,
he should have been present there to carefully maneuver the ship around
the ice.
• The captain was under the influence of alcohol which is against the
protocols.
• The third mate could not adjust the rudder accordingly and then the ship
was led into the Bligh reef. This could have happened because the third
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mate was tired and sleepy. He should have informed about his condition
to the captain.
• The personnel in vessel traffic center did not use a higher scale in their
radar and this is why the Exxon Valdez was not tracked properly.
• For a couple of minutes, the ship was in the red zone of Busby light. This
was left unnoticed by the lookout and even the third mate.
• The Exxon did not provide a well-rested staff that would have navigated
the ship properly
All of these findings suggest that the accident could have been avoided had the
crew members were more careful.
These were the causes that actually made the accident happen but the fault
tree analysis, further in the report, shows all the failures that could have led to
the grounding of the ship happen.
The Design Factor
After the Exxon Valdez incident, it was required by U.S law for oil tankers to be
double hulled. The Valdez was a single hulled ship and it is believed that if it
had been a double hulled ship the oil would not have leaked. (Haycox, 2012).
The Event Tree
The Event Tree (Fig.1) analyzes the responses that led to the disaster. As
discussed earlier in the report, majority of the causes were influenced by the
crew onboard. If appropriate actions were taken for the critical events, depicted
in the event tree, the grounding would have been totally avoided or at least the
oil spill would be contained. The event tree is displayed on the next page.
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New route Third mate Third mate Third mate
suggested by Captain in Third mate In-time
Auto-pilot inquires captain steers in time takes action Double Hulled
traffic center charge to reduces speed containment of Possible outcome
Engaged and asks him and no when in Busby Ship
beforehand due guide the ship while in doubt oil spill
for help grounding red sector
to ice hazard
Yes
Grounding Avoided
Yes
Grounding Avoided
No
The Exxon Yes Grounding Avoided
Valdez
encounters Ice No
Yes
floe Grounding Avoided
No Yes Grounding Avoided
No Yes Grounding Avoided
No
Yes Grounding Avoided
No Yes
Contained radius of
oil spill
No Yes
Contained radius of
oil spill/ No oil leak
No
No Grounding & Oil
Figure 1: Event Tree Diagram
Spill
Fishbone Diagram
Fishbone diagram are also known as the Ishikawa diagram or cause-effect
analysis. It is a useful tool to brainstorm the possible causes. Before beginning
the fault tree analysis, the fishbone diagram also helped in determining some of
the causes.
Various reasons that relate to design, inspection, equipment, human factors,
and policies were described in the fishbone. The fish bone diagram is displayed
on the following page.
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Design Inspection Equipment
Following Navigation Navigation aid
engineering Equipment equipment
standards inspection
Appropriate
material Engine Emergency
selection inspection equipment
Double hull
design of Hull
Faulty inspection
ship construction
Grounding of Exxon
Staff acts in Valdez
accordance
to protocols Policies for
emergency
Rudder
Competent Policies to response
failure
experienced prevent
staff fatigued staff Engine
from failure
navigating
Policies
Coordinated
against use Bad weather
crew
of alcohol
Human
Policies Misc.
factors
Figure 2: Fishbone Diagram
Fault Tree Analysis
The fault tree (Fig. 2) looks at the possible causes that were involved in the
catastrophe. The fault tree analysis has pointed out three major causes and
those are navigation errors, design flaws and human influences.
Navigation is crucial when it comes to marine transport. Things can still go
wrong and following are the four reasons which are explained below and
highlighted in the fault tree as well:
• Planned improper course (A1): It is possible that the planner might have
used inappropriate nautical charts and the arranged course will be faulty.
It is also possible for the crew to wrongly implement the plan.
• Bridge equipment failure (A2): If no safety checks were made before the
journey, it is probable for the equipment to completely fail or operate
erroneously. The critical equipment on board is the GPS and the
echosounder and failure of those can lead to serious navigation issues
• Violation of protocol (A3): There are a complete set of navigation rules for
ships that the crew should abide by. Failure in compliance of those can
lead to grave consequences (IACS, 1992).
• Unforeseen factors (A4): Unpredictable factors can also contribute to a
failure. In the case of ships, bad weather is always a trouble. Also, the
internal parts of the ship e.g., the rudder, engine or other supporting
machinery can fail without any apparent reason and then loss of power
and other problems can ensue.
Ensuring that the design is safe is the first precaution in avoiding failures. The
only design flaw that the Exxon Valdez had was that it was single hulled. Below
are some other flaws that can lead to a major event:
• Single hulled ships (B1): All oil tankers are required to be double hulled
after the incident. Single hulled ships are more likely to leak out their
contents.
• Improper material for ship (B2): All oil tankers are of steel construction.
The HT36 and HT32 high strength steel is used in making these ships
(Parkway, 2012). Any other material might cause dire consequences.
• Improper construction for ship (B3): If a proper methodology was not
followed during the construction or if the construction was rushed and
poor quality was employed then chances of failure will increase
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Wrong decisions, improper actions, lack of coordination and miscommunication
all are errors that cause drastic events. The reasons are discussed further
below:
• Improper amendments to the ship’s course (C1): It is essential that the
ship’s master makes the right decision. In Valdez’s case, the drunk
master diverged out of the defined traffic lane and instead of navigating
the ship vigilantly he turned auto-pilot on and transferred his duty to the
third mate. Later on, the third mate failed to position the ship and ended
up making faulty course changes. (National Transportation Safety Board
(NTSB), 1990). This shows that the duties should be assigned
accordingly and not based on hunches. Also, that chart positioning plays
a major role when making adjustments to the ship’s course.
• Communication gap (C2): There should be frequent coordination with the
master and the rest of the crew. The orders that the master issues are to
be communicated clearly to avoid confusion. Good coordination means
that the orders are followed as they were meant to be. Additionally, the
ship must be in contact with the vessel traffic center during all decisions
to increase coordination. However, other factors like a transmitter failure
can also cause a communication gap between the ship and vessel traffic
center.
• Interpretation Failure (C3): Understanding the situation and then reacting
to it is human nature but sometimes misunderstanding can occur. The
lookout officer or master can cause an interpretation failure. Even in the
Exxon incident, the lookout did not interpret the danger of staying in the
Busby red sector. Also, some situations require data from equipment and
due to faulty equipment, this can cause misinterpretation.
• Improper Judgement (C4): It was proven by an investigative report,
(National Transportation Safety Board (NTSB), 1990), that the master
was drunk. This was the reason the master could not judge the situation
properly. The other cause could be fatigued staff. The third mate was
tired and he made wrong rudder changes which became the final cause
of the grounding. Also, inexperienced personnel can lead to improper
judgement problems.
The fault tree is shown on the next page.
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Grounding of
Exxon Valdez
A C
B
Navigation B Human Influences
Errors
Design Flaws
C1 C4
A1 A2 B B
A3 A4 Improper
Bridge Improper
Planned Unforeseen Amendments to C3
Equipment
Violation Judgement
improper of factors ship’s course C2
B
course error/failure B
protocol Interpretation
s Communication
Gap Failure
Fault in Chart
Improper positioning Fatigued/
Faulty Inappropr- duties Sleep
execution ate use of Bad Internal deprived
assigned
of plan nautical weather staff
Ship & Vessel
charts Uncoordinated
Traffic Center
Master &
miscommunication
Bridge Team
Inexperie-
Failure to nced
Use of
correctly personnel
Inappropri
Rudder Engine Auxiliary position ate charts
Echo No failure failure machines fix ship
sounder safety GPS failure
failure checks Failure Lack of
Transmitter
Personnel
Failure coordination
under
influence
B C3 of alcohol
B
Design Flaws Interpretation
Failure
B1 B2 B3
Single Improper Interpretation
Hulled Material Improper Interpretation Failure due to
Interpretation Symbol Key
Ship for Ship construction Failure of equipment
Failure of
Lookout Master
Radar GPS OR AND Intermediate Event
Failure Failure
Figure 3: Fault Tree Diagram Continued on
Basic Event
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Conclusion
The Exxon Valdez was the biggest oil spill disaster in 1989 that U.S history
had ever witnessed. An oil tanker, under the leadership of a drunk master,
grounded into the Bligh Reef which was a well-known hazard. Even the
emergency response was slow which increased the oil to spread across a
wider radius. Winds and waves carried the oil to the shores as well.
The failure analysis, shown in the report, sums up the possible grounding
of the oil tanker. The findings have suggested that the ship’s crew heavily
influenced the events which led to the grounding of the Exxon Valdez.
Some recommendations to avoid future accidents are as follows:
• Stricter checks and policies should be implemented to prevent the
crew from the use of alcohol.
• In order to avoid fatigued/tired staff from navigating, sufficient number
of staff should be present on-board ship to reduce workload.
• The oil tankers should be double hulled to increase the factor of
safety.
• When the ship diverged out of the traffic lane, the vessel traffic center
should have inquired and coordinated more frequently. Strict
monitoring should be done when ship’s change/divert out of planned
routes.
• Ice floes were a common hazard in the Bligh reef. The route should
have been planned earlier and not during travel.
• The ship’s navigation equipment must be checked before travel.
• Emergency response for the oil response was not quick in the
incident of Exxon Valdez. Had the response been quicker, the oil spill
would have been contained.
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References
Chen, J. et al. (2020) ‘Marine oil spill pollution causes and governance: A
case study of Sanchi tanker collision and explosion’, Journal of Cleaner
Production, 273, p. 122978. doi: 10.1016/j.jclepro.2020.122978.
Haycox, S. (2012) ‘“Fetched Up”: Unlearned Lessons from the Exxon
Valdez’, Journal of American History, 99(1), pp. 219–228. doi:
10.1093/jahist/jas050.
IACS (1992) ‘INTERNATIONAL ASSOCIATION OF CLASSIFICATION
SOCIETIES Requirements concerning NAVIGATION’.
National Transportation Safety Board (NTSB) (1990) ‘Marine Accident
Report Grounding of teh U.S. tankship Exxon Valdez’, p. 256. Available at:
http://www.ntsb.gov/investigations/AccidentReports/Reports/MAR9004.pdf.
Parkway, M. V. (2012) ‘Design and Construction of Oil Tankers’.
Wolfe, D. et al. (2009) ‘The Fate of the Oil Spilled from the Exxon Valdez’,
Environmental Science & Technology, 28(13), pp. 560A-568A. doi:
10.1021/es00062a001.
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