FRAM analysis of a berthing accident in a high-throughput Brazilian port - failing safely in a complex and non-linear workplace

Abstract

This paper presents an accident reanalysis using the FRAM (Functional Resonance Analysis Method) methodology to understand a vessel grounding that occurred during a night-time approach for berthing at a large-scale deep-water, multi-terminal industrial port complex on the Brazilian coast, designed for high-throughput cargo handling and continuous operations, with segregated access channels, breakwater-protected waters, and intensive vessel traffic management. Although this accident resulted in no injuries, environmental impact, or intense structural damage, it exposed latent vulnerabilities in maneuvering, port operations and coordination routines. The official investigation relied on a linear accident analysis combining the 5 Whys and a Fault Tree Analysis (FTA), noticing discrete basic causes and recommendations focused solely on procedure revisions and training. While useful for identifying missing barriers, this linear approach can under-represent the coupled, adaptive, and time-compressed character of port entry and berthing operations in high-complexity and high-traffic cargo facilities. The FRAM reanalysis, though, revealed tight coupled interactions involving passage planning, bridge operations, port communication, coastline visual navigation and support resources, unveiling a hidden complexity blurred by linear methodologies. Indeed, moving beyond linear cause-effect methodologies, this FRAM reanalysis provided a more coherent understanding of how organizational, technological, environmental, and individual factors interact to shape maneuvering performance in complex workplaces of a VUCA and BANI world. Therefore, to properly recognize the real work conditions and constraints that took place in the accident of this study, the FRAM was applied to comprehend its complex nature, especially during nighttime operations.

Keywords: FRAM, Human Factors, Safety Engineering, Accident Analysis

DOI: 10.54941/ahfe1007980