Marine Safety

(Human Error Investigation)

Even Semester 2017/2018

Arranged by :
1. Jamal Ramadhan 04211640000047
2. Alem Reyhan Savero S. 04211640000105

Departement of Marine Engineering

Faculty of Marine Technology
Institut Teknologi Sepuluh Nopember
Surabaya
2018
 1. Data of Marine Accident in Indonesia

MV Levina 1 Fire in Java Sea

KM Levina 1 is a ferry ship with a total weight of 2000 tons. The ship is 27 years old, and is owned
and operated by PT Praga Jaya Sentosa. This ship is made in Japan. On the day of the incident, the
ferry made a voyage from Jakarta to Bangka Island.

On February 22, 2007, the MV Levina 1 was en route from the Jakarta, to the island of Bangka.
The vessel caught fire several hours after leaving port, at a location 60 nautical miles (110 km)
from the start port of Tanjung Priok. Hundreds of passengers escaped the burning ship by jumping
into the Java Sea. Over 290 people had to be rescued. At least 51 people were killed in the disaster,
but the Indonesian Red Cross Society says the number of deaths could be as high as 89. The ship's
log claimed the ship was carrying 228 passengers, 42 trucks and eight cars, but the navy claims it
had at least 350 passengers on board. It is common for logs of passengers to be left incomplete and
boats to be overloaded in Indonesia. In reference to the incomplete manifest, Transport Minister
Hatta Rajasa said: "It is a big mistake that the ferry company never registered the identity of
children passengers. It is a big, big mistake. I am going to give them heavy sanctions for that."

The ferry's sister ship, Levina II, rescued many passengers, as did the Filipino ship Princess
Vanessa. In total, two warships, three helicopters, a tug boat and nine cargo ships participated in
the search and rescue operation. The injured were either transported straight to hospital, or treated
at a makeshift centre set up at the port. 60 people were save able to swim to a nearby island.

After the fire can be extinguished, TB Jayakarta III tug boat brought the ship to near the Tanjung
Priok port. The next day, many reporters conducted an investigation on the ship. The Indonesian
investigative authority, the KNKT, had not given the group permission to board, but they saw other
journalists on board, and followed suit. Shortly after the party boarded the vessel, it suddenly listed
sharply.Police officers monitoring the vessel from a nearby boat used a loudspeaker to order an
immediate evacuation of the ship. Most of those on board rushed down to deck two, where they
escaped via a window at the end of the deck. The ship sank within five minutes.

An investigation disasters by the National Transportation Safety Committee and the Police
Forensic Laboratory. The investigation established that the fire started in a truck on the car deck.
It is believed to have been a chemical fire, as the ship's crew reported that when they attempted to
douse the tarpaulin-covered truck with water, the ferocity of the fire increased. The trucker's
ticketing agency shows that one of the trucks was loaded with cases of premixed petroleum. The
ship's captain was interviewed as part of the investigative procedure. Preliminary reports suggest
that negligence on the part of the operator, PT Praga Jaya Sentosa, contributed to the disaster. The
investigation revealed that no inspection of the boat's documents was conducted prior to departure.
The vessel's skipper, as well as four other crew members, were also the subject of a criminal
investigation regarding possible negligence.
 2. Human Error Investigation by Using SHEL (Software-Hardware-
Environment-Liveware) Model
Software:

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Hardware:

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Environment:

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Liveware:

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