System-Theoretic View of Marine Pilotage Accident in Busan New Port

A contact accident with gantry cranes involving the container ship MV Milano Bridge in Busan New Port took place on 6 April 2020. The report concluded that the pilot unreasonably piloted the ship with impaired maneuverability and without a proper pilotage plan. Analyzing the entire system by CAST model gives a holistic approach in linking all the key components and their roles as well as violations that led to the accident, stepping away from placing the blame on only one component in the system. Furthermore, analyzing the accident as an system theory gives a clear overview of the relationships between system components and how these interactions led to the accident.