Learning from failure by using a hybrid model technique: the Suez Canal Incident

This paper examines the 23 March 2021 grounding of M/V Ever Given in the Suez Canal using a hybrid analytical framework that integrates Fault Tree Analysis (FTA), Reliability Block Diagram (RBD), and Bowtie Modelling enhanced by the Haddon Matrix. The framework identifies causal pathways leading to the loss of navigational control and subsequent canal blockage, while evaluating safety barriers for preventing and mitigating similar incidents. FTA structures the causal logic and defines basic events, which are then mapped into an RBD to reveal system vulnerabilities and limited redundancy. The Bowtie model organises preventive and mitigative barriers across pre event, event, and post event phases, and the Haddon Matrix ensures that human, environmental, and equipment factors are addressed in a balanced manner. The analysis highlights three dominant vulnerability strands: procedural non compliance, reduced situational awareness under adverse weather, and navigation challenges in restricted waters. The prevalence of series type configurations in the RBD indicates a high susceptibility to single point failures. The study concludes that the hybrid framework offers a coherent and practical approach to tracing causal logic, visualising system level vulnerabilities, and systematising safety barrier design. It provides a structured foundation for learning from failure in restricted water navigation.