MV Rocknes maritime accident and system thinking

MV Rocknes: the ship was transporting Rocks from Canada to Norway, loaded by a too short conveyor belt, putting the load on one side of the ship. The first officer (under time pressure) signs it off and pumps ballast water into the ballast tanks on the other side to keep the ship level. At sea nobody rearranges the load in the hull (which would have been possible) therefore the ship remains on level only due to ballast water. The ship enters Norwegian Fjord to Bergen- a very busy shipping lane. The pilot comes on board. The pilot is unfamiliar with a newly discovered shallow spot in the Fjord as it has been discovered but not PROPERLY published by the authorities for quite some time. The is no useful display on his map. The pilot steers the ship too far out in a curve. Many short steering inputs noticed by the Data recorder. The load shifts massively in the tight curve and starts to slowly tip sideways. The pilot hears sounds in the hull and runs out of the bridge to the upper side of the ship, leaving the steering wheel and the crew behind. The ship tips over and lays in the fjord hull up. A large part of the crew dies. The crew inside the hull initially survives in an air bubble but is not saved by cutting hole into the hull due to fear of sudden sinking. The pilot survives because he ran.