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Chapter Chapter Chapter Chapter Chapter Chapter Chapter Chapter 1: 2: 3: 4: 5: 6: 7: 8: Initiation of an Accident Investigation (53 Kb PDF) Initial Actions (53 Kb PDF) Managing the Investigation (53 Kb PDF) Witnesses and Interviews (204 Kb PDF) Physical Evidence (220 Kb PDF) Human Factors (251 Kb PDF) Analyses, Tools, and Techniques (548 Kb PDF) Conclusions and Recommendations (125 Kb PDF)
1. 2. 3. 4. 5. 6. 7. 8. The Investigator, the investigative team, and teamwork (145 Kb PDF) Command center/ Meeting room (88 Kb PDF) Personal safety during accident investigations (113 Kb PDF) Accident investigation checklist (353 Kb PDF) IMO Code for the investigation of marine casualties and incidents (641 Kb PDF) Quick check lists for field investigators for various accidents (194 Kb PDF) MAIIF contacts -- http://www.maiif.net/address.htm Tips from (227 Kb PDF)
Initiation of an Accident Investigation.
The Need for Investigation.
The objective of any marine casualty investigation is the prevention of further similar casualties by discovering the reasons behind the casualty and then promulgating actions, information and recommendations where appropriate with a view to preventing similar casualties. It is important that any recommendations arising from an investigation are based on sound analysis and are capable of practical implementation.
It follows from this that any accident, from the trivial to the major can be the subject of a marine casualty investigation. A simple personnel accident with the potential for learning something which could prevent recurrences might be worth investigating thoroughly while a major collision resulting from a straightforward wrong application of the COLREGS might not show anything new. Another different collision might indicate a need to look at fatigue, management procedures, training, certification and bridge design. Each accident which is reported should be assessed on its merits.
However, the “Code for the Investigation of Marine casualties and Incidents”1 does provide some guidance. It states that:
“Flag States are encouraged to ensure that investigations are carried out into all casualties occurring to its ships. All cases of serious and very serious casualties should be investigated.”
What is a casualty?
The Code defines a casualty as an event which has resulted in:
• death or serious injury (caused by or in connection with the operations of a ship) • loss of a person from a ship (caused by or in connection with the operation of a
• the loss, presumed loss, or abandonment of a ship.
IMO Resolution A.849(20) adopted 27 th November 1997.
• material damage to a ship. • the stranding or disabling of a ship, or its involvement in a collision. • material damage being caused by, or in connection with the operation of a ship. • damage to the environment.
However, this definition is not truly helpful and needs to be interpreted with care. For example, what is “material damage”? Is a minor contact while manoeuvring really a collision?
A true definition of a casualty is not easy. To fulfil the purposes of marine accident investigation it is obvious that all sorts of incidents may need to be investigated, so that a true definition is probably along the lines of :“any accident or incident which causes or threatens significant damage or injury”. Within this scope it is for the accident investigator to determine the need for investigation in respect of each one that is reported.
The Code also defines Serious Casualties and Very Serious Casualties.
A serious casualty is a casualty which involves a fire, explosion, grounding, contact, heavy weather damage, ice damage, hull cracking or suspected hull defect resulting in:
• structural damage rendering the ship unseaworthy (such as penetration of the hull
underwater, immobilisation of the main engines, extensive accommodation damage etc.; or
• pollution in any quantity; and/or • a breakdown necessitating towage or shore assistance. Very Serious casualty
A very serious casualty means a casualty which involves the total loss of the ship, loss of life or severe pollution.
The Code is clear that these serious and very serious casualties “should be investigated”, but it should not be forgotten that any accident can have the potential to reveal, in its analysis, a need for changes to prevent recurrences.
The selection of which accidents to investigate should be made with this in mind as it is normally a physical impossibility for any organisation to investigate every single reported accident, many accident investigation organisations suggest that they only conduct investigations in about 3% or 4% of reported accidents. It is essential, therefore, to select very carefully those accidents which merit an in-depth investigation.
Assessment of the Information available in an accident report.
Most flag state administrations and accident investigation authorities will have systems in place for reporting accidents. The first task in any investigation process is to assess this incoming data with a view to deciding which reported cases warrant investigation.
Obviously a major incident with injuries, environmental damage and media coverage requires no further discussion, an investigation should be mounted immediately and it will probably be a major investigation involving several investigators and a back up team of specialists. At the other end of the scale, many investigations can be dealt with by a request for reports from the ship and a close examination of those reports.
Probably the most common scale of investigation will involve one or two investigators who attend the ship, study the physical evidence, collect documentary evidence, and interview the participants. They then undertake any research that is necessary and compile to final report.
Levels and types of Investigation.
There are broadly 3 main levels of investigation depending on the severity of the casualty and its consequences, each requiring a different approach.
The most serious events require a major mobilisation of resources. There will be a team of several investigators under a lead investigator, supported by media co-ordinators, technical specialists, laboratory research facilities and a range of others, all in turn supported by the Flag Administration. The compilation of the final report may well involve an assessment board in some countries and will involve contributions from all those participating..
Less serious events will normally require a lower level of response, typically one or two investigators will attend, interview witnesses, collect evidence and then making use of
support facilities within the flag state and any necessary research work, compile the final report for the flag state.
Minor events, if a field investigation is warranted, will normally require only one investigator on scene who will conduct interviews, collect and examine evidence and then either prepare a brief report for consideration by the flag state or store the basic details for statistical analysis.
The majority of reported incidents tend to be of a minor nature and will not require the attendance of investigators on site. It will often be sufficient to call for reports from the ship and examine them to establish the essential facts. Further investigations can be undertaken if the examination suggests a need, but in most cases the incident can be closed on the basis of the reports from the ship.
Appointing the investigator.
Each flag administration will have its own system of accident investigation, most commonly either a specialised accident investigation unit with a staff of dedicated investigators or a system where individual surveyors, normally engaged in ship survey work are tasked with accident investigation when necessary. Both systems have their individual strengths and are both are equally valid in meeting international Convention obligations to investigate casualties..
The number of investigators appointed to conduct any investigation depends on the size of the investigation, the need for speed, the impact of the investigation, the location of the accident, and the individual skills and strengths of the investigators. Ideally investigators should be specially trained, at least in the techniques of interviewing witnesses. There are a range of techniques available such as cognitive interview techniques, which have the capability to allow an investigator to establish a much greater amount of recall from a witness than can be established by the untrained interviewer.
Legal powers of investigators.
The actual powers which can be exercised by an investigator will vary depending on the jurisprudence of the flag state. When the casualty occurs in international waters (on the “high seas”) with no impact or consequences for any coastal state, it will normally be the flag state which has sole jurisdiction and power to investigate.
This situation is modified when the event is a collision on the high seas, each flag state involved has sole jurisdiction in the case of its own ship and therefore, to make any reasonable investigation, there has to be an accommodation between the two flag states to agree some degree of co-operation.
When a casualty occurs in the territorial waters of another state, then the coastal state or states may, depending on domestic legislation, have some powers of investigation.
When the investigating team is attending a casualty outside its own state boundaries they will therefore be interacting in many cases with local officials from the state in whose waters the accident has occurred. In general terms a flag state has jurisdiction over its own ships and on board its own ships. However, it is also the case in international law that a port state has a degree of jurisdiction over events arising from a ship which impact on the external world in the port state. Thus if a ship grounds, spills oil, collides, involves local fire services or rescue services etc. the port state gains a jurisdiction. In virtually all casualty investigations where a state other than the ship’s flag state is involved to any degree, that port state will have some right of involvement in the investigation.
The Code provides for co-operation between states and this, coupled with the growth of the Marine Accident Investigators International Forum (MAIIF), has greatly assisted in smoothing out differences in these cases. However it remains the case that a variety of legal jurisdictions and national interests will often become involved and there can be no guarantee of co-operation and simple things such as access to local pilots or VTS operators for example can be denied.
The appointed investigator, subject to the detailed powers assigned by the laws of his or her country, will normally have powers to interview witnesses, collect evidence, preserve evidence, and examine the scene.
In some cases he may have even wider powers and it is essential that before attending any casualty the investigator is fully aware of exactly what legal powers he or she can exercise. It is almost inevitable that either the owners lawyers or officials from the port state or both will seek to follow their own agendas and that there will be conflicts. The investigator need to be very clear as to what powers he or she can exercise.
Notification of an accident may come in to the investigator in a variety of ways, possibly in a message from the owners, possibly one from the ship, possibly in press and media reports, possibly by notification from a port state or an RCC.
However the notification arrives, and assuming the event is one which warrants investigation there are a number of immediate actions that are needed. Not all of them will be needed in all cases but the following list is a good guide assuming a fairly major incident:-
At the flag state.
1. Designate an investigator or an investigating team depending on the seriousness of the event and despatch them to the scene. 2. Contact Owners, Managers, Classification Society and Port State officers to inform them that investigators are en-route and elicit their co-operation. If possible provide them with the names of the investigator(s) and their travel arrangements. 3. Contact emergency response agencies who may be involved at the scene and inform them that an investigation is being undertaken and seek their cooperation and assistance in preserving evidence at the scene. 4. Contact any other “interested states” who might be involved with a view to a co-operative investigation. 5. If the incident is a major one, prepare an initial press release and nominate someone with experience to deal with media queries.
At the investigation site (the investigation team).
1. Meet with representatives of any “interested states” if applicable. 2. Make an early overview of the ship / scene and get a broad picture of events from which a basic plan of approach can be drawn up. Take photographs / videos as soon as possible before the scene is disturbed. Often a ship’s master will already have drawn up a report to owners which can be used to get an overview of the events. 3. Make arrangements for the preservation of the accident scene and for the control of access if possible, particularly if the accident involves property belonging to a third party. 4. Make arrangements for a base ashore. Ideally this will be somewhere like the investigators hotel where a small room should be set aside on “neutral ground” where the investigators can interview witnesses and hold their own discussions and briefings. Telephone and fax facilities, and possibly photocopying, computer and data access facilities, will be needed in most serious cases.
In a major casualty, there will need to be a “command centre” ashore where the investigation team have facilities for interviewing numerous witnesses, collating large amounts of evidence, possibly storing physical evidence, and conducting their own briefing meetings. A large dedicated conference style room is ideal with separate private rooms available for interviews. The centre will need photocopying and communications facilities for fax, phone and data, preferably on dedicated lines. An important function for the “Command Centre” will be media management and there should be facilities for press briefings, and interviews.
5. Make arrangements for access to local witnesses, pilots, VTS operators, members of the public, stevedores etc. if this is appropriate and set up appointments for interviews. Arrange interpretation facilities if necessary. Obtain copies of any VTS tapes, radio recordings, radar recordings and similar evidence. If officials such as pilots refuse to co-operate, seek the co-operation of the Port State and their jurisdiction to compel co-operation if possible.
Initial Assessment of Available Evidence.
In every case, from a grounding when the investigators reach the ship after she has been refloated, to a fire where the ship is alongside and burning when the investigators arrive there will be a need to gather initial evidence as quickly as possible. No matter what the circumstances, the passage of time will dilute the available evidence. Potential witnesses will depart, physical evidence will decay, documentation will be collected by a variety of people, and memories will fade.
Perhaps more importantly witnesses and those involved will begin to rationalise their recollections of the events and, without meaning to, will tend to vary their memories and adjust the priorities of remembered facts as they inevitably talk with others. There may be press speculation and media coverage which, in turn, will tend to colour people’s recollections.
It is critical, therefore, for the investigators to gather an overview as quickly as possible and then plan the scope and direction of the investigation to minimise these effects.
In many cases the most useful initial source of information is the ship’s Senior Officers. In many cases they will, immediately after the event, have drafted a report to owners, or at least made log entries. It is in the nature of seafarers to do this and these initial reports are usually written virtually contemporaneously. They will often give a good picture of;
the overall events, key timings and the personnel involved.
In the absence of this sort of information the investigator should seek to establish, as quickly as possible from whatever source, this same basic information. In conjunction with the owners representatives and agents, if appropriate, the investigators should then set the priorities for evidence collection and witness interviews and make a basic plan which captures the best information possible.
In many cases the investigators will not arrive at the ship until a few days after the accident. Obviously it is in the nature of ships that, unless she is a total loss, controls and equipment will have been moved or used when recovering from the accident and making the ship safe with a view to returning her to service. The flag state co-ordinator who has despatched the investigation team should already have stressed to the personnel on-site the importance of preserving evidence as far as possible.
In the case of a major casualty there will be a corresponding need for the best possible preservation of evidence. Steps which should be considered, where appropriate, and which can be taken in any investigation include: • removing and excluding all persons from the accident scene except essential emergency response personnel. • • • cordoning off the area and locking doors and gates. posting warning signs. utilising security personnel to control access.
As important as the initial impression of the events is an initial “walkthrough” of the accident scene. This may, in some cases be the only and best opportunity the investigators have to assess the scene before it is disturbed by others and this opportunity should be taken to: • •
photograph the scene as thoroughly as possible. make contemporaneous notes, sketches and diagrams, especially of evidence which can easily be destroyed - positions of controls and switches, location of used emergency equipment, extent of damage etc. It is often useful to take a small tape recorder and make continuous voice notes for later transcription while walking through the scene. record exactly what any emergency response personnel are doing. This allows the best chance of working back to the state of the scene before they started their activities.
Meetings with interested parties.
It is inevitable that in any casualty there will be other interested parties. Indeed the number of these, in the initial stages, will probably be greater in less serious cases than in major events. In major casualties, particularly those with loss of life, the other parties will often tend to defer to the flag state investigator. In less serious cases they will each be seeking to protect their own or their client’s positions. Regardless of the casualty investigation, there will be ensuing litigation and the parties involved will be anxious to protect their positions. It is probable that in many cases the investigator will come across all or some of: •
Investigators and surveyors from the Salvage Association.
• • • • • • • •
Surveyors from the owners P&I Club. Experts appointed by the P&I Club. Lawyers representing P&I interests. Surveyors and experts appointed by cargo interests. Lawyers representing cargo interests. Lawyers representing individual crew members. Lawyers representing salvors. Lawyers representing owners.
All these are in addition to emergency services and port state officials who may be present.
In an incident, especially one which is not a major disaster, these representatives will all be seeking to protect their own client’s interests. When there has been damage, especially cargo damage, the owner will be very conscious of the fact that in the future, he will be facing litigation in respect of cargo and insurance claims, and while these other parties will usually defer to the investigator in major cases, or where there has been loss of life, in other cases they will actively pursue their own cause.
The investigator should remember that most of these representatives have a right to be there and many of them may well arrive on-scene before the investigator. They can, sometimes unknowingly, cause problems for the investigation. The owner’s lawyers, for example, will almost certainly wish to interview the crew and may well have started this process before the investigator arrives. They represent their clients interests and while they will not usually hide evidence they will often, in their questions, have the effect of leaving crew members with a recollection which can be biased towards the owners view of events. They may also seek to remove certain physical evidence for analysis by their own experts to support their client’s case. They will certainly attempt to obtain and hold documentary evidence. It must be remembered that in many cases they will have a perfect legal right to do so.
In these circumstances there can be often be a conflict between the investigator and these representatives and for this reason the investigator needs to be very certain of his or her own legal powers as they apply to the situation.
The most effective way forward in these situations is for the investigator to hold a briefing meeting with all the interested parties as soon as possible after arriving on-scene.
The briefing meeting should seek to set out and explain for everyone:
• that the flag state investigation is the prime investigation, but the investigator will cooperate with others as far as possible so long as it does not interfere with the prime investigation.
• the legal powers held by the investigator making it clear that they will be used if
• the procedures for interviews and the legal rights of interviewees, the legal status of their
statements and rights of access to them, and the rules governing access by third parties to interviews.
• the procedures for dealing with physical evidence and documentation and the
procedures for sharing copies of this with other interested parties.
An effective meeting can go a long way to avoiding conflicts and duplication of work.
Managing the Investigation
Preservation of Evidence
There are three types of evidence: physical, human, (obtained through witness statements or interviews) and documentary (including photographic media.)
Physical evidence may include solids, liquids, or gases. Documentary evidence includes all documentation developed by the investigator as well as accident related paperwork (and electronic data) such as charts, logbooks, instrument charts, as-built drawings, schematics, engineering analyses, vendor information, correspondence, computer software and data printouts. Particularly valuable are contemporaneous notes made by personnel involved such as bridge and engine room notebooks.
Most physical evidence can be left intact at a protected accident scene to await later investigation. Some evidence may be perishable and have to be removed quickly and preserved ( for example liquid samples that might require chemical analysis need to be collected quickly and sealed if the subsequent analysis of content is to be useful, likewise fluid samples which might evaporate or be absorbed need to be collected quickly). Some physical evidence may have been removed during the emergency response or casualty evacuation and the investigator should be aware of this and an early question to be directed to emergency response personnel should be in relation to any material of any kind that they might have removed from the scene during their work.
For physical evidence to be truly useful its integrity needs to be preserved and the investigator, before moving anything should record, :the exact location of the evidence at the scene, its orientation, its time of collection and its status using measurements, logs, sketches, photographs or video where appropriate.
Collected evidence needs to be stored and to maintain its integrity after collection, the investigator should ensure:
• that it is stored in a secure location; • that a “chain of custody” record is created which documents clearly the chain for each
• that access is controlled where necessary.
Note: The investigator should be conservative in deciding what items are “evidence”. It is easy to discard those “not useful” but virtually impossible to return and collect “forgotten” items later.
Human evidence also needs preservation. Human recollection of events, like many types of physical evidence, tends to degrade over time and recollections recorded immediately after the event tend to be more accurate than those collected later. All persons involved in any accident will tend naturally to try and “make sense” of the event afterwards and shipboard personnel will naturally talk to eachother and speculate on the causes in the aftermath. This leads to an inevitable tendency for witnesses to unconsciously vary the priority and importance of certain facts that they have witnessed to suit the group’s overall picture of the event.
These distortions are natural and can be filtered out by careful questioning but the best way to avoid them is to collect the human evidence as quickly as possible. This should not preclude the opportunity to interview the same witness again later. It is equally true that many people will remember useful facts surrounding the accident only some time afterwards and it is often the case with key personnel that an initial interview will reveal the main facts while a subsequent interview will bring out further detail which can sometimes be crucial.
Note: Quickly identify key witnesses and collect their statements because their “initial” statements are often more accurate and have greater credibility than those made later, but be prepared to return to the same witnesses some time later when they are often able to add detail in key areas.
Other persons such as emergency response personnel, members of the public, persons who arrive at the scene shortly after the incident and anyone else who might be expected to provide material information should be identified, located and asked to provide statements. If circumstances prevent the investigation team from taking all the witness statements immediately, the names and contact details of witnesses should be recorded so that they may be contacted later. Note; Access to the owners employees, (the ship’s crew) is usually a right enjoyed by the owners lawyers who will certainly make use of it, but the same lawyers will not usually have jurisdiction or a right to interview other persons which gives the investigator a major advantage in collecting all the evidence and developing a complete picture of the events.
Table 3.1 Types of witnesses who should be able to provide important preliminary statements. Type of Witness Principal Witnesses Relationship to the Accident Persons directly involved in the event or who suffered injury from it (for example):Master, Pilots, Watchkeepers, Stevedores Eyewitnesses Participants Observers who saw the accident or the events immediately preceding, during or following it. Emergency response personnel Persons arriving at the scene shortly after the accident and involved in actions to save life, property and/or the environment Company shore management personnel Port Officials Members of the public Persons engaged in the operation of the ship such as shift workers on duty prior to the accident, repair personnel who worked on the ship/equipment prior to the accident. Equipment or vessel designers, naval architects, fire experts, other experts.
Other potential witnesses
To ensure that the list of potential witnesses is a complete as possible and to identify any who may have left the scene it is useful to ask all witnesses (at every interview) to list any others who were in the vicinity or who were seen near the time.
It is also useful to ask witness to make a sketch of the accident setting out the positions of other persons and of events. Such sketches when collated can produce useful confirmation of the sequence of events and can suggest avenues of investigation which may not be clear from statements alone.
Note: There are a number of interview techniques, commonly used by other investigative bodies, such as “cognitive interviewing” which can be very useful in collecting the maximum amount of evidence from witnesses. Courses in these techniques are available and all investigators should, wherever possible, be conversant with these techniques
Managing the analysis
The lead investigator is responsible for ensuring that events and causal factors analysis and other analysis methods are begun as soon as initial facts are available. This helps to identify information gaps early, to drive the data collection process and identify questions for interviews. Accident investigation software is available and can sometimes be useful for identifying information gaps and for organising causal factors. Note: Particularly in a major investigation an alternative and useful technique is to make use of a wall board with coloured adhesive notes to set out elements of the events and casual factors. All team members can observe progress, provide input and plan changes.
As the investigation and analysis proceeds the lead investigator needs to monitor and discuss progress to ensure that:-
• If there are several members in the team, they are all working collectively to produce a
• If analysis and evidence gathering tasks are assigned to separate groups, the groups or
individuals are interacting regularly to improve co-ordination, strengthen the analytical process and maintain focus;
• Analyses are iterative (i.e. repeated so that each version produces results that stage by
stage approximates more closely to the end result. Several iterations may be needed as new information becomes available;
• Analyses address all organisational concerns, management systems and line management
oversight functions that may have contributed to the accident causes;
• Causal factors, conclusions and judgements are supported by evidence; • Significant facts and analyses do not result in a “dead end”; rather they are linked to
Format of the Report.
There are two aspects to final casualty reports, the actual report and the requirements to report to the International Maritime Organization.
The actual report.
The Code sets out (Paragraph 14) a basic report layout. This layout is logical and helps develop a structured report. Circumstances may dictate a variation on format, but whenever possibl the final report generated by the investigation team should contain: e
1. a summary This part outlines the basic facts of the casualty stating whether any deaths, injuries or pollution have occurred as a result. It may contain the main conclusions in a summary form. 2. factual details. This part includes the identity of the ship, flag, owners, managers Classification society as well as the relevant basic ship details:- type size power crew etc. 3. factual; narrative This section sets out in plain terms the established facts of the casualty. It is necessary here to clearly separate established fact from conclusions and presumptions. The section needs to be written with care and confined purely to facts which are established with certainty. There will inevitably be gaps but the investigator should avoid trying to fill gaps in this section, that an be done in the analysis section. Any reader should be able to establish from this section exactly what events are established as occurring with certainty in their chronological order. 4. analysis and comment In this section the investigator is free to take the facts from Section 3, and analyse them, adding in expert analysis and drawing together different facts to reach supported conclusions on the causes behind the casua lty. The basic arguments behind each conclusion need to be set out in this section and each conclusion needs to draw on facts and demonstrate its basis. It is always possible that the investigator is certain of some elements but the investigation is unable to find sufficient facts to firmly prove those elements.
It is permissible in this section to state this and expressions like “on the balance
of probabilities the following is concluded as the reason for ..” can be used when there is no alternative and provided that there is sound evidence and technical analysis pointing towards reaching this conclusion. The section should end with a set of conclusions derived form the analysis, and noting where the conclusions are reached by argument without firm evidence. 5. analysis of casual elements a section, or sections, analysing and commenting on causal elements, both mechanical and human. Similar comments apply to this section as with the preceding section. 6. Recommendations. A set of recommendations addressed to flag state, Class, Owner, Crew, etc. as appropriate and derived from the analysis conclusions where the analysis and conclusions suggest any changes that could prevent a recurrence.
Reports to IMO.
There is an obligation arising from Regulation I/21 of SOLAS for flag states to report casualties to the International Maritime Organization. Regulation I/21 of SOLAS says:-
“Each Administration undertakes to conduct an investigation of any casualty occurring to any of its ships.........” and
“Each contracting Government undertakes to supply the Organization with pertinent information concerning the findings of such investigations.”
Similar provisions are included in Articles 8 & 12 of the MARPOL Convention.
Submission of reports to IMO under Regulation 1/21 of SOLAS is not required if the flag state judges that the investigation has not demonstrated a need for change in existing international regulations. Indeed IMO member states are obliged to demonstrate a compelling need for a change in any regulation before an item may be placed on the agenda of an IMO committee. However, it is also true that there is a general perception now that all casualties should be reported regardless of the strict interpretation of Regulation 1/21.
IMO Circulars MSC/Circ.827 / MEPC/Circ.333 of December 1997 set out Harmonised reporting procedures developed by the International Maritime Organization for flag states to fulfil their obligations under the Conventions. The Circulars provide standard reporting
formats in which the basic details can be inserted for submission to IMO and also set out an agreed time frame for the submission of various reports.
Table 3.1 Information to be submitted to IMO. Information to be submitted Annex 1 of the IMO report form This is a basic summary in which the key information is provided by ticking the relevant boxes Annexes 2 & 3 of the IMO report form Annex 2 is similar to Annex 1 but requires more detail. Annex 3 is a summary sheet which requires some summary input on findings and recommendations In the case of In the case of In the case of In the case of Very Serious Serious Less Serious Marine casualties: Casualties: Casualties: Incidents: within 6 months after the casualty within 6 months after the casualty may be provided if there are important lessons to be learned may be provided if there are important lessons to be learned
at the end of the investigation
at the end of the investigation
may be provided if there are important lessons to be learned
may be provided if there are important lessons to be learned
Full investigation report
at the end of the investigation in all cases
may be provided if there are important lessons to be learned
may be provided if there are important lessons to be learned
may be provided if there are important lessons to be learned
In addition there are other Annexes to the IMO reporting format which should be submitted in addition to the Annexes 1, 2 & 3 where applicable. These are:
Annex 4, for information from casualties involving dangerous goods or marine pollutants in packaged form on board ship or in port areas
Annex 5, for information from casualties involving stability or ship damage, these need to be completed in the case of steel seagoing ships of 25 metres in length or more for all b reaches of the hill causing flooding of any compartment above the double bottom.
Annex 6, for information from casualties involving fires.
Annex 7, for information from casualties where the GMDSS system is used for alerts. Annex 8 , for information from casualties where fatigue is a contributory factor
Annex 9, for information from casualties where there have been accidental spillages of harmful substances of 50 tonne or more.
Managing Report Writing.
Many investigating teams have found the writing of the final report to be the most difficult part of the investigation, often requiring several iterations. Report quality is crucial, because the final report is the official record of the investigation and no matter how high the quality of the investigation the whole effort is lost if the final report fails to adequately communicate a clear set of facts, supporting evidence and firm conclusions supported by the facts and evidence.
The lead investigator, or sole investigator should;
• Develop a report outline as soon as possible, using the Code model and if several
authors are involved he should strive to ensure that there are no overlaps in assignments so that content is not duplicated.
• Begin drafting ( in outline form) the accident chronology, background information and
facts as soon as possible.
• Continuously review the progress to identify where sections should be added or
• If supervising a team effort, pair strong and weak writers together to avoid delays and
• If necessary use a technical report writer to evaluate grammar, format, consistency,
technical content and links between sections and facts so that the report ends up technically correct, clear, concise, logical and consistent in style and approach.
Release of Information to Interested Parties.
In many investigations there will be a number of interested parties who will press for information as the investigation process goes on. Amongst the interested parties may be:
Relatives of anyone lost in the casualty:
Bereaved relatives will obviously have a keen interest in the progress of the investigation for a variety of reasons, they may wish to pursue legal claims, they may wish only to know they are not forgotten. Given that an investigation may take several months it is only right that these persons be kept fully informed. Indeed they have a moral right to know what has happened to their relatives and what is being done to find out why it happened. The most effective way is to arrange occasional briefings for them where the lead investigator, or another senior figure from the flag state, can privately advise them of progress, estimates of completion dates, and where possible and appropriate key facts that have been established. These briefings need to be handle d with care. Bereaved relatives can be understandably sensitive and if they feel that information is being withheld they will often approach the press with the result that media speculation can distort the whole process. On the other hand the same result occurs if they are given incomplete, or partial facts without explanation which can lead them to an erroneous conclusion.
It seems to be generally the case that, if the investigators are open and clear in briefing relatives on progress with explanations of the facts so far known with guidance on the direction of the investigation, relatives will feel that they are a part of the process and will assist rather than hinder the process.
Shipowners and lawyers
In many cases there will be litigation of some kind following a casualty. The owners and their representatives will want a copy of the report as soon as possible so that it can be defended or argued against as necessary in court. To avoid repetitious letters from lawyers demanding publication dates or interim details, it is usually effective to identify quickly the main parties and send a simple briefing letter to them at regular intervals simply stating the amount of progress and the expected completion date with an assurance that they will receive a copy of the report on publication. These regular update notes often serve to prevent regular demands on the investigators.
In other cases, the owner may well have a direct interest in finding out exactly what happened so that he can take steps to avoid the same problem on other sister ships for example. Often in such cases there is no litigation involved and the owner will have no interest other than finding out the cause and fixing it. In these cases it is often best to provide the owner with as much information as is available when it is available and certainly as soon as tentative conclusions emerge. The end purpose of the investigation is to prevent a recurrence and this may well be best served by working closely with an owner to identify the cause and prevent it from happening again.
Press and other Media.
In any casualty which has drawn the attention of the media, there will be demands in the early days for information so that the writers and broadcasters have some data to put in their reports. Within days this usually recedes as the casualty loses “front page” appeal but most media people will keep a forward note on the subject and will bring it up again after an interval with demands for final answers. In a case where the media are likely to be interested in a final report it is often useful to provide them with the same regular briefing notes as suggested in (2). This tends to pre-empt ill informed speculation and criticism.
Witnesses and Interviews
Collecting data is a critical part of the investigation. The detailed information collected by the accident investigation team is the foundation for the entire investigation, including the analyses and conclusions. These in turn become the basis for identifying preventive measures to preclude recurrences, Consequently, it is important to ensure that all relevant information is collected and that the information is accurate. Gathering and analyzing information is an interdependent process that takes place throughout the first three weeks of the investigation cycle. As preliminary analysis is conducted on the initial evidence, gaps will become apparent, requiring the team to collect additional evidence. Generally, many data collection and analysis iterations occur before the team can be certain that all pertinent evidence has been gathered and analyses are finalized. Three key types of evidence are collected during the investigation: Human or testamentary evidence includes witness statements and observations. Physical evidence is matter related to the accident (e.g., equipment, parts, debris, hardware, and other physical items). Documentary evidence includes paper and electronic information, such as records, reports, procedures, and documentation. Collecting evidence can be a lengthy, time-consuming, and piecemeal process. Witnesses may provide sketchy or conflicting accounts of the accident. Physical evidence may be badly damaged or completely destroyed. Documentary evidence may be minimal or difficult to access. Thorough investigation requires that team members be diligent in pursuing evidence and adequately explore leads, lines of inquiry, and potential causal factors until they gain a sufficiently complete understanding of the accident. The process of collecting data is iterative. Preliminary analysis of the initial evidence identifies gaps that will direct subsequent data collection. Generally, many data collection and analysis iterations occur before the team can be certain that all analyses can be finalized, The process of data collection also requires a tightly coordinated, interdependent set of activities on the part of several investigators. 16
TIP It maybe helpful for the lead investigator to designate one team member to oversee evidence collection and to maintain a master list of evidence collected to date. The process of pursuing evidentiary material involves: Collecting human evidence (locating and interviewing witnesses) Collecting physical evidence (identifying, documenting, inspecting, and preserving relevant matter) Collecting documentary evidence Examining organizational concerns, management systems, and line management oversight Preserving and controlling evidence.
Collecting Human Evidence
Human evidence is often the most insightful and also the most fragile. Witness recollection declines rapidly in the first 24 hours following an accident or traumatic event. Therefore, witnesses should be located and interviewed immediately and with high priority. As physical and documentary evidence is gathered and analyzed throughout the investigation, this new information will often prompt followup questioning.
Principal witnesses and eyewitnesses are identified and interviewed as soon as possible. Principal witnesses are persons who were actually involved in the accident; eyewitnesses are persons who directly observed the accident or the conditions immediately preceding or following the accident. General witnesses are those with knowledge about the activities taking place prior to or immediately after the accident (the previous watch, for example). Prompt arrival on scene by team members and expeditious interviewing of witnesses helps ensure that witness statements are as accurate, detailed, and authentic as possible. Table 6-1 lists sources that investigators can use to locate witnesses.
Witness testimony is an important element in determining facts that reveal causal factors. It is best to interview principal witnesses and eyewitnesses first, because they often provide the most useful details regarding what happened. If not questioned promptly, they may forget important details. 17
Preparing for Interviews
Much of the investigation’s fact-finding occurs in interviews. Therefore, to elicit the most useful information possible from interviewees, interviewers must be well prepared and have clear objectives for each interview. Interviews can be conducted after the team has established the topical areas to be covered in the interviews and after the lead investigator has reviewed with the board the objectives of the interviews and strategies for obtaining useful information. Table 6-2 provides guidelines for interview People’s memories, as well as their willingness to assist an investigative board, can be affected by the way they are questioned. Based on the availability of witnesses, team members’ time, and the nature and complexity of the accident, the lead investigator and team members must determine who to interview, in what order, and what interviewing techniques to employ. Some methods that previous accident investigation boards have found successful are described below. TIP A witness interview is not an interrogation. Investigators should convey the sense of a cooperative, informal meeting.
Individual Versus Group Interviews.
Depending on the specific circumstances and schedule of an accident investigation, investigators may choose to hold either individual or group interviews. Generally, principal witnesses and eyewitnesses are interviewed individually to gain independent accounts of the event. However, a group, interview may be beneficial in situations where a work crew was either involved in or witness to the accident. Moreover, time may not permit interviewing every witness individually, and the potential for gaining new information from every witness may be small. Sometimes, group interviews can corroborate testimony given by an individual, but not provide additional details. The team should use their collective judgment to determine which technique is appropriate. Advantages and disadvantages of both techniques are listed in Table 4-3. These considerations should be weighed against the circumstances of the accident when determining which technique to use.
Table 4-3 Group and individual interviews have different advantages. Individual Interviews Advantages
Obtain independent stories Obtain individual perceptions Establish one-to-one rapport More time-consuming May be more difficult to schedule all witnesses
More time-efficient All interviewees supplement story; may get more complete picture Other People serve as “memory joggers” Interviewees will not have independent stories More vocal members of the g4roup will say more and thus may influence those who are quieter “Group Think” may develop; some individual details may get lost Contradictions in accounts may not be revealed.
Interviewing: Do’s and Don’ts. Table 4-4 lists actions that promote effective interviews, and Table 6-5 lists actions to avoid while conducting interviews.
Table 4-4. Interviewing Do’s.
Create a Relaxed Atmosphere
Introduce yourself and shake hands. Be polite, patient, and friendly. Treat witnesses with respect.
Prepare the Witness
Describe the investigation’s purpose: to prevent accidents, not to assign blame Explain that witnesses may be interviewed more than once. Stress how important the facts given during interviews are to the overall investigative process.
Rely on a court reporter to provide a detailed record of the interview. Note crucial information immediately in order to ask meaningful followup questions.
Establish a line of questioning and stay on track during the interview. Ask the witness to describe the accident in full before asking a structured set of questions. Let witnesses tell things in their own way; start the interview with a statement such as “Would you please tell me about...?” Ask several witnesses similar questions to corroborate facts. Aid the interviewee with reference points; e.g., “How did the lighting compare to the lighting in this room?” Keep an open mind; ask questions that explore what has already been stated by others
in addition to probing for missing information. Use visual aids, such as photos, drawings, maps, and graphs to assist witnesses. Be an active listener, and give the witness feedback; restate and rephrase key points. Ask open-ended questions that generally require more than a “yes” or “no” answer. Observe and note how replies are conveyed (voice inflections, gestures, expressions, etc.).
Close the Interview
End on a positive note; thank the witness for his/her time and effort. Allow the witnesses to read the interview transcript and comment if they so desire. Encourage the witness to contact the board with additional information or concerns. Remind the witness that a follow-up interview may be conducted.
Table 4-5. Interviewing Don’ts. DO NOT rush the witness while he/she is describing the accident or answering questions. DO NOT judge, display anger, refute, threaten, intimidate, or blame the witness. DO NOT suggest answers. DO NOT make promises that cannot be kept (for example, unrestricted confidentiality). DO NOT use inflammatory words (“violate, ” “kill, ” “lie, ” “stupid, ” etc.). DO NOT omit questions during the interview because you think you already know the answer. DO NOT ask questions that suggest an answer, such as “Was the odor like rotten eggs?”
It is important to create a comfortable atmosphere in which interviewees are not a rushed to recall their observations. Interviewees should be told that they area part of the investigation effort and that their input will be used to prevent future accidents and not to assign blame. Before and after questioning, interviewees should be notified that followup interviews are a normal part of the investigation process and that further interviews do not mean that their initial statements are suspect. Also, they should be encouraged to contact the team whenever they can provide additional information or have any concerns. Interviewees should be aware of whether the information that they provide during the investigation may or may not be precluded from release to the public. Following these guidelines will help ensure that witness statements are provided freely and accurately, subsequently improving the quality and validity of the information obtained. 20
Use of an Interpreter
Preferably an interpreter will be supplied by a government approved interpretation service. However, sometimes one must hire an interpreter on scene. Local embassies or consulates and universities are good sources to inquire about interpreter availability. If necessary, contact a commercial interpreter firm and arrange for an interpreter to travel to the scene. This is costly but, without adequate interpreter services, the investigation cannot be properly conducted. When using an interpreter in interviewing it is important that the interpreter be fluent in the language and dialect spoken by the witness. The interpreter must also have a proper command of the language of the investigator. The interpreter must be able to grasp technical marine terms, and it may be necessary to arrange a prior meeting and/or have a list of common nautical terms available so that the interpreter has time to research the appropriate translation. The interpreter must be able to pass to the witness the information, as well as reflect the attitude and manner of expression you wish to convey. Further, the interpreter must be able to recognize any idiosyncrasies in the answers a witness may give and bring them to your attention, along with the reply. The witness should generally be seated in a chair opposite you with the interpreter in between but slightly to one side, so that the interpreter may conveniently face either the investigator or the witness as the conversation flows. Questions should be directly to the witness using the first person. The questioner should not refer to the witness in the third person, or ask the interpreter to "ask him" or "tell him" anything. Further, attempt to keep questions short. However, should it be necessary to pose a lengthy question, instruct the interpreter to translate the question in “bite size” pieces. In such instances, explain to the interpreter that you will pause occasionally to allow the interpreter an opportunity to translate incremental portions of the question. An interpreter should: 1.) 2) 3) 4) 5) merely act as a vehicle for accurately interpreting and passing information back and forth between you and the witness. imitate your voice inflection and gestures as much as possible. not carry on a conversation with the witness, other than directed by you. pass on faithfully everything the witness said, including trivial remarks and exclamations. not evaluate the conversation him or her self.
Using an interpreter complicates an interview and can often more than double the time it take to complete the interview. Such interviews can be successful if they are well planned and
controlled. At the conclusion of an interview, when the witness has left, it may be worthwhile asking the interpreters assessment of the witness.
Evaluating the Witness’s State of Mind
Occasionally, a witness’s state of mind may affect the accuracy or validity of testimony Provided. In conducting witness interviews, investigators should consider: The amount of time between the accident and the interview. People normally forget 50 to 80 percent of the details in just 24 hours. Contact between this witness and others who may have influenced how this witness recalls the events. Signs of stress, shock, amnesia, or other trauma resulting from the accident. Details of unpleasant experiences are frequently blanked from one’s memory. Investigators should note whether an interviewee displays any apparent mental or physical distress or unusual behavior; it may have a bearing on the interview results. These observations can be discussed and their impact assessed with other members of the team. Investigators should also be aware of cultural differences that may be expected and the sub-cultures that may be on board a ship, particularly those with multi-national crewing. Issues of status and loss of face may be encountered from time to time. There may be a tendency for an interviewee to provide answers that he/she thinks the interviewer wants to hear, or a tendency to agree, just out of politeness. In other cases, the use of English or other common language may have different meanings or inferences. Under any of these circumstances an interpreter may prove really useful.
Collecting Physical Evidence
TIP To ensure consistent documentation, control, and security, it may be useful to designate a single team member or the administrative coordinator to be in charge of handling evidence. The investigative team proceeds in gathering, cataloging, and storing physical evidence from all sources as soon as it becomes available. The procedures for access to, and the controlling of, evidence maybe subject to National Legal requirements which vary from country to country. The most obvious physical evidence related to an accident or accident scene often includes solids such as: Equipment Tools Materials Hardware Pre- and post-accident positions of accident-related elements Scattered debris Patterns, parts, and properties of physical items associated with the accident. Less obvious but potentially important physical evidence includes fluids (liquids and gases). Ships use a multitude of fluids, including chemicals, fuels, hydraulic control or actuating fluids, and lubricants. Analyzing such evidence can reveal much about the operability of equipment and other potentially relevant conditions or causal factors. Care should be taken if there is pathogenic contamination of physical evidence (e.g., blood); such material may require autoclaving or other sterilization. Specialized technicians experienced in fluid sampling should be employed to help the team collect and analyze fluid evidence. If required, expert analysts should be requested to perform tests on the fluids and report results to the team.
High speed vessel collisions or accidents involving explosions by result in an accident scene that is contaminated with human blood, body fluids or tissue remains. Upon entering such a scene, the investigative team must take proper precautions to protect itself from exposure to bloodborne pathogens. When handling potential bloodborne pathogens, universal precautions such as those listed in Appendix I, Chapter 5 should be observed to minimize potential exposure. All human blood and body fluids should be treated as if they are infectious. The precautions listed should be implemented for all potential exposures. Exposure is defined as reasonable anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials. Physical evidence should be systematically collected, protected, preserved, evaluated, and recorded to ultimately determine how and why failures occurred and whether use, abuse, misuse, or nonuse was a causal factor.
Documenting Physical Evidence
Evidence should be carefully documented at the time it is obtained or identified. The Accident Investigation Physical Evidence Log can help investigators document and track the collection of physical evidence. In a multi-investigator team investigation, the use of an evidence log will prevent several investigators asking for the same piece of evidence, thereby avoiding duplication of effort. Additional means of documenting physical evidence include sketches, maps, photographs, and videotape.
Sketching and Mapping
Sketching and mapping the position of debris, equipment, tools, and injured persons may be initiated by the team as soon as it arrives on scene. Position maps convey a visual representation of the scene immediately after an accident. Evidence may be inadvertently moved, removed, or destroyed, especially if the accident scene can only be partially secured. Therefore, sketching and mapping should be conducted immediately after recording initial witness statements. Precise scale plottings of the position of elements can subsequently be examined to develop and test accident causal theories.
Photographing and Videotaping Physical Evidence
Photography is a valuable and versatile tool in accident investigation. Photos or videos can identify, record, or preserve physical accident evidence that cannot be effectively conveyed by words or collected by any other means. Photographic coverage should be detailed and complete, including standard references to help establish distance and perspective. Videotapes should cover the overall accident scene, as well as specific locations or items of significance. A thorough videotape allows the team to minimize trips to the accident scene. This may be important if the scene is difficult to access or if it presents hazards.
Good photographic coverage of the accident is essential, even if photographs or video stills will not be used in the investigation report. However, if not taken properly, photographs and videos can easily misrepresent a scene and lead to false conclusions or findings about an accident. Therefore, whenever possible, accident photography and videotaping should be performed by professionals. Photographic techniques that avoid misrepresentation, such as the inclusion of rulers and particular lighting, may be unknown to amateurs but are common knowledge among professional photographers and videographers. Even if photos are taken by a skilled photographer, the investigation team should be prepared to direct the photographer in capturing certain important perspectives or parts of the accident scene. Photographs of evidence and of the scene itself should be taken from many angles to illustrate the perspectives of witnesses and injured persons. In addition, team members may wish to take photos for their own reference, If available, digital photography will facilitate incorporation of the photographs into the investigation report. However, if this is not practical, high-quality 35mm photographs can be scanned for incorporation in the report. As photos are taken, a log should be completed noting the scene/subject, date, time, direction, and orientation of photos taken, as well as the photographer’s name and camera settings.
Inspecting Physical Evidence
Following initial mapping and photographic recording, a systematic inspection of physical evidence can begin. The inspection involves: Surveying the involved equipment, vehicles, structures, etc., to ascertain whether there is any indication that component parts were missing or out of place before the accident Noting the absence of any parts of guards, controls, or operating indicators (instruments, position indicators, etc.) among the damaged or remaining parts at the scene Identifying as soon as possible any equipment or parts that must be cleaned prior to examination or testing and transferring them to a laboratory or to the care of an expert experienced in appropriate testing methodologies Noting the routing or movements of records that can later be traced to find missing components Preparing a checklist of complex equipment components to help ensure a thorough survey. These observations should be recorded in notes and photographs so that investigators avoid relying on their memories. Some investigators find a small cassette tape recorder 25
useful in recording general descriptions of appearance and damage; however, the potential failure of a recorder, inadvertent tape erasure, and limitations of verbal description suggest that verbal recorded descriptions should be used in combination with notes, sketches, and photographs. Removing Physical Evidence Following the initial inspection of the scene, investigators may need to remove items of physical evidence. To ensure the integrity of evidence for later examination, the extraction of parts must be controlled and methodical. The process may involve simply picking up components or pieces of damaged equipment, removing bolts and fittings, cutting through major structures, or even recovering evidence from beneath piles of debris. Before evidence is removed from the accident scene, it should be photographed and its position noted on an appropriate sketch of the scene. Remember, once it has been moved, it will never be able to be returned to exactly the same position that it occupied before it was moved. It should then be carefully packaged and clearly identified. The readiness team or a pre-assembled investigator’s kit can provide general-purpose cardboard tags or adhesive labels for this purpose. Equipment or parts thought to be defective, damaged, or improperly assembled should be removed from the accident scene for technical examination, If improper assembly is suspected, investigators should direct that the part or equipment be photographed and otherwise documented as each subassembly is removed. Items that have been fractured or otherwise damaged should be packaged carefully to preserve surface detail. Delicate parts should be padded and boxed. Both the part and the outside of the package should be labeled. Greasy or dirty parts can be wrapped in foil and placed in polyethylene bags or other nonabsorbent materials for transport to a testing laboratory, command center, or evidence storage facility. If uncertainties arise, subject matter experts can advise the board regarding effective methods for preserving and packaging evidence and specimens that must be transported for testing. When preparing to remove physical evidence, these guidelines should be followed: Normally, extraction should not start until witnesses have been interviewed, since visual reference to the accident site can stimulate one’s memory Extraction and removal or movement of parts should not be started until position records (measurements for maps and photographs) have been made Be aware that the accident site maybe unsafe due to dangerous materials or weakened structures Locations of removed parts can be marked with orange spray paint or wirestaffed marking flags; the marking flags can be annotated to identify the part removed and to allow later measurement
Care during extraction and preliminary examination is necessary to avoid defacing or distorting impact marks and fracture surfaces The lead investigator and team members should concur when the parts extraction work can begin, in order to assure that board members have completed all observations requiring an intact accident site.
Collecting Documentary Evidence
Documentary evidence can provide important data and should be preserved and secured as methodically as physical evidence. This information might be in the form of logbooks, equipment readouts, course recorder traces, licenses, documents, certificates, papers, photos, videotape, magnetic tape, or electronic media, either at the site or in files at other locations. Some work/process/system records are retained only for the workday or the week. Electronic data is often stored in a memory buffer and is overwritten as new data is acquired. Once an accident has occurred, the investigator must work quickly to collect and preserve these records so they can be examined and considered in the analysis. In some cases it may be necessary to obtain the services of a suitably competent translator. Accident investigation preplanning should include procedures for identifying records to be collected, as well as the people responsible for their collection. Because records are not always located at the scene of the accident, and some documents may be overlooked in the preliminary collection of evidence. Documents often provide important evidence for identifying causal factors of an accident. This evidence is useful for: Thoroughly examining the policies, standards, and specifications that molded the environment in which the accident occurred Indicating the attitudes and actions of people involved in the accident Revealing evidence that generally is not established in verbal testimony. Documentary evidence generally can be grouped into four categories: Management control documents that communicate management expectations of how, when, where, and by whom work activities are to be performed Records that indicate past and present performance and status of the work activities, as well as the people, equipment, and materials involved
Reports that identify the content and results of special studies, analyses, audits, appraisals, inspections, inquiries, and investigations related to work activities Follow-on documentation that describes actions taken in response to the other types of documentation. Collectively, this evidence gives important clues to possible underlying causes of errors, malfunctions, and failures that led to the accident. Analysis of documents may involve two major aspects, cross checking documents from different sources that contain the same information or scientific analysis. Analysis could include cross checking the bridge movement or "bell" book with the engine room records. It cannot be emphasized enough that contemporaneous records, those made at the time, are of value, fair copies of log books, e.g. the scrap log copied out in a fair hand are of limited value. Of greater value is the cross checking of ship's records with external sources such as VTS tapes, harbor control tapes or log books, cargo terminal records, police records, customs records, or even TV or radio recordings. Investigators must keep an open mind and think latterly asking "who else may have similar information". Photocopies. Investigators should be sensitive to the possibility that photocopies of documents may not truly depict the original document. Erasures and/or the use of “white out” correction liquids, which may be apparent on the original document, may not show up on a photocopy of the document. Further, as in the case of logbooks, entire pages may be removed. If the investigator does not examine the original document, he will not know for sure that the photocopy provided him is, in fact, a true and accurate copy. Before photocopies of documents are accepted, the investigator should compare the copy with the original to assure that there have been no alterations to the original. Marine Documents. A list of maritime documentation that may be collected or reviewed during a marine accident investigation can be found on Appendix II of Chapter 5. The list while lengthy, is far from complete. The specific documents needed by the investigator will vary depending on the type of accident.
International Safety Management System
Accident investigations must thoroughly examine organizational concerns, management systems, and line management oversight processes to determine whether deficiencies in these areas contributed to causes of the accident. The investigation team should consider the full range of management systems through all levels of management in accordance with the International Safety Management (ISM) Code. It is important to note that this focus should not be directed toward individuals.
The ISM Code documentation should be inspected as a matter of routine. It is important to ensure that the procedures in the code are adhered to. The ship operator’s “Documentation of Compliance” is valid for 5 years, subject to annual verification. The ship’s “Safety Management Certificate” is valid for 5 years subject to periodical verification by the administration. All aspects of the code are important to an investigator and include but are not confined to the following. ◊ ◊ ◊ ◊ ◊ ◊ ◊ ◊ ◊ ◊ ◊ Training (ISM Code 6.3) Passage planning and procedures with pilot embarked (ISM Code ?) Information and language of ISM Code.(ISM Code 6.6) Plans, instructions, check lists for the safety of the ship and pollution prevention.(ISM Code 7.0) Emergency preparedness (ISM Code 8.0) Reporting non-conforming incidents (ISM Code 9.1) Corrective Action (9.2) Maintenance (ISM Code 10.1) Critical equipment (ISM Code 10.3) Documentation (ISM Code 10.1) Record of internal audits (ISM Code 12.3)
If there was a departure from the code it is important to identify the non-conformity to establish whether the departure was consistent with reasonable decision making (see Course 1.3.4). Depending upon the incident it may also be necessary to check the ship’s reporting of “non-conforming incidents”(ISM Code 9.1) and the management receipt of such records and subsequent action, which may include a record of corrective action (ISM Code 9.3).
Preserving and Controlling Evidence
Preserving and controlling evidence are essential to the integrity and credibility of the investigation. Security and custody of evidence are necessary to prevent its alteration or loss and to establish the accuracy and validity of all evidence collected. The point of contact is responsible for assuring that a chain of custody is established for all evidence removed from the accident scene before the board arrives. The board chairperson is responsible for establishing an evidentiary custody protocol to ensure that all evidence is well documented at the accident scene and carefully controlled when it is removed and stored after the board arrives. Evidence control procedures similar to the following guidelines will help assure that evidence is not adulterated, corrupted, or lost and that subsequent engineering tests, if conducted, and other analytical results are valid.
Evidence should be photographed and/or videotaped in its original location immediately following the accident, provided it does not interfere with rescue or amelioration activities. A log should be maintained stating the location, date, and time that photos and videos are taken. The Accident investigation Photographic Lag Sheet can be used for this purpose. Avoid using photographic attachments that digitally record the date and time on the negative because these images become a permanent part of the photo and may obscure evidence or important details in the photo or video. The computerized/printed date on the back of photos provided by film processors should be used in conjunction with, not in lieu of, a photo log, because the date on photos gives the day the film was processed, not the day the photos were taken. Board members should prepare and sign an inventory of all evidentiary items collected, including statements regarding: Lists of items removed from the scene Date and time items were removed from the scene Person who removed items from the scene Location where those items will be stored. Evidence should be controlled by signature transfer (signatures of the recipient and the person relinquishing custody) and made available only to those who need to examine and use the evidence during the accident investigation. The Accident Investigation Physical Evidence Log Form may be used for this purpose. Secure storage should be obtained immediately, and access to evidence controlled throughout the investigation. Access to the room or suite of offices used by the investigation board should be restricted. No one other than board members, advisors, and support staff should have access to the board’s office space; this includes janitorial staff. The board chairperson should determine the disposition of evidence at the conclusion of the investigation. Documentary evidence can easily be over-looked, misplaced, or taken. Documents can be altered, disfigured, misinterpreted, or electronically corrupted. Computer software and disks can be erased by exposure to magnetic fields. As with other evidence collected during the investigation, documentary evidence should be collected, inventoried (logged), controlled, and secured (in locked containers, if necessary.)
APPENDIX I - Chapter 5 Universal Precautions to Prevent Contact with Bloodborne Pathogens
On December 6, 1991, the U.S. Occupational Safety and Health Administration (OSHA) issued the regulation called “Occupational Exposure to Bloodborne Pathogens (BBP)," found in Title 29, Section 1910.1030 of the Code of Federal Regulations. The standard covers those occupations having a high potential for exposure to bloodborne pathogens, including law enforcement, emergency response, and accident investigation personnel. Individuals covered by this standard should observe Universal Precautions to prevent contact with human blood, body fluids, tissues and other potentially infectious materials. Universal Precautions require that employees treat all human blood, body fluids, or other potentially infectious materials to be infectious for hepatitis B virus (HBV), human immunodeficiency virus (HIV), and other bloodborne pathogens. Appropriate protective measures to be taken to avoid direct contact with these materials include: Use barrier protection at all times. Prohibit eating, drinking, smoking, or applying makeup at the accident scene/mass disaster. Use gloves when there may be hand contact with blood or other potentially infectious materials. Gloves should always be worn as if there are cuts, scratches, or other breaks in the skin. In some instances where there is heavily contaminated material, the use of double gloves is advisable for additional protection. Change gloves when contaminated or as soon as feasible if torn, punctured, or when their ability to function as a barrier is compromised. Always wash hands after removal of gloves or other personal protective equipment (PPE). The removal of gloves and other PPE should be performed in a manner which will not result in the contamination of unprotected skin or clothing. Wear safety goggles, protective facemasks or shields, or glasses with side shields to protect from splashes, sprays, spatters, or droplets of blood or other potentially infectious materials. These same precautions must be taken when collecting dried stains for laboratory analyses. Use disposable items, such as gloves, coveralls, shoe covers, etc., when potentially infectious materials are present. Place contaminated sharps (e.g. broken glass, needles, knives, etc.,) in appropriate leakproof, close-able, puncture-resistant containers when these sharps are to be discarded, transported, or shipped. If transported or shipped, containers should be appropriately labeled. DO not bend, recap, remove, or otherwise handle contaminated needles or other sharps. Use a protective device, such as a CPR mask, when performing mouth-to-mouth resuscitation. Decontaminate all equipment after use with a solution of household bleach (diluted 1:10), 70% isopropyl alcohol, or other appropriate disinfectants. After all evidence has been collected and the crime scene has been released, the owner or occupants of the affected property should be made aware of the potential risks from bloodborne pathogens. Evidence containing blood or other body fluids should be completely dried before it is packaged and shipped to the laboratory for analysis. Appropriate biohazard warning labels must be affixed to the evidence container indicating that a potentially infectious material may be present.
APPENDIX II - Chapter 5 A. Plans, Diagrams and Lists 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. B. General arrangement plans General arrangement of engineroom machinery (elevation & plan views) Shell expansion plans Capacity plan Main engine control system plans and description Main engine fuel oil supply and return pumping/piping and tanks plans Fuel oil service and transfer pumping/piping system plans and description Fuel oil tank venting piping plan Engineroom ventilation system plans Passenger and crew ventilation system plans General loading plans and procedures Ullages and ullage tables Bilge pumping and piping diagram and system description Cargo pumping & piping plans and system description Cargo tanks venting piping plans IGS plans and system description Ballast pumping & piping plans and description Ballast tanks venting piping plans Ballast tank coatings Damage control plan (fire doors dampers, etc) Fire detection plans and system description Firemain piping & pumping system and description CO piping system diagram and system description Foam piping system diagram and description Halon system diagram and description One line electrical distribution diagram List of bridge/radio room communication equipment List of vessel navigation equipment
Statutory and Other Certificates 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Gross tonnage/deadweight tonnage Copy of the U.S. Certificate of Inspection (U.S. vessel only) Copy of Cargo Ship Safety Construction Certificate Copy of Cargo Ship Safety Radio Certificate Copy of Cargo Ship Safety Equipment Certificate Copy of MODU Certificate Copy of Passenger Ship Safety Certificate Copy of International Load Line Certificate Copy of International Oil Pollution Prevention Certificate Copy of Certificate of Class for Hull and Machinery Copy of Vessel Radio Communication License
12. 13. 14. 15. 16. 17.
Minimum Safe Manning Certificate Ship’s Certificate of Registry Copy of Control Verification Certificate Copy of Certificate for fire extinguishing system inspection International Safety Management System (ISM) Documentation Copies of Officers' licenses and STCW Certificates ratings STCW certificates
Charts, Log Books and Other Records 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. Chart of area of casualty Bunkering records Crew list with addresses Name and addresses of previous master, chief mate, and chief engineer Passenger list with addresses Passenger boarding passes Cabin assignments for passengers and crew Terminal generated checklist and cargo loading/discharge data sheets Vessel generated checklist and cargo loading/discharge data sheets Liquid cargo data sheets Analysis of cargo samples Deck log (smooth and rough) Cargo control room log (smooth and rough) Engine log (smooth and rough) Radio log (smooth and rough) Boiler/main engine maintenance log Original of course recorder printout at time of casualty List of certificated lifeboatman On-board crew conducted repair and maintenance records for one year prior to accident On-board repairs conducted by shore side company or personnel Vessel repair/spare parts requisitions to company Copy of last shipyard repair/survey specifications Classification survey reports (annual and special and damage surveys) Copy of the bridge record card Port State and Flag State inspection reports (annual & drydocking) Independent survey reports by insurance, towing, and/or fire/explosion specialist. Copy of Control Verification Examination Booklet Passenger and crew medical log (ship's doctor/purser) Shore Fire Department response records Dangerous Stores Manifest Trim and Stability Booklet
Operating Procedures and Manuals 1. 2. Oil transfer procedures for cargo and bunkers (fuel) From the vessel's operation manuals: main and emergency electrical power system description, engineroom control system, mooring gear on deck, cargo pumping and piping system description, ballast pumping and piping system description, steering and control system, boiler automation control system List of safety manuals maintained on vessel Company and vessel procedures for tank opening and entry Oxygen Analyzing equipment specifications (model & type) and operating manual Combustible gas analyzer (model & type) and operating manual Description of the vessel's planned maintenance system Lifeboat and liferaft launching plan Vessel Evacuation Plan Copy of posted firefighting procedures for engine room and other spaces Specific company orders to masters/chief engineers Standing orders of ship master/chief mate/chief engineer. Company training records for officers and crew Company training and safety manuals Station Bill Company/vessel firefighting procedures SAR data, including communication tapes from RCCs involved Operating manual including stability control (MODU)
3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. E.
Miscellaneous 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 8x10 pre-accident color photo of vessel (profile view) General vessel characteristics Bunker analysis from terminal and samples on vessel and at terminal Fuel oil heating in tanks and through engineroom heaters Type of tank gauging system Previous accidents to this vessel, sister vessels, type and class Loading Plan for last cargo(s) Cargo regulations Type of blowers (fans) used to vent tanks Description of all temporary and permanent post-casualty repairs List of the quantity and location of steel plating and internals (including piping) removed post-casualty prior to drydocking and at drydocking Copy of next shipyard repair/survey specifications Company organization chart
This chapter is intended as a general guide on the investigation of the human contribution to marine occurrences. An understanding of the predictable human capabilities and limitations and the application of this understanding to the investigation of occurrences can help to identify sources of safety deficiencies needing rectification, in order to prevent repetitive occurrences. In keeping with the IMO Resolution A.849(20), Code for Casualty Investigation (1997), this chapter advocates a systems approach to the investigation. The use of a systems approach will ensure that the investigation of human factors is integrated within the investigation proper. OBJECTIVE OF THE HUMAN FACTORS INVESTIGATION The objectives of the investigation of human factors in occurrences are to advance marine safety by: * * * Discovering how limitations in human performance could have caused or contributed to the occurrence. Identifying safety hazards conducive to human error or arising out of limitations in human performance. Making recommendations designed to eliminate or reduce the consequences of faulty actions or decisions made by any individual or groups involved in the occurrence.
SCOPE OF THE HUMAN FACTORS INVESTIGATION The size and scope of the investigation of human factors will depend on the circumstances of the occurrence; it can involve one investigator who is also responsible for all other aspects of the investigation, or one or more investigators dedicated solely to the investigation of human factors. Whether the investigation is large or small, the investigator(s) assigned to the investigation of human factors should adopt a team approach, taking advantage of the expertise of human factor specialists and others, who, although not physically present at the site, are available for consultation. The collection and analysis of human factors information should be as methodical and complete as any other traditional area of the investigation. The investigation should extend beyond the
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examination of the actions of front-line operators such as masters, pilots, ship=s officers, ratings, and maintainers, etc. to include an analysis of any individual or group involved in the occurrence, be it management, the regulator, or the manufacturer. In a complex, interactive and well-guarded transportation system such as the marine industry, accidents rarely originate from actions or non-actions of the front-line operators alone; accidents are a result of the combination of failures or deficiencies in organizational policy and procedures, human actions, and equipment (Cox and Tait, 1991). In almost every facet of an investigation, from management and supervisory decisions to maintenance activities and ship crew=s performance, one can identify human factors which may help to identify and explain the effects of the interaction of latent unsafe conditions on the occurrence event sequence. An investigation that focuses on only the front-line operators becomes a barrier to the identification of systemic safety hazards and the opportunity to eliminate or reduce the consequence of safety hazards. The information contained in this chapter is based upon several human factors frameworks: SHEL (Hawkins, 1987) and Reason's (1990) Accident Causation and generic error-modelling system (GEMS) frameworks, as well as Rasmussen's Taxonomy of Error (1987). These frameworks are discussed in IMO Resolution A.849(20), Code for Casualty Investigation (1997). Additional references for all frameworks are cited in Appendix B. GATHERING HUMAN FACTORS INFORMATION The success of the investigation of human factors depends largely on the type and quality of the information collected. As no two occurrences are the same, the investigator will need to determine the type and quality of data to be collected and reviewed. As a rule, the investigator should be over-inclusive in gathering information initially and set aside superfluous data as the investigation unfolds. SOURCES OF HUMAN FACTORS INFORMATION Information relevant to an marine occurrence can be acquired from a variety of sources. Primary sources relating specifically to human factors include hardware evidence, paper documentation, voyage recorders, Marine Communications and Traffic Services recordings, interviews, direct observation of marine personnel activities and simulations. Secondary sources include marine occurrence data bases, reference literature and human factors/ergonomics professionals and those from associated disciplines such as psychologists, medical practitioners, and sociologists. Some common primary sources of human factors information are presented in the body of this chapter. DATA COLLECTION USING THE SHEL MODEL
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The SHEL Model was originally developed by Edwards (1972) and modified by Hawkins (1984, 1987). It has been found to be a useful means of defining information requirements during an occurrence investigation. Once the information requirements are identified, the investigator can gather the facts from appropriate sources. There are four components to the model: Liveware - L Hardware - H Software - S Environment - E The SHEL Model is commonly depicted graphically (see Figure 6.1)1 to display, not only the four components, but also the relationships, or interfaces, between the Liveware and all the other components. Figure 9.1 attempts to portray the fact that the match or mismatch of the interfaces is just as important as the characteristics of the blocks themselves. A mismatch can be a source of human error and identification of a mismatch may be the identification of a safety deficiency in the system. Liveware (Central Component) The most valuable and flexible component in the system is the human element, the Liveware, placed at the centre of the model. Each person brings his or her own capabilities and limitations, be they physical, physiological, psychological, or psychosocial. This component can be applied to any person involved with the operation or in support of the operation. The person under consideration interacts directly with each one of the four other elements. The person and each interaction, or interface, constitute potential areas of human performance investigation. Liveware (Peripheral) The peripheral Liveware refers to the system's human-human interactions, including such factors as management, supervision, crew interactions and communications. Hardware Hardware refers to the equipment part of a transportation system. It includes the design of workstations, displays, controls, seats, and all other physical parts of a vessel or system.
From Hawkins, F.H. Human Factors in Flight. 1987.
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Software Software is the non-physical part of the system including organizational policies, procedures, manuals, checklist layout, charts, maps, advisories, and increasingly, computer programs. Environment Environment includes the internal and external climate, temperature, visibility, vibration, noise and other factors which constitute the conditions within which people are working. Sometimes the broad political and economic constraints under which the marine system operates are included in this element. The regulatory climate is a part of the environment in as much as its climate affects communications, decision making, control, and coordination. DATA GATHERING GUIDELINES The investigation of human factors attempts to determine what people did and why they did it. The investigator concentrates effort on the behaviour of the people involved. Key events or actions are highlighted, and often these key actions will be unsafe acts. It may be tempting to stop when these unsafe acts are identified, but safety is not well served by doing so. As noted by Chapanis (1965), when causes of accidents are attributed to carelessness, faulty attitude, inattention, or some other such label, little is achieved in preventing recurrence. Safety can be better served by explaining the behaviour behind the label. To this end, the following guidelines are structured to help investigators determine whether a factor, such as attention, was an antecedent to an occurrence, by providing the possible effects of the factor on performance. Following the performance effects for each factor is a listing of the type of information to consider gathering during the data collection phase to corroborate the factor's existence and effect. Primary sources for this information are also provided. Some of the information to be considered for corroboration will be self-evident to the investigator; the relevance of other information may be found in standard texts (such as those found in the bibliography); still other information may require consultation with a human factors specialist to determine that information's significance on performance. It should be noted that the listing of factors for consideration is not definitive. For ease of use, the guidelines are structured to reflect the components of the SHEL Model, beginning with the central component, the Liveware, followed by the SHEL interfaces. The Liveware (Central Component) This area is concerned with the physical, physiological, psychological, and psychosocial factors unique to the central component, the individual. Liveware Physical Factors
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This area deals with the physical capability of the individual to perform required actions and movements; physical limitations influence the ability to see, to act, to move, to reach, and to grab. Consider such factors as age, sex, strength, weight, sitting height, reach, etc. Information related to physical factors may be obtained through medical records INFORMATION SOURCES and interviews with the individual concerned, or in the event of a fatality through interviewing a personal physician, a spouse, or family members and/or through the post-mortem examination. Liveware Physiological Factors This area is concerned with the physiological condition of the individual, including stable and transitory states such as disease, fatigue, stress or other internal factors which could affect the individual's situational awareness and/or behaviour. Discussion of several physiological factors which can affect performance follows. Nutritional Factors can potentially affect an individual's ability to respond to action, concentrate on a task, or resist fatigue. Consider factors such as time since last meal, food intake in last 24 hours, recent weight loss, recent dietary habits, etc. Health can have an effect on the individual's ability to perform. Health problems can lower performance, reduce motivation, lead to distraction. Consider such factors as the effects of diseases, pains, dental conditions; pregnancy; obesity; recent blood donation, etc. Stress can have an impact on health, resulting in sleep disorders, gastrointestinal problems, headaches etc.; on behaviour, causing restlessness, impulsive behaviour, etc.; on cognitive processes, making it more difficult to concentrate on a task, to perceive cues, to determine priorities, etc.; on feelings, making one anxious, aggressive, moody, etc. Consider stressors such as environmental stressors, domestic stress, bereavement, financial and time commitments, work stress, relationships with colleagues and management, etc. Information related to nutrition, health and stress are normally obtained through INFORMATION SOURCES medical records and interviews with a personal physician, a spouse, family members. Colleagues and supervisors may provide additional information. Fatigue chronic or acute fatigue can have an impact on memory, consistency in performance, motivation, concentration, information processing and decision-making, cooperativeness,
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communication skills, mood, reaction time, error rates, risk-taking, etc. Consider such factors as time on duty, shift schedule, workload demands, time zone shifts, previous schedules, layover schedule, travel time to and from work, and other operational demands such as those found in pilotage or cargo loading and off-loading. Also consider time of rest, hours of rest, quality of rest, off-duty activities, stress, and sleep disorders. Information related to fatigue is normally obtained through a 72-hour history INFORMATION SOURCES taken during interviews (The 72-hour period is the minimum recommended sleep history period and in some cases a longer period is preferable). If necessary, it can also be reconstructed through examination of personal logbooks, company duty rosters, examination of the sleep location, and interviews with anyone who may have come in contact with the individual in the last 72-hour period such as a spouse, family members, colleagues, and supervisors. Additional data may be obtained from hotel records of telephone calls and room key card entry/exit data. Alcohol affects the ability to discriminate and perceive visual and auditory stimuli; it has an impact on memory, decision-making processes, judgement, coordination; it slows reaction times and increases risk-taking. Consider such factors as time since last drink, alcohol consumption rate and amount, body weight, consumption of food, type of drink, blood/alcohol concentration, hangover effects, evidence of alcohol addiction; i.e., medical records, drinking and driving violations, etc. Consider also stress, fatigue, sleep and biological rhythm disturbance, and circadian effect. Drugs can cause drowsiness and dizziness; they can affect mood and coordination; they can reduce mental functions and sensory perceptions. Consider over-the-counter medication, prescriptions, illicit drugs, and other stimulants such as coffee, cigarettes, etc. Factors such as fatigue, stress, sleep and biological rhythm disturbance, circadian effect might be antecedent conditions to the use of drugs. Partial Incapacitation can be hard to detect and can result in a wide-range of symptoms such as dizziness, loss of consciousness, decrease in judgement and decision-making processes. Consider such factors as carbon monoxide or food poisoning, medical conditions, fumes, motion sickness, hypoglycaemia, fatigue, stress, sleep and biological rhythm disturbance or medication. INFORMATION SOURCES
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Factors related to alcohol, drugs and incapacitation can be investigated through interviews with a spouse, family members, neighbours, friends, colleagues, supervisors, and a family or personal physician. Additional information can be obtained from toxicological analysis, medical records, motor vehicle records, law enforcement records and, in the case of a fatality, the post-mortem examination and personal effects. Sensory Limitations include visual, auditory, olfactory, kinaesthetic limitations. Consider such factors as visual acuity requirements, focus time, light adaptation, depth perception and external cues, requirement for glasses or contact lenses; auditory threshold and range, etc. Factors related to sensory limitations can be investigated through interviews with INFORMATION SOURCES the individual, a spouse, family members, or a family or personal physician. Documentary information can be obtained from medical records and employer records. Illusions occur when an individual's mental model differs from the real world. There are three sensory systems that contribute to the perception of orientation: the kinaesthetic sensors, vision, and the vestibular organs in the inner ear. Illusions of orientation can be brought on by misinterpretation of visual information, by limited peripheral vision, and by the sensitivity of the vestibular organs to linear and angular acceleration. Consider such factors as expectancy and experience, anthropometric considerations, instrument monitoring and actions, environmental conditions at the time of the occurrence, geographical peculiarities of the location. Factors related to illusions can be investigated through interviews with the INFORMATION SOURCES individual and other crew members. Information relating to the environment can be obtained from sources such as weather reports and charts. Liveware Psychological Factors Maintaining an accurate mental model, that is, maintaining situational awareness, is paramount to ensuring safe voyage. Situational awareness develops on three different levels. First the person must perceive the situational elements from information displays, communication, or from viewing the scene; the person then integrates the information by using his/her experience and knowledge; finally, the person projects the information into the future to make and modify plans as tasks are completed or delayed and new developments arise (Endsley, 1994). The following factors directly influence the individual's ability to process information so that accurate situational awareness is maintained.
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Information Processing The way in which humans process information can be represented by a series of stages wherein information is received, decisions are made, and responses are selected and executed. Failures can occur at any of the mental operations involved in information processing; as a result, situational awareness becomes faulty and errors are made. The stages and limitations of information processing are discussed below: Sensing The sensory receptors (e.g., eyes, ears) detect physical stimuli in the form of sounds and shapes which is stored for a brief period of time. Should the stimuli not be sensed by the sensory receptors or should the information decay before it is processed, decisions and actions will be made and carried out without all the information. Consider such factors as sensory system threshold and range, distractions, workload, expectation. Perception involves converting the sensory information into meaningful messages. Delayed perceptions and inaccurate perception (mental picture) of a task to be performed can lead to slow or wrong reaction. Consider such factors as clarity and accuracy of information received, expectation, experience, habit, workload, opportunity for visual and vestibular illusions. Decision-making follows perception. Decision-making can be appropriate or inappropriate depending upon a number of factors such as the conclusions about the meaning of the message, the type and amount of information available to the individual, previous experience, group influences, etc. Consider such factors as experience and expectation, training, distractions, workload, fatigue, stress, medication, motivation, operational pressures. Action and Feedback are the stages in the information process where decisions are translated into responses (or non-responses) and mechanisms that provide the individual with feedback are activated. Responses are in the form of actions or words or both, or execution of automatic motor programs. Feedback can be direct as in the form of tactile feedback or it may be indirect as takes place in advanced bridge layouts where crew members must monitor instruments to obtain feedback of his/her actions. Consider sources of error at this stage as those errors that originated earlier in the processing system, design-induced error, errors due to attention limitations, distractions, etc. or inadequate or inappropriate feedback.
Factors related to information processing can be investigated through interviews INFORMATION SOURCES with crew members and observation of individuals performing the involved task sequences. Examples of supporting documentary information are procedural manuals, voice recordings, human factors simulations and models.
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Attention limitations of the central decision-maker restrict the number of stimuli humans are able to attend to. Normal limitations can be further exacerbated by such factors as the operating environment, causing the individual to omit, mistime, misorder, forget, repeat or commit the wrong action. Consider such factors as sources of interruptions and distractions, designinduced errors, previous experiences, ambiguous cues, delays between planning an action and executing that action, stress, fatigue, workload, etc. Memory, both working and long term, can potentially limit the processing of information. Working memory is limited in how much information it can retain; information is maintained by a process of rehearsal. If it is not rehearsed, information will be lost in 10 to 20 seconds. Memory of events stored in long term memory is not static but is influenced by many factors, including what the individual expected should have happened. Automatic motor routines stored in long term memory can be carried out without conscious control. Errors can occur when the automatic motor routines are not monitored. Consider the number of unrelated items presented, whether the information, related or not, was chunked or clustered, whether the stimuli were verbal or visual, whether delays occurred, whether biases were induced as a result of long term memory, as well as such factors as previous experiences, training, distractions, etc. Workload can limit the processing of information. Low workload levels can induce boredom, inattention, cause slow reaction time, and lead to poor monitoring; high workload can result in missing of important cues, stress/panic, incorrect prioritization of tasks, task shedding, etc. Consider such factors as task priorities, operating procedures, equipment design, phase of voyage, crew complement, distribution of duties, crew actions that might have increased or decreased the perceived workload, actions of others, stress, fatigue, etc. Factors related to attention, memory and workload can be investigated through INFORMATION SOURCES interviews with crew members and observation of individuals performing the involved task sequences. Examples of supporting documentary information are procedural manuals, voice recordings, and human factors simulations and modeling. Attitudes of individuals toward their work, mission, others, and themselves can affect performance. Attitudes can influence quality of work, judgement, decision-making, motivation, risk taking, etc. Consider such factors as knowledge about the object of the attitude, strength of belief held about the attitude, and, if applicable, the behaviour displayed. Consider the influences of group, job demands, monetary gain, training,
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previous experiences, etc. Personality traits may predispose an individual to a certain response pattern in a given situation. Consider such factors as risk assessment, risk taking, interactive styles of personnel, experience levels, training, etc. INFORMATION SOURCES
Factors related to attitudes and personality traits can be investigated through interviews with individuals, their colleagues and their families. Documentary evidence relating to risk taking may be obtained through company records (e.g. infractions, accidents and incidents) and through external records such as motor vehicle and law enforcement records. Experience/Recency includes suitability of individual's experience, knowledge, and training for the situation. Consider the individual's overall or recent experience in the position, on the type, for the mission, on instruments, with the procedures, in the environment, etc. Knowledge on the part of the individual may be inadequate, resulting in reduced confidence, confusion, or inappropriate actions. Consider such factors as the individual's knowledge about the equipment, systems, procedures, or environment. Consider previous experiences, that is, the individual's or the influencing effects of others' experiences, training, etc. Training relates to developing skills, knowledge or attitudes. Insufficient, irrelevant and nonapplicable training can affect performance. Poor learning and reduced performance may originate in the training programme itself, in the work situation, or in social or domestic factors. Consider such factors as the type of training received, training methods used, instruction materials, quality of instruction, instructor selection and training qualifications; any indications of positive or negative transfer, weaknesses observed during training, motivation, anxiety, stress, fatigue etc. INFORMATION SOURCES
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Factors related to experience, knowledge and training can be investigated initially through interviews with crew members, supervisors, training personnel and previous employers. Supporting documentary information can be obtained from current and previous employer training records and from certification documentation. Liveware Psychosocial Factors These factors may have a role in the investigation as they influence an individual's approach to a situation. Psychosocial factors include any event or condition in the individual's social environment (friends, family, peers, money, activities, life-style, work) which are important enough to influence on-the-job behaviour. Typically, these factors are not directly causal, but they can manifest physically as in loss of sleep, in poor eating habits, in feelings of anxiety, stress, etc. Consider such factors as personal loss, interpersonal conflicts, financial problems, significant lifestyle changes, family pressure, culture differences. Psychosocial factors can be investigated through interviews with individuals, INFORMATION SOURCES spouses, family members, and personal physicians. The SHEL Interfaces The central component, the liveware or individual, does not act alone, but interacts directly with each of the other SHEL components. Data collected during the investigation should include these interactions. Liveware-Hardware Factors This area includes any physical or mental interactions between the human and the machine, design limitations and peculiarities in work-station configuration. Design of system hardware can contribute, through design-induced errors, to unsafe acts. A hazard at the liveware-machine interface can increase the likelihood of error; increase the likelihood of non-use or misuse of the equipment; increase reaction time; induce negative transfer; increase delays and costs; increase workload; cause a decrease in operator satisfaction, cause discomfort, confusion, distractions, and lead to fatigue, injuries and attrition rates. In evaluating the liveware-hardware interface, normal patterns of human behaviour should be taken into account. A sampling of these behaviours is as follows: most people cannot judge distances, clearances, or velocities very well, tending to over-estimate short distances and underestimate large distances; people expect something to operate in a certain manner; many people carry out most tasks while thinking about something else; most people perform in a mechanical manner, employing previous habit patterns (under stress they almost always revert to these habit patterns); most people are reluctant to recheck their operational or maintenance procedures for
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errors or omissions; in emergency situations people often respond irrationally and with seemingly random behaviour patterns; and people are unwilling to admit errors or mistakes of judgement or perception and thus will continue a behaviour or action originally initiated in error (Nertney and Bullock, 1976). In investigating the liveware-hardware interface, the following considerations can be evaluated: Workspace and Comfort are concerned with ensuring that human variability considerations are taken into account in the design of the workspace. Although people vary in body size and shape, there can be considerable variability in other measurements such as in physiological and psychomotor abilities, e.g., endurance and reaction time. Typically, design of a workspace, as in a bridge, will accommodate the 5th to 95th percentile range of the population. Use of anthropometric data in design is fundamental in determining whether given equipment design has appropriate clearance, reach, and visibility characteristics. Consider such factors as adequate clearance for headroom, shoulders, and lower limbs, including space for entry and exit; adequate reach, both hand and foot, for operating controls; a common eye reference point for correct positioning relative to internal and external workstation sightlines to displays, environmental conditions, other operators, etc. Physical Space and Arrangement Considerations are concerned with workplace components, such as controls, displays, manuals, etc. being located and arranged to optimize vision, reach, and clearance requirements. Consider the following four general principles for evaluating physical space and arrangement considerations: importance principle - the most important components should be placed within the primary reach envelope and field of view; the frequency of use principle - the most frequently used components are placed within the primary reach envelope and field of view (should frequency and importance conflict, importance should supersede); the functional grouping principle - related components should be grouped according to function and in accordance with importance and frequency of use principles; and the sequence of use/operation principle - after the initial three principles have been applied, components should be arranged in the order of their use and operation. Control Considerations are concerned with the transfer of information from the operator to the equipment. Consider, in addition to the physical space and arrangement considerations listed above, control considerations such as visual or tactile dissimilarity for controls located in proximity to one another; symbolism in control design, wherein the control mimics the function; prevention of inadvertent use of control by recessing, guarding, locking, or isolating the control; controldisplay compatibility wherein the display actions match the control movements; control loading wherein controls do not require undue force to
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operate; and standardization of controls in their location and sense of use. Display Considerations are concerned with the transfer of information from the equipment to the operator. Primarily, there are two types of displays: visual and auditory. Visual displays include lights, markings, scales, alphanumerics, icons, and pictorial representations. Auditory displays include horns, bells, whistles, music, and synthesized speech. Consider, in addition to physical space and arrangement considerations, display considerations such as display-control compatibility; standardization of displays; the match between the type of display and how the information the display provides is put to use by the operator; illumination of visual displays based on environmental conditions; location of displays that allows for acceptable viewing or hearing distances from the operator; viewing angle of visual displays; the size, font, resolution, contrast, etc. of alphanumeric displays. User Acceptability Considerations are concerned with those factors that contribute to the determination by the operator as to what is acceptable for use. Consider such factors as comfort, efficiency, reliability, safety, maintenance, mission, cost and aesthetics, etc. Liveware-Hardware Factors can be investigated through examination of the INFORMATION SOURCES bridge layout, workstation and equipment used by ship and shore-based personnel, vessel wreckage, similarly configured vessels, manufacturer=s data, drawings and pictures, company records and logs, maintenance and servicing equipment, marine communication and traffic services facilities and equipment, maintenance recorders, electronic components with non-volatile memory, event recordings and radar tapes, simulator training systems. Liveware-Liveware Factors This field explores the nature of human interactions and communication breakdown between individuals. Verbal Communication can lead to misunderstandings, misinterpretations, etc., when information necessary for safe and effective operations and maintenance is not sent, received, or understood by the intended recipients in a clear, unambiguous and intelligible form. Communication involves all parties involved in the operation: deck crew, engineering crew, repair crew, catering crew, shore personnel, etc. Consider such factors as language barriers, ambiguity, pronunciation, improper language usage, frequency of word use, length of words used, relevancy of words, phraseology, noise interference, noise exposure, content and rate of speech, readback/hearback, language barrier, stress, fatigue,
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workload, operational pressures, quality of communication equipment, personal hearing deficiencies, age, hearing expectations, etc. Factors related to verbal communication can be investigated through interviews INFORMATION SOURCES with crew, voice recordings (where available), examination of the capabilities and limitations of communications equipment, and through medical records (hearing acuity). Visual signals can replace, support, or contradict oral and other information, and may include body language or other "non-verbal" cues. Consider such factors as body language which can direct an action, cause confusion, stress, misunderstanding, or create negative emotions or pressures. Crew Interaction may cause individuals to work for or against each other, or fail to use all available resources. Consider such factors as crew compatibility/pairing in terms of personality, experience level and working habits, cultural differences, language differences, training, briefings, crew coordination, task assignment, age, transbridge authority gradient, group influences on decision-making, peer pressure, etc. Factors related to crew interaction can be investigated through interviews with INFORMATION SOURCES ship and shore personnel, marine communication and traffic services personnel, and through examination of employer staffing and training records. Passenger behaviour can have an impact on crew actions, attitudes, and behaviour. Consider such factors as passengers who are physically challenged, as well as passenger pressure, cooperation, intoxication, apprehension, anxiety, etc. Factors related to passenger behaviour can be investigated through interviews INFORMATION SOURCES with catering crew and interviews with and questionnaire surveys of passengers. The passenger manifest is invaluable in identifying and locating passengers. Worker-Management factors include the level where decisions and plans are formulated and resources allocated. Also included is the supervisory level where actions are monitored and instructions followed. Crew behaviour cannot be accurately assessed in isolation of the organizational climate. A discussion of the effects of the organizational climate on performance and the factors to consider follows. Organizational factors may affect human performance by causing excessive workload
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or an unhealthy work environment, etc. Consider such factors as organizational philosophy, policies, procedures and practices, compatibility of organizational goals with safety, the effect of the structure of the organization on internal communications between management and operations or maintenance. Consider the safety climate of the organization in terms of the identification and dissemination of information about known risks and their management, the provision, for personnel, of adequate detection and warning systems, commitment to ensuring an error-tolerant system. Consider personnel selection and recruitment policies, staffing policies, personnel policies, training policies, remuneration/incentive structure, scheduling policies, seniority policy, etc. Supervision factors are concerned with the practices that reflect the philosophy and policies of the organization. Deficiencies in an organization's operating philosophy and policies can lead to deficiencies in its procedures and/or practices. Consider such factors as the existence, implementation, availability, currency, completeness, and accuracy of company policies, prescribed procedures, and quality controls. Consider also accepted operating or maintenance practices which differ from prescribed procedures, the adequacy of personnel monitoring and support programmes, scheduling practices, remuneration practices, supervisory presence (or absence), supervisory style, supervisory duties, etc. Work Environment Organizational policies can set up conditions that are conducive to committing unsafe acts or making safety-related errors due to psychological as well as physical conditions in the workplace which influence individual or team performance. Consider such factors as real or perceived pressures due to operational policies, peers, management. Consider also turnover rates, company morale, compatibility of company policies and work practices, and work settings including reliable equipment, adequate lighting, etc. Associations and Unions can create conditions conducive to human error and unsafe acts. Consider the effect of union philosophies, policies, and practices on workers, management, work habits; consider also post-merger negotiations, contract negotiations, etc. INFORMATION SOURCES
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Factors related to worker-management can be investigated through interviews with crew members, supervisors, management, and union. Observation of practices can support a comparison of prescriptive procedures versus actual practices and the reason behind mismatches. Supporting documentary information can be obtained from company policy documents, procedures manuals, manning records, and accident/incident reports, as well as records detailing contracts and contract negotiations. Regulatory Requirements and Overview include both the reaction of the operating organization to regulatory requirements as well as the adequacy of the role of the regulatory organization with respect to governing transportation operations and maintenance. Consider, in so far as the operating organization is concerned, if regulatory requirements are relegated to a low importance in the organization's values or if members are encouraged to bend the rules. Consider, for the regulator, if there are deficiencies in the rules and regulations governing transportation operations and maintenance, deficiencies in the certification of equipment, personnel, and/or procedures, and deficiencies in surveillance, audit and inspection of transportation operations and maintenance. Factors related to regulatory requirements and overview can be investigated INFORMATION SOURCES through interviews personnel from regulatory agencies. Examples of supporting documentary information are regulations, certifications, and records of audits. Liveware-Software Factors This field deals with the nature of the information transfer between the human and supporting systems found in the workplace. Data requirements span such subjects as regulations, signage, manuals, checklists, publications, standard operating procedures, and computer software design. Written Information includes manuals, checklists, standing orders, or any other written documentation. Poorly designed documentation can lead to increased response time, can create confusion, can increase the risk of items being missed, can be susceptible to distractions, can be conducive to shortcuts, etc. Consider such factors as length, format, and content. Consider font type, font size, pitch, type face, character spacing, and use of colour. Consider also consistency, accuracy, availability, completeness, ordering of items, and redundancy of written information as well as timeliness of revisions. Consider appropriateness of checklist response requirements; i.e., a value vs status, especially for critical items. Consider conflict of operational time constraints and use of checklists, etc. Consider stowage of documentation on the bridge, etc. Consider knowledge and training of individuals on documentation.
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Consider mechanism for dissemination of safety critical information. Factors related to written information can be investigated through interviews INFORMATION SOURCES personnel from regulatory agencies. Examples of supporting documentary information are company standard operating procedures, standing orders, equipment operating manuals, checklists, repair work cards, technical manuals, ship safety bulletins, and regulatory documentation. Automation ideally reduces operator's workload; however, automation can affect individuals' attitudes toward their work and their mental picture of the task, sometimes by impacting workload at critical times. Missing of important information, over-reliance, mode confusion, increased reaction time, monotony and boredom, lack of knowledge to deal with failures of automatic systems, or blatant errors can be byproducts of automation. Consider rate of false alarms, loudness of auditory warnings; consider also keyboard accessibility, compatibility of keyboards and displays, physical space and arrangement characteristics of automated equipment, control and display considerations, number of modes. Consider workload, training, knowledge, skill, procedures, etc. Factors related to automation can be investigated through interviews with crew INFORMATION SOURCES members. Observation of tasks and associated equipment is an excellent means of understanding how individuals are interacting with equipment. Supporting documentary information are manufacturer technical specifications and drawings and user manuals. Regulatory Requirement issues centre on individuals' essential qualifications and certifications for the task. Consider such factors as current licences or ratings, qualifications in position and on equipment type, infraction history, medical certification, etc. Factors related to regulatory requirements can be investigated through interviews INFORMATION SOURCES with crew members and also with personnel from regulatory agencies. Examples of supporting documentary information are regulations and certification documentation. Liveware-Environment Factors This area deals with the relationship between the individual and the internal and external environment. The internal environment is that of the work area. Physical environmental factors can effect
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the liveware-hardware interface of a system either by compromising the health or safety of an operator, or by causing a failure of the structure or function of the workstation. The physical environment can have an effect on the human component by contributing to a degradation in operator performance, which in turn could lead to a hazardous situation. Consider such factors as noise, its intensity, the individual's exposure rate to noise, and its effects on the ear, on the ability to communicate, and as a cause of fatigue and stress. Consider the detrimental effects of vibration - fatigue, stress, headaches, and muscular discomfort. Consider the stressful effects of temperature that is too hot or too cold, on the body - tiredness, difficulty in concentrating and a decline in decision-making ability. Consider also ambient light and air quality. Factors related to the internal environment can be investigated initially through INFORMATION SOURCES interviews with the crew members. Supporting documentary information can be obtained from manufacturer=s records or technical specifications. If there is an indication that any environmental factors may have contributed to the occurrence, then specific measurements (e.g. noise levels or lighting)can be taken to determine the extent of the problem. The external environment includes the physical environment outside the immediate work area. This area also includes the broad political and economic constraints under which the marine system operates, which can lead to the taking of shortcuts, biased decisions, etc. Consider the effect of delays, on the operator, caused by weather, dispatch, port infrastructure. Consider the effects of geographical peculiarities of the location, harbour characteristics, lighting intensity, etc. Consider economic or regulatory pressures. For maintenance facilities, consider equipment, availability of parts, operational standards, procedures and practices, quality assurance practices, servicing and inspection practices, training, and documentation requirements.
Factors related to the external environment can be investigated initially through INFORMATION SOURCES interviews with crew members, and later with company personnel outside the immediate work area and with members of associated outside agencies. Supporting documentary information can be obtained from agencies such as Port State Control, Weather Services, Marine Communications and Traffic Services. Summary The guidelines in this chapter are focused on gathering data using the systematic approach that the SHEL model provides. The chapter has dealt primarily with understanding the effect that various factors can have on performance; in addition, the chapter has provided a listing of the
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types of information investigators need to gather to determine if any of those factors were antecedent to an occurrence. The next section of this chapter provides examples based on the process described in IMO Resolution A.849(20), Code for Casualty Investigation (1997). The process takes investigators from the data gathering phase of an investigation into the identification of unsafe acts and conditions and the latent factors that facilitated their development, and culminates in the identification of potential safety problems.
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WORKED EXAMPLES To be developed
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Chapanis, A. (1965). Man-machine engineering. Belmont, CA: Wadsworth. Cox, S.J. and Tait, N.R.S. (1991). Safety, reliability and risk management: An integrated approach. London: Butterworth-Heineman. Edwards, E (1972). Man and machine: Systems for safety. In Proceedings of the BALPA Technical Symposium, London. Endsley, M.R. (1994). Situation awareness in dynamic human decision making measurement. In R.D. Gilson, D.J. Garland, and J.M. Koonce (Eds.), Situational awareness in complex systems (pp. 27-58). Daytona Beach, FL: Embry-Riddle Aeronautical University Press. Hawkins, F.H. (1987). Human factors in flight. Aldershot, UK: Gower Technical Press. Nagel, D.C. (1988). Human error in aviation operations. In E.L. Weiner and D.C. Nagel (Eds.), Human factors in aviation (pp. 263-303). San Diego, CA: Academic Press. Norman, D.A. (1981). Categorization of action slips, Psychological Review, 88 (1), 1-15. Norman, D.A. (1988). The psychology of everyday things. New York: Basic Books. Rasmussen, J. (1987). The definition of human error and a taxonomy for technical system design. In J. Rasmussen, K. Duncan, and J. Leplat (Eds.), New technology and human error. Toronto: John Wiley & Sons. Reason, J. (1990). Human error. New York: Cambridge University Press. Nertney, R.J. and Bullock, M.G. (1976). Human factors in design (Contract No. E(10-1)-1375) Idaho: System Safety Development Centre.
Recommended Readings In addition to the cited references, the following readings are recommended:
Boff, K.R. and Lincoln, J.E. (Eds.). (1988). Engineering data compendium; Human perception and performance. Wright-Patterson Air Force Base, OH: Harry G. Armstrong Aerospace Medical Research Laboratory. Campbell, R.D. and Bagshaw, M. (1991). Human performance and limitations in aviation. Oxford, UK: BSP Professional Books. Gilson, R.D., Garland, D.J., and Koonce, J.M. (Eds.). (1994). Situational awareness in complex systems. Daytona, FL: Embry-Riddle Aeronautical University Press. Green, G.G., Muir, H., James, M., Gradwell, D., and Green, R.L. (1991). Human factors for pilots. Aldershot,UK: Gower Technical Press. Hudson, P.T.W. (1991). Prevention of accidents involving hazardous substances: The role of the human factor in plant operation. Revised discussion document originally prepared for the OECD Workshop, Tokyo, 22-26 April 1991, (pp 17-56). O'Hare, D., Wiggins, M., Batt, R. and Morrison, D. (1994). Cognitive failure analysis for aircraft accident investigation, Ergonomics, 37 (11), 1855-1869.
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O'Hare, D. and Roscoe, S. (1990). Flightdeck performance: the human factor. Ames: Iowa State University Press. Reason, J. (1991). Too little and too late: A commentary on accident and incident reporting systems. In T. van der Schaaf, D. Lucas, and A. Hale (Eds.), Near miss reporting as a safety tool. Oxford, UK: Butterworth-Heineman. Trollop, S.R. and Jensen, R.S. (1991). Human factors for general aviation. Englewood, CO: Jeppesen Sanderson. Weiner, E.L. and Nagel, D.C. (Eds.) (1988). Human factors in aviation. San Diego, CA: Academic Press.
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Analyses, Tools and Techniques
Careful and complete analysis of the data collected following an accident is critical to the accurate determination of an accident’s causal factors. The results of comprehensive analyses provide the basis for corrective and preventive measures. The analysis portion of the accident investigation is not a single, distinct part of the investigation. Instead, it is the central part of the iterative process that includes collecting facts and determining causal factors. Well chosen and carefully performed analytical methods are important for providing results that can aid investigators in developing an investigation report that has sound judgments of need. Caution must be taken in applying analytic methods. First, no single method will provide all the analyses required to completely determine the multiple causal factors of art accident. Several techniques that can complement and cross-validate one another should be used to yield optimal results. Second, analytic techniques cannot be used mechanically and without thought. The best analytic tools can become cumbersome and ineffective if they are not applied to an accident’s specific circumstances and adapted accordingly.
Immediately following any serious accident, much of the available information maybe conflicting and erroneous. The volume of data expands rapidly as witness statements are taken, emergency response actions are completed, evidence is collected, and the accident scene is observed by more individuals. The principal challenge of the investigation team is to distinguish between accurate and erroneous information in order to focus on areas that will lead to identifying the accident’s causal factors. This can be accomplished by: Understanding what activity was being performed at the time of the accident Personally conducting a walkthrough of the accident scene Challenging “facts” that are inconsistent with other evidence (e.g. physical) Corroborating facts through interviews
Testing/inspecting pertinent components to determine failure modes and physical evidence Reviewing policies, procedures, and work records to determine the level of compliance or implementation. TIP Prevention is at the heart of the entire investigation process; therefore, any accident investigation must focus on fact-finding not fault-finding. Fact-finding begins during the collection of evidence. All sources of evidence (e.g., accident site walkthroughs, witness interviews, physical evidence, policy or procedure documentation) contain facts that, when linked, create a chronological depiction of the events leading to an accident. Facts are not hypotheses, opinions, analysis, or conjecture. However, not all facts can be determined with complete certainty, and such facts are referred to as assumptions. Assumptions should be reflected as such in the investigation report and in any closeout briefings. Team members should immediately begin developing a chronology of events as facts and evidence are collected. Facts should be reviewed on an ongoing basis to ensure relevance and accuracy. Facts and evidence later determined to be irrelevant should be removed from the accident chronology but retained in the official investigation file for future consideration. Contradictory facts can be resolved in closed team meetings, recognizing that the determination of significant facts is an iterative process that evolves as gaps in information are closed and questions resolved. The team revisits the prescribed scope and depth of their investigation often during the fact-finding and analysis process. Doing so ensures that the investigation adheres to the parameters prescribed in the team’s appointment memorandum. Causal factors of an accident are identified by analyzing the facts. Judgments of need, and the subsequent corrective actions, are based on the identified causes of the accident. Therefore, the facts are the foundation of all other parts of the investigative process.
Using the Core Analytical Techniques
TIP The purpose of any analytic technique in an Accident investigation is to answer tbe question — “How did it happen?’ It is tbe job if the investigative team to apply whatever techniques can help them determine the causal factors of an accident. Accident investigation teams commonly use four techniques to analyze the factual information they have collected, to identify conditions and events that occurred before and immediately following an accident, and to determine an accident’s causal factors.
Following are descriptions of and instructions for using these four core analytic techniques: Events and causal factors charting and analysis Barrier analysis Change analysis Root cause analysis.
Events and Causal Factors Charting
Accidents rarely result from a single cause. Events and causal factors charting and analysis is useful in identifying the multiple causes and graphically depicting the triggering conditions and events necessary and sufficient for an accident to occur. For purposes of this manual events and causal factors charting and events and causal factors analysis are considered one technique. They are addressed separately because they am conducted at different stages of the investigation. Events and causal factors charting is a graphical display of the accident’s chronology and is used primarily for compiling and organizing evidence to portray the sequence of the accident’s events. It is a continuous process performed throughout the investigation. Events and causal factors analysis is the application of analysis to determine causal factors by identifying significant events and conditions that led to the accident. As the results of other analytical techniques (e.g., change analysis and barrier analysis) are completed, they are incorporated into the events and causal factors chart. After the chart is fully developed, the analysis is performed to identify causal factors. Events and causal factors charting is possibly the most widely used analytic technique because the events and causal factors chart is easy to develop and provides a clear depiction of the data. By carefully tracing the events and conditions that allowed the accident to occur, team members can pinpoint specific events and conditions that, if addressed through corrective actions, would prevent a recurrence. TIP To identify causal factors, team members must have a clear understanding of the relationships among the events and the conditions that allowed the accident to occur. Events and causal factors charting provides a graphical representation of these relationships.
The benefits of events and causal factors charting include:
Illustrating and validating the sequence of events leading to the accident and the
conditions affecting these events Showing the relationship of immediately relevant events and conditions to those that are associated but less apparent— portraying the relationships of organizations and individuals involved in the accident Directing the progression of additional data collection and analysis by identifying information gaps Linking facts and causal factors to organizational issues and management systems Validating the results of other analytic techniques Providing a structured method for collecting, organizing, and integrating collected evidence = Conveying the possibility of multiple causes Providing an ongoing method of organizing and presenting data to facilitate communication among the investigators Clearly presenting information regarding the accident that can be used to guide report writing Providing an effective visual aid that summarizes key information regarding the accident and its causes in the investigation report.
Constructing the Chart Constructing the events and causal factors chart should begin immediately. However, the initial chart will be only a skeleton of the final product. Many facts and conditions will be discovered in a short amount of time, and therefore, the chart should be updated almost daily throughout the investigative data collection phase. Keeping the chart up to date helps ensure that the investigation proceeds smoothly, that gaps in information are identified, and that the investigators have a clear representation of accident chronology for use in evidence collection and witness interviewing. Investigators and analysts can construct an events and causal factors chart using either a manual or computerized method. Accident investigation teams often use both techniques during the course of the investigation, developing the initial chart manually and then transferring the resulting data into computer programs. The manual method employs removable adhesive notes to chronologically depict events and the conditions affecting these events. The chart is generally constructed on a large conference room wall or many sheets of poster paper. Accident events and conditions are recorded on removable adhesive notes and affixed sequentially to the wall in the team’s conference room or “command center.” Because the exact chronology of the information 57
is not yet known, using removable adhesive notes allows investigators to easily change the sequence of this information and to add information as it becomes available. Different colored notes or inks can be used to distinguish between events and conditions in this initial manual construction of the events and causal factors chart. If the information becomes too unwieldy to manipulate manually, the data can be entered into a computerized analysis program. Using specialized analytical software, investigators can produce an event and causal factors graphic, as well as other analytical trees or accident models. Whether using a manual or a computerized approach, the process begins by chronologically constructing, from left to right, the primary chain of events that led to an accident. Secondary and miscellaneous events are then added to the events and causal factors chart, inserted where appropriate in a line above the primary placed above or below these events. Figure 7-1 illustrates the basic format of the events and causal factors chart. Guidelines for constructing the chart are shown in Table 7-1. Figure 7-2 explains the symbols and conventions used in constructing the chart.
Secondary Event Sequence Primary Event Event 1 Sequence
Secondary Event 1
Secondary Event 2
Figure 7-1. Simplified Events and Causal Factors Chart.
Table 7-1. Guidelines Are active (e.g., “crane strikes building”) Should be stated using one noun and one active verb Should be quantified as much as possible and where applicable (e. g., “the worker fell 26 feet, ” rather than, “the worker fell off the platform”) Should indicate the date and time of the event, when they are known Should be derived from the event or events and conditions immediately preceding it. Are passive (e.g., “fog in the area-) Describe states or circumstances rather than occurrences or events As practical, should be quantified Should indicate date and time if practical/applicable Are associated with the corresponding event. Encompasses the main events of the accident and those that form the main line of the chart.
Primary Event Sequence
Secondary Event Encompasses the events that are secondary or Sequence contributing events and those that form the secondary line of the chart.
Figure 7-2. Explanation of symbols & conventions used in constructing Events & Causal Factors Diagram.
Events & Causal Factors Diagram
1. All events are enclosed in rectangles 2. All conditions are enclosed in ovals 3. All events are connected to the preceding and succeeding event by arrows.
Events & Causal Factors Diagram (Continued)
4. All conditions are connected to other conditions and/or events by dashed arrows.
5. Presumptive events or conditions are shown by dashed rectangles or ovals.
6. “Primary” sequences of events are depicted in a straight horizontal line with the relative time sequence from left to right.
1 2 3
7. Secondary event sequences, contributing factors, and systemic factors are depicted above or below the primary sequencing line.
Figure 7-3. In evaluating events and conditions, ask simple questions.
Ask the Questions
Why did the system allow the conditions to exist?
How did the condition originate?
Causal Factors Relationship
Supervision Specific Condition Event Event Event Accident
Always ask why an unwanted condition was allowed to exist Figure 7-4. The further removed from the event line that a condition exists, the higher the level of management involved.
Depending on the complexity of the accident, the charts may result in a very large complex sequence of events covering several walls in the “command center.” For the purpose of inclusion in the investigation report and closeout briefings, the chart is generally summarized. Note that “assumed conditions” may appear in the final chart. These are conditions the team presumed affected the accident sequence, but the effect could not be substantiated with evidence. Such presumptive conditions, however, should be clearly identified as assumptions and given appropriate weight in the final analysis.
Barrier analysis (sometimes called barrier and control analysis or energy trace and barrier analysis) is based on the premise that an energy flow is associated with all accidents. Barriers are developed and integrated into a system or work process to protect personnel and equipment from unwanted energy flows (see Figure 7-5). For an accident to occur, there must be:
A hazard, which comes into contact with A target, because Barriers or controls were unused or failed.
Barrier Energy Source Or Hazard
Figure 7-5. Barriers are intended to protect personnel and property against hazards.
Three common types of barriers are shown in Figure 7-6.
Types of Barriers
Surpervisory/Manage ment Barriers
Guard Rails Fences Conduit Safety Devices Shields Protective Clothing
Engineering Design Work Procedures Hazard Analysis Work Processes
Training Knowledge/Skills Supervision Management Oversight
Figure 7-6. Three types of barriers may be integrated into work processes. Investigators use the barrier analysis technique to identify hazards associated with an accident and the barriers and controls that should have been in place to prevent it. Hazards are the potential for an energy flow to result in an accident or otherwise adverse consequence. Energy flow is the transfer of energy from its source to another destination. This transfer of energy can be either wanted or unwanted. For example, the flow of electricity through an electrical cable to a piece of equipment is a desired energy flow. A worker coming into contact with that electricity is an undesired energy transfer. For the purposes of this technique, energy is defined as kinetic, biological, acoustic, chemical, electrical, mechanical, potential, electro-magnetic, thermal, radiation, or any other energy source. A target is a person or object that an unwanted energy flow may damage, injure, or cause a fatality. Barriers are anything used to control, prevent, or impede energy flows. Investigators evaluate: (a) the adequacy of existing barriers and controls to determine why they were not used or failed, and (b) whether barriers were installed, and if not, why not. Evaluating these barriers and their failures facilitates identification of causal factors.
Table 7-2. The Basic Barrier Analysis Process Define Final Loss Event – the events that result in loss or damage (e. g., injury sustained, equipment damaged) Identify Barriers – both barriers that were in place and those that should have been in place; note that more than one barrier may be associated with each unwanted event Evaluate Purpose of Barrier – describe the purpose of the barrier and its intended function in eliminating hazardous conditions Evaluate Barrier’s Performance – describe how and why the barrier failed, and the consequences of the failure Validate Analysis – ensure that results are consistent with or complementary to the results of other analytic techniques
When evaluating the effectiveness of barriers and controls, investigators should understand the function, location, and features of each barrier. Sources of needed data for a barrier analysis include: Preliminary drawings of equipment Systems or facilities Hazard analysis results Maintenance procedures Operational procedures Site maps. The minimum data needed to perform a barrier and control analysis includes: Facts and evidence in chronological order Identification of all relevant hazards Identification of all relevant barriers and controls Facts regarding the function of each barrier and control. A barrier’s exact function and location should be considered after determining how energy sources and targets can come together and what is required to keep them separated. Obvious barriers are those placed directly on the hazard (e.g., a guard on a grinding wheel); those placed between a hazard and a target (e.g., a railing on a second-story platform); or those located on the target (e.g., a welding helmet). Barriers such as those defining the exposure limits required to minimize harm to personnel are less obvious. Therefore, investigators must cross-validate the results of the barrier analysis with other core analytic techniques to ensure that all failed, unused, or uninstalled barriers are identified. Accurate and complete causal factors of the accident can then be determined.
Constructing a Worksheet. A barrier analysis worksheet is a useful tool in conducting a barrier analysis.
Figure 7-7. Barrier Analysis Worksheet
Hazard/Energy Flow Barrier or Control Possible Factors Contributing to Barrier/Control Failure Possible Root Cause of Failure Evaluation
In conducting barrier analysis, it is often useful to employ results of supplementary techniques such as change analysis or root cause analysis. These supplementary techniques can be used to more systematically identify and examine possible contributing and root causes leading to each failure.
TIP While the barrier analysis technique helps identify multiple failures, such failures may not always lead to contributing and root causes. However, the results of barrier analysis can directly feed into and facilitated root cause analysis.
Figure 7 – 8. In most accidents, a series of barriers must fail in order for the accident to occur.
#1 #2 #3 #4
Change is one of the most important factors in the cause of accidents. Change is anything that disturbs the “balance” of a system operating as planned. Change is often the source of deviations in system operations. Change can be planned, anticipated, and desired, or it can be unintentional and unwanted. It is an integral and necessary part of daily business; for example, requirements change, procedures change, policies and directives change, the personnel performing certain tasks change (i.e., personnel turnover). Change can improve efficiency, productivity, and safety, or can result in errors, loss of control, and accidents.
TIP Change analysis is particularly useful in identifying obscure contributing causes of accidents that result from changes in a system.
Change analysis examines planned or unplanned changes that cause undesired outcomes. In an accident investigation, this technique is used to examine an accident by analyzing the difference between what is expected or planned (i.e., an accident-free situation), and the actual sequence of events. The person performing change analysis systematically identifies specific elements or differences that caused the outcome of a certain task to deviate from the anticipated outcome. For example, why would a system that operates correctly 99 times out of 100 fail to operate as expected one time?
Conducting Change Analysis. Change analysis is a relatively simple technique to employ. As illustrated in Figure 7-9, it consists of six steps. The last step, in which investigators combine the results of the change analysis with the results from other methods, is critical to developing a broad and comprehensive understanding of the accident.
Describe accident situation Identify differences Analyze differences for effect on accident
Compare Describe comparable accident-free situation
Integrate information into investigation process
Figure 7-9. The change analysis process is relatively simple. During the application of change analysis, investigators identify changes as well as the results of those changes. The distinction is important, because identifying only the results of change may not prompt investigators to identify all causal factors of an accident. The results of a change analysis can stand alone, but are most useful when they are incorporated with other methods, such as the events and causal factors analysis, in searching for direct, contributing, and root causes. To conduct a change analysis, the analyst needs to have a baseline situation. This baseline situation can be: The same situation but before the accident (e.g., previous shift, last week, or last month) A model or ideal situation (i.e., as designed or engineered). Generally, it is recommended that teams compare the accident sequence to the same situation in an accident-free state-the operation prior to the accident—to determine differences and thereby identify accident causal factors. In order for the comparison to be effective, investigators must have sufficient information regarding this comparative situation. 68
TIP In change analysis, differing events and conditions are systematically reviewed and analyzed to determine potential causes.
The following data sources can be a starting point for acquiring a good working knowledge of the system, facility, or process under study prior to the accident or event; however, the list of input requirements should be tailored to fit the specific circumstances and needs of the investigation: Blueprints Equipment description documents Drawings Schematics Operating and maintenance procedures Roles and responsibilities Job/task descriptions Personnel qualifications Results of risk analysis Performance indicators Personnel turnover statistics. Table 7-9 lists questions that should be considered for inclusion in a change analysis worksheet. (As noted, the worksheet should be tailored to include any conditions, events, or factors pertinent to the specific accident). Figure 7-10 shows a sample change analysis worksheet to demonstrate the change analysis approach. The worksheet allows the user to compare the “accident situation” with the “accident-free situation” and evaluate the differences to determine each item’s effect on the accident. The differences or changes identified can generally be described as causal factors and should be noted on the events and causal factors chart and used in the root cause analysis, as appropriate. Table 7-10. Considerations for Completing the Change Analysis Worksheet
WHAT? What is the accident? What occurred to create the accident?
What occurred prior to the accident? What occurred following the condition or accident? What operational activities were under way when the accident occurred ? What maintenance activity was under way when the accident occurred ? Was there a training activity under way when the accident occurred? What equipment was involved in the accident? What barriers should have been in place to prevent the accident? What barriers were in Place but failed to stop the unwanted transfer of energy?
WHEN? When did the accident occur? What was the facility’s status at the time of occurrence? What was the facility’s status at the time the accident was identified? Did the time of day have an effect on the condition? Personnel availability? Did the accident involve shift-work personnel? For how many continuous hours had any involved personnel been working? WHERE? Where did the accident occur? What were the physical conditions in the area? Where was the accident identified ? Was location a factor in causing the accident? WHO? Who were the personnel involved in the accident? Which personnel witnessed the accident? Which personnel reported the accident? Which personnel ameliorated the accident? What was the training/qualifications of the personnel involved? Who was supervising this activity? HOW? Was the accident caused by an inappropriate action? Was procedure use a factor in the condition? If so: Did the procedure have sufficient detail? Did the procedure have sufficient warnings and precautions? Did the procedure cover work tasks in proper sequence?
Figure 7-11. Sample Change Analysis Worksheet
Accident Situation Accident-Free Situation Comparison/ Differences Evaluation
Note: Not recognizing the compounding of change (for example, a change that was instituted several years earlier coupled with a more recent change) is a potential deficiency of change analysis. It is incumbent upon the investigator to guard against this potential shortcoming by being aware of this and continuing to search for all changes that affected the accident.
Determining Causal Factors
The following describes the process for using the events and causal factors chart to determine the causal factors of an accident. This process is an important first step in later determining the root causes of an accident. The results of this analysis can be used with a tier diagram (discussed below) if desired. The quality and accuracy of root cause
analysis depends on the results of the events and causal factors analysis. Therefore, the events and causal factors analysis must be complete and thorough. Events and causal factors analysis requires deductive reasoning to determine which events and/or conditions contributed to the accident.
Getting Started. Before starting to analyze the events and conditions noted on the chart, an investigator must first ensure that the chart contains adequate detail. Both a change analysis and a barrier analysis should be conducted and the results incorporated into the chart before the analysis begins.
Also, the team members must resolve any obvious gaps in data before this analysis begins. By the time the team is ready to conduct a preliminary analysis of the chart they will have spent a great deal of time adding, removing, and rearranging events and conditions on the chat. In all likelihood, the chart will be lengthy, possibly containing a hundred events or more. Given the magnitude of data one can become overwhelmed with where to begin identifying causal factors. It is easiest and most logical to begin with the first event on the chart. It will not be immediately apparent to the team which causal factors are contributing causes and which are root causes; this will become clear only after a root cause analysis. However, the team should keep the definitions in mind when trying to determine all of an accident’s causal factors.
Conducting the analysis. Examine the first event that appears on the chart. Evaluate its significance with respect to the accident. If it is relatively unimportant (e.g., “worker punched into work”), proceed to the next event. Repeat this process until a significant event is identified. When the first significant event is identified, carefully examine the conditions associated with that event. As the examination of a particular event chain (an event and its associated conditions) proceeds, ask a series of questions:
Why did this event happen? Why did this particular condition exist? How did this condition originate? Who/what allowed this condition to exist? Why was this condition allowed to exist? What is the significance of this condition with respect to the accident? Is this condition associated with/linked to another condition in this event chain that may indicate a more general or larger deficiency?
Is this condition associated with/linked to another condition in another event chain that may indicate a more general or larger deficiency? Other questions may arise to help identify the significance of the event or condition. The team uses these questions to deductively determine the most significant conditions in a particular event chain. The steps in this process are repeated through the entire chart. As causal factors are identified, they are identified on removable adhesive notes and placed above the event chain from which they were derived. The investigative team should be sure to differentiate the causal factors from other conditions in the event chain. If a computer graphics program is used to record the chart, use a hexagon to represent causal factors (see Figure 7-12). When constructing the chart manually with colored adhesive notes, using the notation “causal factor,” or a different color ink maybe equally effective.
TIP Not all events will produce causal factors. However, it is important to prepare a complete set of events in order to understand the circumstances leading up to the accident and to assure that all significant events have been identified.
Ask the Questions
How did the condition originate?
Why did the system allow the conditions to exist?
Condition Why did this event happen? Event Event Event Event
Figure 7-12. Events and causal factors analysis; driving events to causal factors.
Sometimes conditions from several different events can logically be associated to indicate a larger or more significant causal factor. For example, in two side-by-side events, the conditions “procedure not known by worker” and “worker new to job” maybe associated to indicate that the training of new workers is insufficient or nonexistent. In such a case, the investigator can write one causal factor concerning training, place it on the chart, and connect it with an arrow to the two event chains from which it was derived. Alternatively, the investigator can record the same causal factor twice, placing it above each of the event chains from which it was derived. When the investigator has applied this methodology to each event on the chart, the process should be repeated with another person and preferably with all team members to ensure that nothing has been overlooked. When the investigative team is satisfied that all causal factors have been identified on the chart, efforts can then be focused on initiating the root cause analysis.
Root Cause Analysis
Tip Root cause analysis should be conducted for every occurrence, regardless of severity or complexity. Minor incidents often foreshadow more serious events.
Accidents, however serious, are symptoms of a larger problem within a system. Though accidents generally stem from many causal factors, correcting the symptoms of a problem does little to prevent the possibility of a similar or more severe accident. To identify and “treat” the true ailment in a system, the root causes of an accident must be identified. Root cause analysis is any methodology that identifies the causal factors, including management systems deficiencies, which, if corrected, would prevent recurrence of the accident. Simply stated, the root cause is the underlying reason that answers the investigators’ question, “Why?” In this way, root cause analysis does not only apply to a specific accident or occurrence, but is intended to have generic implications for lessons learned to a broad group of vessels or vessel operations. Once several (or all) of the recommended core analytic techniques have been performed, the accident investigation team should have a broad understanding of the accident’s events and conditions, along with a fairly extensive list of suspected causal factors. A root cause analysis is performed to define the list of causal factors and categorize each according to its significance and impact on the accident. This section discusses analytical tools that can help accident investigators determine the root causes of art accident. Root cause analysis is not an exact science and therefore requires a certain amount of judgment.
A “root cause” is a causal factor that, if corrected, would prevent recurrence of the accident. Root causes involve both local problems (localized) or problems within the entire system (systemic) that allow or create deficiencies that cause or could cause unwanted occurrences. Root cause analysis is a systematic process that uses the facts and previously performed analyses to determine the underlying reasons for the accident. In accident investigations, finding root causes is prerequisite to the development and implementation of corrective and preventive measures. The intent of this analysis is to identify and address only those root causes that can be controlled within the system being investigated. (This would exclude events or effects that cannot be reasonably anticipated or controlled, such as earthquakes, tornadoes, floods, and other natural disasters). Core analytic techniques, such as events and causal factors, change, and barrier analyses, provide answers to an investigator’s questions regarding what, when, where, who, and how. Root cause analysis is primarily performed to resolve the question, “Why?’
There may be more than one root cause of a particular accident, but probably not more than three or four. If more are thought to exist at the conclusion of the analysis, the team should re-examine the list of causal factors to determine which causes can be further combined to reflect more fundamental (root) causes.
TIP In any accident, there may be a series of causal factors, one leading to another. One of the most important responsibilities of the investigation team is to pursue each factor in the series until the team is assured that actual root causes are identified. Regardless of which technique is used, the main focus of the team should be finding concise and valid root causes that address the fundamental system deficiencies that led to the accident.
To initiate a root cause analysis, the facts surrounding the accident must be known. In addition, the facts must be analyzed using other analytic methods to ascertain an initial list of causal factors. A rather exhaustive list of causal factors must be developed prior to the application of root cause analysis to ensure that final root causes are accurate and comprehensive.
TIP If a root cause analysis is attempted before all the significant facts are known or the full spectrum of causal factors is determined, it is likely that the real root causes will not be discovered.
To acquire needed information, investigators should examine the evidence collected from the accident scene, witness statements, interviews, and facility documents to determine what additional information will be needed for the particular root cause technique they are performing.
Root cause analysis can be performed using computerized or manual techniques. Regardless of the method, the intent is to use a systematic process for identifying root causes. It is important that the accident investigation team work together to determine the root causes of an accident. The primary mission of the investigative team is to identify the root causes of an accident so that judgments of need can be prepared and appropriate corrective measures can be developed and implemented. Therefore, all team members must participate in the root cause analysis; it cannot be left solely to the lead investigator or to a single member of the team.
Tier Diagramming. Tier diagramming is a technique used to identify both the root causes of an accident and the level of line management responsibility associated with contributing and root causes.
The team uses the tier diagram to hierarchically categorize the causal factors derived from an events and causal factors analysis. The diagram is usually divided into six tiers, numbered O through 5, which represent organizational responsibility ranging from the worker level to upper management. In a series of steps, causal factors are evaluated as potential root causes and linked to a level of responsibility in the line organization. A tier diagram is helpful in identifying and analyzing root causes because it: Helps the team organize and categorize the causal factors identified on the events and causal factors chart causal factors into higher-level, fundamental organizational deficiencies (root causes) Provides a structured and repeatable approach for assigning management responsibility for each causal factor Forces the team to assign responsibility for root causes, from which appropriate judgments of need can later be developed Assists the team in visually and physically organizing significant causal factor data. Before initiating a root cause analysis using the tier diagram method, the investigator should be satisfied with the results of the events and causal factors analysis. In addition, the team must have a solid understanding of the line organization responsible for the activities associated with the accident.
Getting started. Once the events and causal factors analysis is complete, a number of causal factors are noted on the events and causal factors chart. These will be the input to the tier diagram and root cause analysis. Provided below are step-by-step instructions for completing the root cause analysis using the tier diagram. Guidelines and other reminders follow the instructions.
Step 1. Identify significant event/conditions. Review the causal factors listed on the events and causal factors chart to focus only on significant events or conditions (i.e., causal factors). Step 2. Assign letter designators. Starting at the beginning of the chart, assign a letter to each causal factor (A, B, C... ) on an adhesive note. Place the same letter designator on the actual chart where that causal factor is affixed. Later, the analyst will remove the adhesive notes and place them on the tier diagram. By noting where the causal factor originated, the analyst can easily return to the event chain if a question arises during the root cause analysis. Step 3. Develop tier diagram framework. Using Table 7-13 as a model, create a tier diagram with the number of tiers commensurate with the line organization being examined. The grid can be drawn on large butcher paper, a white board, or any other surface large enough for displaying to the team members. For the purposes of this section, a typical organization with six tiers (O-5) is assumed. A review of organizational charts, work control logs, and other such documentary evidence may be helpful in completing this step. Step 4. Begin with Tier O. Remove the “direct cause statement” adhesive note and place it in Tier O, “direct cause.” Remove all other causal factor adhesive notes and place them in Tier 1, “worker actions.” Step 5. Evaluate Tier 1. Beginning with causal factor “A,” ask whether the “worker actions-Tier 1” is the organizational level responsible for this causal factor that is, can this causal factor be attributed to the worker(s) involved in the accident? Use the categories and questions listed in Table 7-14 as guidance in completing this step. Step 6. Evaluate Tier 2. If the causal factor can be attributed to the worker, ask whether the causal factor is solely attributable to the “worker actions” tier. Did the worker’s supervisor have any responsibility for this causal factor? If not, leave the causal factor in Tier 1. If the supervisor had any responsibility for this causal factor, write a letter “A” in Tier 1 and physically move the causal factor adhesive note to Tier 2.
Table 7-13. Tier Diagram Worksheet for Root Cause Analysis
Tier Tier 5: Senior Management Tier 4: Middle Management Tier 3: Lower Management Causal Factor Root Causes
Tier 2: Supervision Tier 1: Worker Actions Tier 0: Direct Cause
Table 7-14. Categories and Questions for Completing Root Cause Analysis Tier Diagram
Tier Tier 5: Senior Management Responsibilities for Causal Factor Consideration Policy development Awareness Involvement Lessons learned/feedback Contract terms/conditions Questions for Considering in Assigning Causal Factors Did senior management establish safety-related policies to promote a safe work environment? Was senior management involved in the site wide prioritization of work? Did senior management institutionalize the stop-work authority philosophy? Was senior management aware of previous safety-related incidents? Was senior management visibly involved in assessing safety- related policy implementation? Did senior management use lessons learned/feedback from previous incidents to prevent future similar incidents? Did senior management condone or allow contract terms and conditions that were not consistent with safe working conditions (e.g. accelerated schedules, reduced quality requirements)? Did management implement policy through plans and programs development? Was management aware of the status of plans and program implementation? When problems occurred, did management request feedback on the nature of problems? Did management have a system for monitoring and measuring organizational performance? Was stop-work authority communicated to the organization? Was management involved in the development and implementation of
Tier 4: Middle Management
Policy implementation (plans and programs) Awareness Involvement Feedback
Tier 3: Lower Management
Procedure development Plans and program implementation Awareness Involvement Feedback Corrective actions
Tier 2: Supervision
Work instructions Work environment Procedures Training Communications Tools/Equipment Corrective Actions
corrective actions? Were required procedures developed and kept current to assure a safe work environment? Did management implement required programs for worker safety? Was management swan: of problems regarding procedure implementation and compliance? Was management involved in the work planning, control, and execution process? Did management have a system for eliciting feedback on work-related hazards? Did management have a system for identifying and disseminating work process lessons learned? Was stop-work authority defined for first line supervisors and their staff! Did management take timely corrective actions when problems occurred or were identified? Were the supervisor's work instructions adequate to allow the work to be performed safely? Was the work environment safe? Were required procedures provided or communicated to the worker by supervision? Did the supervisor provide the required training to the worker? Did the supervisor discuss job hazards with the worker prior to starting work? Did the supervisor define stop-work authority for workers? Did the supervisor confirm the readiness to perform work prior to the execution of work? Did the supervisor provide the worker with the proper tools and equipment to perform the work safely? Did the supervisor provide feedback to management on prior incidents and/or safety concerns? Did the supervisor implement timely corrective actions based on previous incidents? Was the work covered by procedures? Was the worker trained on the procedures? Were communications adequate to inform the worker of any hazards? Did the worker understand the work to
Tier 1: Worker Actions
Procedures Training Communications Understanding Experience Direct Cause of occurrence
Knowledge Skills Abilities Human error Tools/equipment
performed? Was the worker knowledgeable of the type and magnitude of hazards associated with the work? Were the worker's knowledge, skills, and abilities adequate to perform the job safely? Was worker error a causal factor in the accident? Did the worker have stop-work authority? Did the worker understand she/he had stop-work authority? Did the worker have the right tools and equipment to perform the job safely?
Tier 0: Direct Cause
Step 7. Evaluate other tiers. Continue a similar line of inquiry about the causal factor at each successive tier until satisfied that the causal factor is placed in the tier commensurate with the highest level of responsibility or authority for it. Again, as a causal factor is moved to higher tiers, note the letter designation in the tier from which it is moved. For example, if responsibility for causal factor “A” is found to reside with upper management, the letter “A” should appear in Tiers 1 through 4, with the actual adhesive note placed in Tier 5. Step 8. Repeat for each causal factor. Repeat steps 1 through 7 for each causal factor previously placed in Tier 1 of the diagram. Step 9. Identify linkages. After arranging all the causal factors on the tier diagram, examine the causal factors to determine whether there is linkage between two or more of them. For example, are two or three causal factors similar enough to indicate poor conduct of operations? Or perhaps several causal factors are related to a lack of worker training. If linkages exist, group the adhesive notes at the highest level where a linkage occurs (see Figure 7-12). For example, if causal factors “B” and “F’ in Tier 3 are related to causal factor “H” in Tier 4, remove “B” and “F’ (noting their location), and affix them to “H” in Tier 4. Next, if one of the causal factors statements accurately describes the commonality among the grouped causal factors, let that causal factor represent the grouping. If not, write a causal factor statement that captures the common theme of all the causal factors in that particular grouping. This statement becomes a potential root cause.
The investigative team members should continue to examine all of the causal factors until they are satisfied that all applicable linkages have been made.
Step 10. Identify root causes. Evaluate each of the causal factor statements that now appear on the chart. Compare each statement to the definition of a root cause to determine whether it appears to be a root cause of the accident. This step will generally involve a
great deal of discussion among team members.
Tip If a causal factor does not meet the criteria for a root cause, do nothing; it remains a contributing cause of the accident.
If a causal factor (singly or representing a group) meets the criteria for a root cause, denote it as such either using the letters “RC” (root cause) or by some other means. You may find that you need to create a root cause statement based on one or more causal factors. If so, write a summary causal factor statement and place it on the appropriate tier. The team may choose to add a third column, “Root Causes,” to the tier diagram. The advantage of adding this column is that moving the root cause statements makes them stand out, along with the associated level of management responsibility. The root cause analysis may reveal causal factors that are not on the events and causal factors chart. These should be added to both the events and causal factors chart and the tier diagram to assure that they are consistent and reflect all of the causal factors as a basis for root cause analysis.
Step 11. Simplify root cause statements. There may be more than one root cause of a particular accident, but probably not more than three. If there are more than that at the end of the tier diagram analysis, the team should re-examine the list of root causes to determine which ones can be further combined to reflect more fundamental deficiencies. When the team is satisfied that the root causes have been accurately identified and the number of root causes is not excessive, the root cause analysis is complete. The team should capture the essence of the root cause analysis for the accident investigation report, noting the direct, contributing, and root causes of the accident in order to develop judgments of need. Guidelines and Reminders:
Root causes may be found in any of Tiers 1 through 5. However, they are generally found in higher tiers because that is where managers are most responsible for directing and overseeing activities. The root cause of an accident can be found at the worker level of the tier diagram if, and only if, the following conditions are found to exist: Management systems were in place and functioning, and provided management with feedback on system implementation and performance Management took appropriate actions based on the feedback Management, including supervision, could not reasonably have been expected to take additional actions based on their responsibilities and authorities.
Root causes can be found at more than one level of an organization. For example, one root cause may be attributable to Tier 3, while two other root causes are attributable to Tier 5. Root causes are generally attributable to an action or lack of action by a particular group or individual in the line organization. Each “corporate” organization is considered separately for its responsibility in the accident. Consequently, the results of one tier diagram may be the input of another. For example, if the upper management of an outside contractor was responsible for a particular root cause, the shipping company management may share responsibility for that particular root cause—there may be a deficiency in the directives from the shipping company, insufficient oversight, or some other responsibility that was inadequately fulfilled.
Tier 5: Senior Management Tier 4: Middle Management Tier 3: Lower Management Tier 2: Supervision Tier 1:Worker Actions Tier 0: Direct Cause
#1 #2 #1
Root Cause # 1
#1 Root Cause # 2 #3 Root Cause # 3
Figure 7-15. Identifying the linkages on the tier diagram.
Conclusions and Recommendations
Developing Conclusions, Recommendations and Judgments of Need
Conclusions and recommendations/judgments of need are key elements of the investigation that must be developed. Conclusions Conclusions are significant deductions derived from the investigation’s analytical results. They are derived from and must be supported by the facts plus the results of testing and the various analyses conducted. Conclusions may: Include concise statements of the causal factors of the accident determined by analysis of facts Be statements that alleviate potential confusion on issues that were originally suspected causes Address significant concerns arising out of the accident that are unsubstantiated conclusion or inconclusive Be used to highlight positive aspects of performance revealed during the investigation, where appropriate. When developing conclusions, the investigator should: Organize conclusions sequentially, preferably in chronological order, or in logical sets (e.g., hardware, procedures, people, organizations) Base conclusions on the facts and the subsequent analysis of the facts n Include only substantive conclusions that bear directly on the accident, and that reiterate significant facts and pertinent analytical results leading to the accident’s causes Keep conclusions as short as possible and, to the extent possible, limit reference citations (if used) to one per conclusion.
TIP The process of determining conclusions seeks to answer the questions— what happened and why did it happen?
Depending on the size of the investigation, its scope, the makeup of the investigative team, the media coverage or lack thereof, and the appointing authority, and its ability to mandate or prescribe changes, most investigations will lead to recommendations which may be prescriptive in nature. These differ from “judgments of need” which are described below. They must, however, be: Stated in a clear, concise, and direct manner Based on the facts/evidence Stated so that they can be the basis for corrective action plans.
Judgments of Need
Judgments of need are the managerial controls and safety measures determined by the investigator to be necessary to prevent or minimize the probability or severity of a recurrence. Recommendations or judgments of need should be linked to causal factors and logically flow from the conclusions. Like recommendations they should be: Stated in a clear, concise, and direct manner Based on the facts/evidence Stated so that they can be the basis for corrective action plans. Judgments of need: Should not be prescriptive corrective action plans or recommendations, nor should they suggest punitive actions. Should not include process issues (e.g., evidence control, preservation of the accident scene, readiness) unless these issues have a direct impact on the accident. These concerns should be noted in a separate memorandum to the appointing official. An interactive process is the preferred approach for generating judgments of need. That is, investigators should work to review causal factors and then begin generating a list of judgments of need. These judgments should be linked directly to causal factors, which are derived from facts and analyses.
TIP Team members should work together to derive judgments of need to assure that the merits and validity of each are openly discussed and that each one flows from the facts and analyses. One method for ensuring that all significant facts and analytical results are addressed in the judgments of need is to develop displays linking judgments of need with facts, analyses, and causal factors. Investigators sometimes find it useful to display these elements on the walls or a whiteboard or chalkboard. Figure 8-1 demonstrates how this information can be arranged to provide an ongoing assessment of linkages among the our elements. It portrays the concept of requirements’ verification analysis. Using this approach, the investigators can identify gaps in the data where a clear, logical flow among the four elements is missing. The investigators can use this information to determine whether judgments of need are supported by linkages connecting the facts, results from analyses, and causal factors. TIP If a judgment of need cannot be clearly linked to causal factors derived from analyses of facts, exclude it from the report.
Fact Fact Fact Fact Analysis Fact Fact Analysis Causal Factor Judgment of Need Analysis Judgment of Need
Causal Factor Judgment of Need
Figure 8-1. Facts, analysis, and causal factors are needed to support judgment of need. Once the investigators have identified the judgments of need derived from their investigation activities, the members can begin writing statements documenting these judgments. Table 8-1 presents guidance on writing these statements. Table 8-1. Guidelines for writing judgments of need. Clearly identify organizations that need to implement actions to prevent recurrence of the accident. Avoid generic statements and focus on processes and systems, not individuals. Focus on causal factors. Be specific and concise; avoid vague, generalized, broad-brush, sweeping solutions Do not tell management how to do something; simply identify the need. Present judgments of need in a manner that allows a specific organization to translate them into corrective actions sufficient to prevent recurrence.
The Investigator, The Investigative Team and Teamwork
Marine accident investigation is a highly specialized task which should ideally only be undertaken by highly trained personnel possessing many qualities, not the least important of which are an inquisitive nature, dedication to this kind of work, diligence and patience. The investigator must have a good sound working knowledge of ship operations. Technical skill, perseverance and logic are the tools of the profession; humility, integrity, and respect for human dignity his guiding rules. Ideally, it is not sufficient to nominate, as the occasion arises, a person with specialist marine knowledge to be the investigator, however, many administrations are unable to maintain a large staff of trained investigators so they must depend on contracted investigators. The standard of the investigator assigned to an accident inquiry determines the thoroughness and class of results obtained and the longer a well-qualified investigator serves, the more expert he becomes. Wherever possible, therefore, at least one experienced investigator should be assigned to each inquiry so that a continuing thread of experience may maintain the standards of accident investigation and reporting. It is desirable that an accident investigator have, as a foundation on which to develop his skills, a professional mariner’s background, either as a deck officer or as an engineering officer. Depending upon the particulars of the accident and the needs of the investigation, it may also be important to employ specific subject matter experts in the investigation, such as human performance specialists, metallurgists, naval architects, etc. In order to discharge effectively their duties, it is essential that marine accident investigators are provided with suitable statutory powers which should, nonetheless, be used with discretion. The investigator will come in contact with many kinds of people, the majority of whom recognize the investigator’s status, and who will, more often than not, feel obliged to offer all assistance they can without the investigator reminding them of the official powers which are vested in him. He will also encounter others who are less well acquainted with his activity and who may show reticence to be forthcoming with evidence, stemming from a natural desire not to become involved. It may, in these latter circumstances, be necessary for the investigator to explain his function and to elicit their willing cooperation. 1
When called to the scene of the accident the investigator should endeavor to arrive as soon as possible; similarly, in his dealings with witnesses and other people concerned in the accident, he should be prompt in attending appointments and correct in his manner, regardless of how he may feel personally. Above all, the investigator must be accurate and factual; he must observe, interpret and record clearly and accurately at all times because his record of what is seen, heard and done, may well prove to be the only record available, the analysis of which may have far-reaching effects on individual people, companies, and marine safety as a whole.
The Investigative Team
Marine accidents, especially accidents of serious consequences, are typically very complicated events, often having safety issues in several areas of technical expertise. It is unrealistic to believe that any one person will have all of the knowledge, experience, and ability necessary to investigate all aspects of an accident in the depth that they deserve. Therefore, whenever possible a team approach to marine accident investigation should be taken, especially for major accidents involving multiple fatalities, great environmental harm, or wide public interest. The make up of the team may be subject to some variation due to the unique issues involved in the accident under investigation. A team investigating the capsizing of a ferry, for instance, would probably have no need for a fire expert as a member. Nevertheless, a “basic” team that should be able to cover most areas involved in most accidents would ideally consist of: The Lead Investigator – the investigator assigned to be in overall charge of the investigation process. The lead investigator manages the investigation and directs the efforts of the team. In addition, the lead investigator assumes responsibility for on scene safety of his team during the investigation. Engineering Investigator – who is tasked with documenting all aspects of the investigation related to engineering operations, procedures, systems, and equipment. Human Performance Investigator –who is responsible for looking into the human factors aspects of the accident. Statistics show that at least 80% of all marine accidents are a result of human error. Survival Factors Investigator – who is responsible for documenting the injuries and/or deaths resultant from the accident and for assessing the post-accident amelioration efforts by the crew and by emergency response agencies. The Survival Factors Investigator is also tasked with the responsibility to assess the performance of emergency systems during the accident.
The investigative team must work together to finish the investigation within the timeframe established by the appointing official. To make this happen, the lead investigator should ensure that strong-willed personalities do not dominate and influence the objectivity of the investigation and that all viewpoints are heard and analyzed. The lead investigator must capitalize on the synergy of the team's collective skills and talents (i.e., the team is likely to make better decisions and provide a higher quality investigation than the same group working individually) while allowing individual actions and decisions. It is important that the lead investigator set the ground rules and provide guidance to the team members and other participants in: Member relationships: Friendship is not required, but poor relationships can impede the team’s ability to conduct a high-quality investigation. The lead investigator can encourage positive relationships by focusing attention on each member's strengths and downplaying weaknesses. The lead investigator can facilitate this by arranging time to allow team members to get to know one another and learn about each other's credentials, strengths, and preferences. Effective interpersonal relationships can save time and promote high-quality performance. Communication processes: It is the lead investigator’s responsibility to make sure that all members get a chance to speak and that no one member dominates conversations. The chairperson should establish communication guidelines and serve as an effective role model in terms of the following: • • • • • • • • • • Be clear and concise; minimize the tendency to think out loud or tell "war stories" Be direct and make your perspective clear Use active listening techniques, such as focusing attention on the speaker, paraphrasing, questioning, and refraining from interrupting Pay attention to non-verbal messages and attempt to verbalize what you observe Attempt to understand each speaker's perspective Seek information and opinions from others, especially the less talkative members Postpone evaluation until all ideas and arguments have been heard Encourage diverse ideas and opinions Suggest ideas, approaches, and compromises Help keep discussions on track when they start to wander.
Decision processes: The lead investigator should gain agreement in advance
regarding how particular decisions will be made. Decisions can be made by consensus, by vote, by the lead investigator, or by an expert. Each method has strengths and weaknesses, and the method used should be the one that makes the most sense for the particular decision and situation, Team members should be aware of which method will be used. Role and responsibilities: Team members should clearly understand both the formal and informal roles and responsibilities of each member, consultant, and support person involved in the investigation. Clarifying these roles helps avoid duplication of effort and omission of critical tasks, and reduces power struggles and other conflicts. The appointing authority should always consider the opinion of the lead investigator but remains the final arbitor when reassigning team member tasks if they encounter problems. Group processes: For an effective investigation, group processes must be efficient. Time and energy may be needed to develop these processes. The lead investigator should pay attention to and note processes that seem to work well, and ask the group to suggest alternatives to processes that are unsatisfactory. TIP Teams are more than individuals, because team members have a clear purpose, capitalize on each other’s strengths, coordinate their efforts, and help each other. Teamwork promotes a higher quality investigation. To control team dynamics, the appointing authority needs to be aware that groups go through predictable stages as they progress from meeting one another to becoming a high-performance team: Forming: At this stage, team members get acquainted, understand their purposes, and define their roles and responsibilities. Members are typically very polite at this stage, and conflict is rare. Little work is accomplished during this stage, as the team is still in the planning phase. The lead investigator can speed this stage by formally organizing the group; by defining goals, roles, and responsibilities; and by encouraging members to become comfortable with one another. Storming: Team members begin to realize the sheer amount of work to be done and may get into conflict regarding roles, planned tasks, and processes for accomplishing the work. There may be power struggles. The team focuses energy on redefining work processes. The lead investigator can speed this phase by encouraging open discussion of methods and responsibilities and promoting non-defensive, solutionfocused communication. Norming: The team develops norms about roles, planned tasks, and processes for working together. Power issues are settled. Team members start to become productive and assist one another. The lead investigator can speed this stage by formalizing new
norms, methods, and responsibilities and by encouraging relationship development. Performing: The team settles into clear roles, understands the strengths of different members, and begins to work together effectively. The lead investigator can help maintain this stage by encouraging open communication, a "learning from mistakes" philosophy, and recognizing progress.
TIP Understanding the four typical stages of team development can help the lead investigator manage team interactions and promote team processes throughout the accident investigation. The lead investigator sets the stage for effective teamwork at the very first team meeting. At this meeting, the lead investigator should encourage the team to define their goals and tasks, clarify their roles and responsibilities, agree on team processes, and become acquainted with each other's strengths.
TIP Many team members may have never worked on an effective team. The lead investigator needs to focus on effective team activities, because the members may not immediately see the value of teamwork or may be caught up in their own tasks to the exclusion of the team.
Command Center/Meeting Room
In some instances the investigative team will have to set up a “Command Center” out of which to conduct the investigation. This may be in a nearby hotel or business office complex. The size of the meeting room required is a function of the number of people expected to participate in the investigation. In general, regardless of the number of investigators dispatched, the meeting room should accommodate at least 30 people. Remember to account for the space required by support personnel, furniture, communications and computer equipment, telephones and power lines and the like when considering the desired capacity of the meeting room. For very large investigations, a hotel ballroom, school gymnasium or other conference center facility may be needed to accommodate the investigation. In such instances, the room should be set up “theater style”, with tables and chairs set up in rows. If possible, an aisle should bisect the room, with aisles on either side of the rows of tables and chairs. There should be a head table at the front of the room to accommodate all investigators. A chalkboard and/or whiteboard should be available and a table should be placed at the rear of the room where reports, documents, and other material to be distributed to the parties can be placed. Another table should be provided for Public Affairs' use and telephones, but should be located away from the head table. Additional Command Center considerations follow: Telephones & Communications. It is absolutely essential that the Command Center be properly equipped to enable the investigators to communicate with their appointing authority. In setting up the communications for the Command Center, there should be a number of outside telephone lines in the meeting room. The telephones are for investigators to communicate with their appointing authority and would be for official use only. If a “public affairs officer” is assigned, at least one outside telephone line should be reserved for him and for in-coming media calls. Because this line will likely receive extensive use, it should be placed away from the other lines so it will not disturb the work of others in the command center. In addition, reserve one line for the investigator’s use only, to receive calls from the appointing authority, and do not release this phone number to others. This will facilitate communications between the appointing authority and on-scene investigators.
It is also a good idea for the investigators to have mobile phones. These telephones may be obtained from the local telephone company, from local car rental agencies, or from local telecommunication specialists. Equipment/Supplies -- The meeting room will serve as the command post for managing the investigation. At the same time, it will also serve as the office and central meeting place for investigation participants. Consequently, the command post should be equipped with many of the tools of the modern office. These include the following: · · · · photocopy machines (with sorters), computers (either laptop or desktop) printers, a telephone message board, and mail boxes and a table to place mail and materials for each of the parties.
Because it may be unreasonable to ask the hotel, school or business center to acquire this equipment on short notice, the investigators should be prepared to arrange with local vendors to rent the equipment and the needed supplies. These supplies include toner and paper for the copiers and printers. The lead investigator should assure that these items are available in the command center: Attendance rosters Subpoena Forms Witness Statements Forms On-scene organizational chart, where appropriate Local telephone directory, and A method to control/limit access by unauthorized personnel to the Command Center. Administrative Support -- Depending on the size of the investigation, its scope, and the availability of administrative support personnel, temporary clerical/secretarial assistance may have to be hired for the command center. On a major investigation, a secretary or other command center assistant will be needed to answer the multitude of phone calls and to take and distribute telephone messages. In addition, someone will be needed to handle other administrative tasks, such as filing and photocopying.
Personal Safety During Accident Investigations
Accidents create unpredictable working conditions for personnel conducting on-scene investigations. Investigators must be prepared to immediately switch from a sedentary office environment to strenuous labor under trying circumstances, in all extremes of climate and conditions prevailing at various waterfront facilities. Although the hazards inherent in this type work are self evident to experienced investigators, it is beneficial to summarize what past experience has taught with respect to personal safety in accident investigations. The desire to get the job done expeditiously, thoroughly, and economically can easily lead to disregard for personal risks. Perseverance, dedication, and initiative are the trademarks of Safety Board investigators. These are precious commodities that have to be preserved by the judicious application of risk controls. Physical Condition The sudden transition from a sedentary life to strenuous activity can be hazardous, and some cautionary remarks are appropriate. Taking a yearly physical exam is strongly recommended but it does not necessarily ensure that you are in top-notch shape with regard to the demands of an on-scene investigation. Do not expect to switch from an 8-hour office day to a 12-or more-hour day in the field without suffering some ill effects or even endangering yourself. The deleterious effect of such an endeavor can be lessened by performing regular moderate to vigorous exercise. Investigators generally agree that regular mild exercise is beneficial in warding off weight gain, and enhancing muscle tone. Sports such as bowling and golf, while somewhat beneficial, are usually neither sufficiently strenuous nor regular enough to provide adequate conditioning effects. Instead, mild calisthenics and activities such as tennis, cycling or short periods of jogging - which can be done in place almost anywhere -can be much more beneficial. Walking also provides many of these same benefits, but must be engaged in for considerably longer periods in order to derive a comparable conditioning effect. Contradictory as it may sound, the investigation will probably be completed quicker, and more efficiently, when the lead investigator sees to it that everybody adheres, as much as possible, to a regular working day, as soon as the investigation is in hand. This not only makes for controlled expenditure - and restoration - of energies, but it provides the opportunity to consolidate and document the day's work and to coordinate the activities
for the next one. Psychological Factors A catastrophic accident can have a disruptive effect on the composure of those who have never been exposed to the confusion and emotions of a true disaster. One of the common defenses against the associated traumatic experiences is the irresistible urge to act, even when human lives are no longer at stake. This need for activity may seek expression without regard for endurance, personal safety, or the safety of others, and sometimes without apparent rationale. The greatest discretion should be used when attempting to guide the activities of those persons into proper channels. The calm and competent behavior of each team member and the firm but understanding leadership of the lead investigator are sufficient, in most cases, to preclude frantic or ill-advised action. Protective Clothing Although it is impossible to plan for all conditions that may exist at a particular accident site, it is expected that every investigator will arrive at the scene equipped with basic and suitable gear. Hardhats, work gloves, safety glasses and steel toed shoes should be worn when working in shipyards, and at vessel repair facilities, inside buildings having overhead equipment, and generally, around wreckage. The use of other safety equipment, as the circumstances require, should always be made mandatory by the lead investigator. Climate and Working Conditions The quickness of our response to a call for action precludes the chance to get acclimated to conditions that vary widely from those we are accustomed to. There is no need to elaborate on the health hazards associated with physical labor in extreme temperatures on either end of the thermometer. It might be important, however, to remind ourselves of the effects of fatigue on the safety of our performance long before total exhaustion takes place. Here again, is an area where supervisors must adjust the workload of their personnel to the circumstances. More specifically, they must be on their guard for the uncontrolled use of overtime for the sole purpose of expediting the return to the home office. The quality of the investigation is best served by management awareness of the need for mental and physical fitness until the job is done. Hazards At the Site Our familiarity with vessels and the hazards at an accident site may make us overlook the lack of experience of those who assist us. For this reason, it is highly desirable that the lead investigator as well as each team member brief non-governmental personnel assisting in the investigation on all known hazards and established safety practices. The possibility that the cargo may contain or consist of hazardous material must be recognized. Although these materials when carried in containers generally are properly
protected against rough handling and moderate impact conditions, it is possible that their integrity may have been compromised by the accident. The best protection against any hazards is timely coordination with shippers and vessel personnel responsible for the dangerous cargo manifest. When appropriate, and particularly in case of doubt, the manufacturers of the material involved should be consulted regarding exposure hazards and protective measures. Vessels also carry a great number of dangerous cargoes (hazardous materials) and petroleum products. No tank or compartment that contained such products will be entered until the atmosphere has been tested for toxicity and flammable vapors and for sufficient oxygen for breathing. Vessels are required to have portable test equipment to enable the crew (normally the Chief Mate) to conduct such tests. However, when a vessel is in port the testing is required to be conducted by a certified marine chemist. No compartment should be entered until it has been certified as “safe for men.” Accidents Involving Hazardous Materials Hazardous Materials are substances which can produce injury during accidents in any of the following ways: o o o o o o Chemical injury--whenever the substance is ingested, inhaled or comes in contact with the skin. Thermal injury--whenever the substance freezes or burns tissue. Asphyxiation--whenever the substance displaces oxygen needed to sustain life. Radiation injury--whenever a radioactive material emits radiant energy or particles that can damage living organisms. Disease--from microbiological agents. Mechanical injury- when you are injured by explosive fragments, rocketing containers, explosive over-pressures and the like.
To avoid such injuries to investigators, the following four steps are suggested. 1. 2. 3. 4. EXPECT WAIT FOLLOW DON'T
EXPECT that hazardous materials (HM) may be present in any accident involving cargo damage until you have ruled out their presence. An investigator should always search for indications of the possible presence of hazardous materials in any accident. These materials may be indicated by warning placards or signs, labels on packages, shipping papers, or verbal information from people at the scene. You should recognize the warning placards and labels described in the regulations. Hazardous materials may be dangerous while they are still in their containers or if they have escaped from their containers. The principle is to scan the wreckage to rule out their presence: assume that hazardous materials can be present until you have conclusively established that they are not. WAIT until potential energy transfers such as fires, explosions, vapors, breached radioactive materials containers, etc., have been eliminated. Hazardous materials can be emitted in many ways for many reasons. Even worse, it is almost impossible to tell precisely when they will react and envelop the danger zone with you in it. Unless you have a compelling reason to go aboard the vessel or enter the accident site while the hazardous materials containment systems are under mechanical or thermal stress, wait for those potential energy transfers to be eliminated. Alternative methods for acquiring evidence can be utilized. For example, aerial photographs, interviews with witnesses whose duties require them to go into the wreckage area, and subsequent examination of physical debris may provide the evidence you need. Consider the tradeoff between the value of the data you need now from the accident site, and the risks to your safety. Stressed containers should be considered to have the potential for abrupt rupture. The contents should be considered to have the potential for an explosion until you have clear and convincing evidence to the contrary from informed experts.
FOLLOW others into the wreckage rather than leading others into the wreckage. A good rule of thumb is to stay away from the vessels or accident site containing hazardous materials until a certified competent expert has certified the area as safe to enter. Check his/her credentials, and ask questions regarding the behavior of the hazardous materials in the accident to satisfy yourself that he/she is truly knowledgeable. From his/her predictions, satisfy yourself that any expected problems pose no threat to your personal safety. In those circumstances, you may wish to follow him/her into the wreckage area. Your ability to predict how the hazardous materials will behave is poor, because this is not your role in an accident investigation. (In the US if assistance or information is requested of you, refer the person making the inquiry to the CHEMTREC emergency toll free telephone number (800-424-9800) for expert advice and assistance. Obey evacuation instructions of police and firemen.) In no event should any investigative personnel follow firemen or other emergency or rescue personnel into the wreckage area. A rule of thumb is to stay at least 2,000 feet away from any fires burning in wreckage where hazardous materials are present.
DON'T take chances. If you have any uncertainty about potentially destructive hazardous materials behavior in an accident area, don't take chances by entering the wreckage. There is very little to be gained and much to be lost if you risk your own safety. Remember, your role is to determine what happened, and not to be a part of what is happening.
Wreckage Involving Radioactive Materials Shipment of radioactive materials may create hazards requiring special precautions and procedures in the course of accident investigations. Where there is damage to cargo, it should be determined as soon as possible whether or not radioactive materials were involved in the accident. The vessel involved should have a manifest that shows whether radioactive materials are involved. Deck Officers should be contacted immediately to determine if radioactive materials were involved. When it is determined that radioactive material is in the damaged cargo, the lead investigator is responsible for assuring that all investigative personnel are so informed and that adequate precautionary measures are taken to avoid exposure to contaminated areas. Seek expert advice before entering or allowing anyone on the investigative team to enter an area of suspected contamination.
Accident Investigation Check List
[__ ] Select investigation methodology/protocols [__ ] Design AI tasks to take full advantage of available resources. [__ ] Identify and define perceived self-interests of everyone affected by investigation [__ ] Negotiate with others who might be investigating [__ ] Identify and control personal risks to investigator [__ ] Define and order investigation tasks
Field investigation tasks
[__ ] Do walkaround/lookaround to familiarize self with scene [__ ] Identify physical objects likely to change [__ ] Identify people data likely to change [__ ] Protect data sources against premature change [__ ] Formulate questions to generate needed data [__ ] Document post-occurrence physical states [__ ] Define pre-occurrence physical states of involved objects [__ ] Define physical changes (damages) during incident [__ ] Document post-occurrence physiological states [__ ] Prepare investigation - photographs [__ ] Prepare investigation - sketches [__ ] Prepare investigation - drawings [__ ] Prepare investigation - maps [__ ] Prepare investigation - charts or graphs [__ ] Define pre-occurrence physiological states [__ ] Define physiological changes (injuries) during incident [__ ] Identify and define change makers that produced outcome [__ ] Define actions required to produce observed ending conditions [__ ] Acquire data about interactions from witnesses [__ ] Acquire data about interactions from object sources [__ ] Transform observations into form entries [__ ] Transform observations into event descriptions [__ ] Organize events sequentially [__ ] Focus energies on remaining unknown events [__ ] Select events to break down or decompose [__ ] Define events pairs or sets for logic testing
[__ ] Apply cause-effect logic to events paris and sets [__ ] Demonstrate causal relationships among interactions [__ ] Define gaps in understanding of what happened [__ ] Hypothesize bounded scenarios to fill gaps [__ ] Acquire data to verify hypotheses [__ ] Develop plans for any testing/simulations [__ ] Apply necessary/sufficient logic to events [__ ] Separate relevant from irrelevant events/data [__ ] Do Quality Control check of final description [__ ] Use events description to define problem relationships [__ ] Use events description to evaluate problems or needs [__ ] Assess gravity of each need ( fix/don't fix) [__ ] Select problems/needs to address with recommendations [__ ] Identify candidate actions to address problems or needs [__ ] Use events sets to evaluate each candidate recommendation [__ ] Develop rationale for selecting recommendations to be proposed [__ ] Develop recommendations effectiveness assessment plans and procedures [__ ] Do objective quality assurance procedures for final investigation outputs
[__ ] Prepare narrative description and explanation of what happened [__ ] Complete analysis to determine cause, causes, causal factors, root cause [__ ] Prepare final report [__ ] Defend final report [__ ] Respond to media inquiries [__ ] Do objective quality assurance procedures investigation process [__ ] Arrange for disposition of wreckage/debris/test objects [__ ] Arrange for archiving of data sources
[__ ] Set daily task priorities for each investigator or group [__ ] Manage work force performance [__ ] Assure needed information exchanges among workers [__ ] Conduct public and private briefings [__ ] Manage quality assurance procedures for team tasks and outputs [__ ] Manage recommendation development process [__ ] Manage report preparation
[__ ] Implement multinational investigating protocols [__ ] Implement customs and conventions of host state
[__ ] Manage multicultural multinational investigation teams [__ ] Negotiate participation by non-government experts [__ ] Critique investigation process
Accident Investigation Preliminary Interview List
Reason For Interview
Location/Shift/Company Notes Affiliation
Documentary Evidence Log Item No. Item Description Source of Document Requested By Rec’d Y/N
Accident Investigation Witness Statement Form Name: Telephone No. Job Title: Home Address:
Location at Time of Accident:
Location of Accident:
Accident Time and Date:
Please fully describe the accident sequence from start to finish (use additional paper as needed):
Please fully describe the work and conditions in progress leading up to the accident (use additional paper as needed):
Note anything unusual you observed before or during the accident (sights, sounds, odors, etc.):
What was your role in the accident sequence?
What conditions influenced the accident (weather, time of day, equipment malfunctions, etc.)?
What do you think caused the accident?
How could the accident have been prevented?
Please list other possible witnesses:
Physical Evidence Log Item No. Item Description Received Date By COC Y/N
COC = Chain of Custody form executed
EVIDENCE TAG ACCIDENT ____________________________ ITEM DESCRIPTION__________________ _____________________________________ _____________________________________ INVESTIGATOR AFFIXING TAG _____________________________ DATE________
ACCIDENT INVESTIGATION EVIDENCE WARNING
THIS ITEM IS EVIDENCE IN AN OFFICIAL ACCIDENT INVESTIGATION. DO NOT DISTURB WITHOUT PERMISSION
Sample Evidence Tag to Identify Pieces of Physical Evidence.
Sample Photographic Log Photographic Log Name: Agency: Address: Date: Time: Accident Identification: Photo No. (Roll/Exposure) Subject Exposure Information Flash
Code for Casualty Investigations
A 20/Res.849 1 December 1997 Original: ENGLISH
ASSEMBLY 20th session Agenda item 11
RESOLUTION A.849(20) adopted on 27 November 1997
CODE FOR THE INVESTIGATION OF MARINE CASUALTIES AND INCIDENTS THE ASSEMBLY, RECALLING article 15(j) of the Convention on the International Maritime Organization concerning the functions of the Assembly in relation to regulations and guidelines concerning maritime safety and the prevention and control of marine pollution from ships, NOTING with concern that, despite the best endeavours of the Organization, casualties and incidents resulting in loss of life, loss of ships and pollution of the marine environment continue to occur, NOTING ALSO that the safety of seafarers and passengers and the protection of the marine environment can be enhanced by timely and accurate reports identifying the circumstances and causes of marine casualties and incidents, NOTING FURTHER the rights and obligations of coastal and flag States under the provisions of articles 2 and 94 of the United Nations Convention on the Law of the Sea (UNCLOS), NOTING IN ADDITION the responsibilities of flag States under the provisions of the International Convention for the Safety of Life at Sea, 1974 (regulation I/21), the International Convention on Load Lines, 1966 (article 23) and the International Convention for the Prevention of Pollution from Ships, 1973 (article 12), to conduct casualty investigations and to supply the Organization with relevant findings,
2 CONSIDERING the need to ensure that flag States are required, under the aforementioned conventions, to investigate all cases of serious and very serious casualties, ACKNOWLEDGING that the investigation and proper analysis of marine casualties and incidents can lead to greater awareness of casualty causation and result in remedial measures, including better training, for the purpose of enhancing safety of life at sea and protection of the marine environment, RECOGNIZING the need for a code to provide, as far as national laws allow, a standard approach to marine casualty and incident investigation with the sole purpose of correctly identifying the causes and underlying causes of casualties and incidents, RECOGNIZING ALSO the international nature of shipping and the need for cooperation between Governments having a substantial interest in a marine casualty or incident for the purpose of determining the circumstances and causes thereof, HAVING CONSIDERED the recommendations made by the Maritime Safety Committee at its sixty-eighth session and by the Marine Environment Protection Committee at its fortieth session: 1. ADOPTS the Code for the Investigation of Marine Casualties and Incidents set out in the Annex to the present resolution; 2. INVITES all Governments concerned to take appropriate measures to give effect to the Code as soon as possible; 3. REQUESTS flag States to conduct an investigation into all very serious and serious marine casualties and to supply the Organization with all relevant findings; 4. REVOKES resolutions A.173(ES.IV), A.440 (XI) and A.637(16).
3 ANNEX CODE FOR THE INVESTIGATION OF MARINE CASUALTIES AND INCIDENTS 1 Introduction
1.1 This Code recognizes that under IMO conventions each flag State has a duty to conduct an investigation into any casualty occurring to any of its ships when it judges that such an investigation may assist in determining what changes in the present regulations may be desirable or if such a casualty has produced a major deleterious effect upon the environment. The Code also takes into account that under the provisions of UNCLOS article 94, a flag State shall cause an inquiry to be held, by or before a suitably qualified person or persons into certain casualties or incidents of navigation on the high seas. However, the Code also recognises that where a casualty occurs within the territorial sea or internal waters of a State, that State has a right, under UNCLOS article 2, to investigate the cause of any such casualty which might pose a risk to life or to the environment, involve the coastal State’s search and rescue authorities, or otherwise affect the coastal State. 1.2 The aim of this Code is to promote a common approach to the safety investigation of marine casualties and incidents, and also to promote co-operation between States in identifying the contributing factors leading to marine casualties. The result of this common approach and co-operation will be to aid remedial action and to enhance the safety of seafarers and passengers and the protection of the marine environment. In achieving these aims, this Code recognizes the need for mutual respect for national rules and practices and puts particular emphasis upon cooperation. 1.3 By introducing a common approach to marine casualty investigations and the reporting on such casualties, the international maritime community may be better informed about the factors which lead up to and cause, or contribute to, marine casualties. This may be facilitated by: .1 .2 .3 .4 Clearly defining the purpose of marine casualty investigation and the guiding principles for its conduct. Defining a framework for consultation and co-operation between substantially interested States. Recognizing that the free flow of information will be promoted if individuals who are attempting to assist the investigation may be offered a degree of immunity, both from self-incrimination and from any ensuing risk to their livelihood. Establishing a common format for reports to facilitate publication and sharing of the lessons to be learned.
1.4 It is not the purpose of the Code to preclude any other form of investigation, whether for civil, criminal, administrative, or any other form of action, but to create a marine casualty investigation process the aim of which is to establish the circumstances relevant to the casualty, to establish the causal factors, to publicise the causes of the casualty and to make appropriate safety recommendations. Ideally, marine casualty investigation should be separate from, and independent of, any other form of investigation.
4 2 Objective
The objective of any marine casualty investigation is to prevent similar casualties in the future. Investigations identify the circumstances of the casualty under investigation and establish the causes and contributing factors, by gathering and analysing information and drawing conclusions. Ideally, it is not the purpose of such investigations to determine liability, or apportion blame. However, the investigating authority should not refrain from fully reporting the causes because fault or liability may be inferred from the findings. 3 Application
This Code applies, as far as national laws allow, to the investigation of marine casualties or incidents where either one or more interested States have a substantial interest in a marine casualty involving a ship under their jurisdiction. 4 Definitions
For the purpose of this Code: 4.1 Marine casualty means an event that has resulted in any of the following: .1 the death of, or serious injury to, a person that is caused by, or in connection with, the operations of a ship; or .2 the loss of a person from a ship that is caused by, or in connection with, the operations of a ship; or .3 the loss, presumed loss or abandonment of a ship; or .4 material damage to a ship; or .5 the stranding or disabling of a ship, or the involvement of a ship in a collision; or .6 material damage being caused by, or in connection with, the operation of a ship; or .7 damage to the environment brought about by the damage of a ship or ships being caused by, or in connection with, the operations of a ship or ships.
4.2 Very serious casualty means a casualty to a ship which involves the total loss of the ship, loss of life or severe pollution. 4.3 Serious casualty means a casualty which does not qualify as a very serious casualty and which involves: .1 .2 .3 .4 a fire, explosion, grounding, contact, heavy weather damage, ice damage, hull cracking or suspected hull defect, etc., resulting in; structural damage rendering the ship unseaworthy, such as penetration of the hull underwater, immobilization of main engines, extensive accommodation damage etc.; or pollution (regardless of quantity); and/or a breakdown necessitating towage or shore assistance.
4.4 Marine incident means an occurrence or event being caused by, or in connection with, the operations of a ship by which the ship or any person is imperilled, or as a result of which serious damage to the ship or structure or the environment might be caused.
5 4.5 Causes means actions, omissions, events, existing or pre-existing conditions or a combination thereof, which led to the casualty or incident. 4.6 Marine casualty or incident safety investigation means a process held either in public or in camera conducted for the purpose of casualty prevention which includes the gathering and analysis of information, the drawing of conclusions, including the identification of the circumstances and the determination of causes and contributing factors and, when appropriate, the making of safety recommendations. 4.7 Marine casualty investigator means a person or persons qualified and appointed to investigate a casualty, or incident, under procedures laid down in national legislation for the furtherance of marine safety and protection of the marine environment. 4.8 Serious injury means an injury which is sustained by a person in a casualty resulting in incapacitation for more than 72 hours commencing within seven days from the date of injury. 4.9 Ship means any kind of vessel which is used in navigation by water.
4.10 Lead investigating State means the State that takes responsibility for the conduct of the investigation as mutually agreed between the substantially interested States. 4.11 Substantially interested State means a State: .1 .2 .3 .4 .5 .6 .7 5 which is the flag State of a ship that is the subject of an investigation; or in whose internal waters or territorial sea a marine casualty has occurred; or where a marine casualty caused, or threatened, serious harm to the environment of that State, or within those areas over which the State is entitled to exercise jurisdiction as recognised under international law; or where the consequences of a marine casualty caused, or threatened, serious harm to that State or to artificial islands, installations, or structures over which it is entitled to exercise jurisdiction; or where, as a result of a casualty, nationals of that State lost their lives or received serious injuries; or that has at its disposal important information that may be of use to the investigation; or that for some other reason establishes an interest that is considered significant by the lead investigating State.
Conduct of marine casualty investigations
5.1 Where an investigation is to be conducted, the following should be taken into consideration: .1 .2 .3 Thorough and unbiased marine casualty investigations are the most effective way of establishing the circumstances and causes of a casualty. Only through co-operation between States with a substantial interest can a full analysis be made of a marine casualty. Marine casualty investigations should be given the same priority as criminal or other investigations held to determine responsibility or blame.
6 .4 Marine casualty investigators should have ready access to relevant safety information including survey records held by the flag State, the owners, and classification societies. Access to information should not be barred by reason of competing investigations. Effective use should be made of all recorded data, including voyage data recorders (VDR), if fitted, in the investigation of a marine casualty or marine incident wherever it occurred. The State conducting the investigation should arrange for the read-out of the VDR. Marine casualty investigators should be afforded access to Government surveyors, coastguard officers, vessel traffic service operators, pilots or other marine personnel of the respective States. The investigation should take into account any recommendations or instruments published by IMO or ILO, in particular those relating to the human factor, and any other recommendations or instruments adopted by other relevant international organizations. Reports of investigations are most effective when released to the shipping industry and public.
5.2 In accordance with 9, other substantially interested States should be invited to be represented during any such investigation and should be admitted as a party in the proceedings and have equal standing, rights and access to evidence as the State conducting the investigation. 5.3 Recognizing that any vessel involved in a casualty may continue in service and that a ship should not be delayed more than is absolutely necessary, the State conducting the investigation should start the investigation as soon as practicable, without delaying the ship unreasonably. Other substantially interested States may, by mutual agreement, join the investigation either immediately or at a later stage. 6 Responsibility for investigating casualties and incidents
6.1 Flag States are encouraged to ensure that investigations are carried out into all casualties occurring to its ships. All cases of serious and very serious casualties should be investigated. 6.2 Where a marine casualty or incident occurs within the territorial sea of a State, the flag and coastal States recognizing the obligations of that State to its citizens and the legal status of the territorial sea under the provisions of UNCLOS and also recognising the duties placed on a flag State, the flag and coastal States should co-operate to the maximum extent possible, and mutually agree which State should take the role of lead investigating State. 6.3 Where a marine casualty or incident occurs on the high seas, a flag State should carry out an investigation into a casualty to, or on, any of its ships. If that casualty is a collision involving a ship of another flag State, then the States should consult with each other and agree which will be the lead investigating State and determine the best means of co-operation under this Code. In line with 9.1, if another State is a substantially interested State by virtue of the nationality of the ship's crew, passengers or other persons, or the location of the casualty, that State or States should be invited to take part in the investigation. 6.4 By fully participating in an investigation conducted by another substantially interested State, the flag State shall be considered as fulfilling its obligations under UNCLOS article 94, section 7.
7 6.5 An investigation should be started as soon as practicable after the casualty occurs. Substantially interested States should, by mutual agreement, be allowed to join an investigation conducted by another substantially interested State at any stage of the investigation. 7 Responsibilities of the lead investigating State
The lead investigating State should be responsible for: .1 developing a common strategy for investigating the casualty in liaison with substantially interested States; .2 providing the investigator in charge and co-ordinating the investigation; .3 establishing the investigation parameters based on the laws of the investigating State and ensuring that the investigation respects those laws; .4 being the custodian of records of interviews and other evidence gathered by the investigation; .5 preparing the report of the investigation, and obtaining and reflecting the views of the substantially interested States; .6 co-ordinating, when applicable, with other agencies conducting other investigations; .7 providing reasonable logistical support; and for .8 liaison with agencies, organizations and individuals not part of the investigating team. 8 Consultation
8.1 Notwithstanding the obligation placed on the master or owners of a ship to inform its flag State authority of any casualty occurring to the ship, where a casualty or incident occurs in the internal waters or territorial sea of another State, the coastal State should notify, with a minimum of delay, the flag State or States of the circumstances and what, if any, action is proposed by the coastal State. 8.2 Following a casualty, the investigating State should inform the other substantially interested States, either through the Consular Office in that State or by contacting the relevant authorities listed in MSC/Circ.781/ MEPC.6/Circ.2. That State and the other substantially interested States should consult, at the earliest opportunity, on the conduct of the investigation and to determine details of co-operation. 8.3 Nothing should prejudice the right of any State to conduct its own separate investigation into a marine casualty occurring within its jurisdiction according to its own legislation. Ideally, if more than one State desires to conduct an investigation of its own, the procedures recommended by this Code should be followed, and those States should co-ordinate the timing of such investigations to avoid conflicting demands upon witnesses and access to evidence. 9 Co-operation
9.1 Where two or more States have agreed to co-operate and have agreed the procedures for a marine casualty investigation, the State conducting the investigation should invite representatives of other substantially interested States to take part in the investigation and, consistent with the purpose of this Code, allow such representatives to:
8 .1 .2 .3 .4 .5 question witnesses; view and examine evidence and take copies of documentation; produce witnesses or other evidence; make submissions in respect of the evidence, comment on and have their views properly reflected in the final report; and be provided with transcripts, statements and the final report relating to the investigation.
9.2 States are encouraged to provide for maximum participation in the investigation by all States with a substantial interest in the marine casualty. 9.3 The flag State of a ship involved in a marine casualty should help to facilitate the availability of the crew to the investigation and encourage the crew to co-operate with the State conducting the investigation. 10 Disclosure of records
10.1 The State conducting the investigation of a casualty or incident, wherever it has occurred, should not make the following records, obtained during the conduct of the investigation, available for purposes other than casualty investigation, unless the appropriate authority for the administration of justice in that State determines that their disclosure outweighs any possible adverse domestic and international impact on that or any future investigation, and the State providing the information authorizes its release: .1 .2 .3 .4 all statements taken from persons by the investigating authorities in the course of the investigation; all communications between persons having been involved in the operation of the ship; medical or private information regarding persons involved in the casualty or incident; opinions expressed during the conduct of the investigation.
10.2 These records should be included in the final report, or its appendices, only when pertinent to the analysis of the casualty or incident. Parts of the record not pertinent, and not included in the final report, should not be disclosed.
Personnel and material resources
Governments should take all necessary steps to ensure that they have available sufficient means and suitably qualified personnel and material resources to enable them to undertake casualty investigations. 12 Issue of marine casualty reports and submission to IMO
12.1 The lead investigating State should send a copy of the draft of the final report to all substantially interested States, inviting their significant and substantiated comments on the report as soon as possible. If the lead investigating State receives comments within thirty days, or within some mutually agreed period, it should either amend the draft final report to include the
9 substance of the comments, or append the comments to the final report. If the lead investigating State receives no comments after the mutually agreed period has expired, it should send the final report to the Organization in accordance with applicable requirements and cause the report to be published. 12.2 By fully participating in an investigation conducted by another substantially interested State that will be reporting to IMO, the flag State shall be considered as fulfilling its obligations under IMO conventions. 12.3 Reports, or relevant parts of reports, into the circumstances and causes of a marine casualty should be completed as quickly as practicable, and be made available to the public and the shipping industry in order to enhance safety of life at sea and protection of the marine environment through improved awareness of the factors which combine to cause marine casualties. 12.4 Where a substantially interested State disagrees with whole or part of the report referred to in 12.1 above, it may submit its own report to the Organization. 12.5 The investigating State, upon determining that urgent safety action is needed, may initiate interim recommendations to the appropriate authority. 13 Re-opening of investigations
When new evidence relating to any casualty is presented, it should be fully assessed and referred to other substantially interested States for appropriate input. In the case of new evidence which may materially alter the determination of the circumstances under which the marine casualty occurred, and may materially alter the findings in relation to its cause or any consequential recommendations, States should reconsider their findings. 14 Contents of reports
14.1 To facilitate the flow of information from casualty investigations, each report should conform to the basic format outlined in 14.2 below. 14.2 Reports should include, wherever possible: .1 .2 .3 .4 .5 .6 a summary outlining the basic facts of the casualty and stating whether any deaths, injuries or pollution occurred as a result; the identity of the flag State, owners, managers, company and classification society; details of the dimensions and engines of any ship involved, together with a description of the crew, work routine and other relevant matters, such as time served on the ship; a narrative detailing the circumstances of the casualty; analysis and comment which should enable the report to reach logical conclusions, or findings, establishing all the factors that contributed to the casualty; a section, or sections, analysing and commenting on the causal elements, including both mechanical and human factors, meeting the requirements of the IMO casualty data base; and
10 .7 15 where appropriate, recommendations with a view to preventing similar casualties.
Contact between Administrations
To facilitate implementation of this Code, States should inform the Organization of the responsible authorities within their Governments that may be contacted regarding cooperation in casualty investigations.
11 Guidelines to assist investigators in the implementation of the Code Introduction The contents of this section should be treated as guidelines to assist investigators cooperating in an investigation. Investigators should bear in mind the information required under the IMO marine casualties and incidents reporting system. In following this Code, participating investigators must be guided by the requirements of the legal system of the State in which the investigation is being conducted. In particular, cooperating investigators must be guided by the requirements of national law over issues such as: 1. 1.1 providing formal notification of an investigation to interested parties; boarding ships and securing documents; arranging interviews with witnesses; the presence of legal advisers or other third parties during an interview.
Information generally required in all cases Particulars of the ship Name, IMO number, nationality, port of registry, call sign Name and address of owners and operators, if applicable, also, if an overseas ship, of agents Type of ship Name and address of charterer, and type of charter Deadweight, net and gross tonnages, and principal dimensions Means of propulsion; particulars of engines When, where and by whom built Any relevant structural peculiarities Amount of fuel carried, and position of fuel tanks Radio (type, make) Radar (number, type, make) Gyro compass (make, model) Automatic pilot (make, model) Electronic positioning equipment (make, model) (GPS, Decca, etc.) Life saving equipment (dates of survey/expiry)
Documents to be produced (Note: Any documents that may have relevance to the investigation should be produced. Where possible original documents should be retained, otherwise authenticated and dated photocopies should be taken in accordance with 9.1.2 of the Code. A number of these documents will contain details sought under 1.1 of these Guidelines.) Ship's register Current statutory certificates ISM Code certification Classification society or survey authority certificates Official log book
12 Crew list Crew qualifications (see also 1.4 of these Guidelines) Deck log book Port log, log abstract and cargo log book Engine movement book Engine-room log book Data logger print-out Course recorder chart Echo sounder chart Oil record book Soundings book Night order book Master's/Chief Engineer's Standing Orders Company Standing Orders/Operations Manual Company Safety Manual Compass error book or records Radar log book Planned maintenance schedules Repair requisition records Articles of Agreement Bar records - daily purchases - voyage receipts, etc. Records of drug and alcohol tests Passenger list Radio log Ship Reporting records Voyage Plan Charts and record of chart corrections Equipment/machinery manufacturer's operational/maintenance manuals Any other documentation relevant to the inquiry 1.3 Particulars of voyage Port at which voyage commenced and port at which it was to have ended, with dates Details of cargo Last port and date of departure Draughts (forward, aft and midships) and any list Port bound for at time of occurrence Any incident during the voyage that may have a material bearing on the incident, or unusual occurrence, whether or not it appears to be relevant to the incident Plan view of ship’s layout including cargo spaces, slop tanks, bunker/fuel lube oil tanks (diagrams from IOPP Certificate) Details of cargo, bunkers, fresh water and ballast and consumption 1.4 Particulars of personnel involved in incident Full name Age Details of injury Description of accident
13 Person supervising activity First aid or other action on board Capacity on board Certificate of Competency/Licence: grade; date of issue; issuing country/authority; other Certificates of Competency held Time spent on vessel concerned Experience on similar vessels Experience on other types of vessels Experience in current capacity Experience in other ranks Number of hours spent on duty on that day and the previous days Number of hours sleep in the 96 hours prior to the incident Any other factors, on board or personal, that may have affected sleep Whether smoker, and if so, quantity Normal alcohol habit Alcohol consumption immediately prior to incident or in the previous 24 hours Whether under prescribed medication Any ingested non-prescribed drugs Records of drug and alcohol tests 1.5 Particulars of sea state, weather and tide Direction and force of wind Direction and state of sea and swell Atmospheric conditions and visibility State and height of tide Direction and strength of tidal and other currents, bearing in mind local conditions 1.6 Particulars of the incident Type of incident Date, time and place of incident Details of incident and of the events leading up to it and following it Details of the performance of relevant equipment with special regard to any malfunction Persons on bridge Persons in engine-room Whereabouts of the master and chief engineer Mode of steering (auto or manual) Extracts from all relevant ship and, if applicable, shore documents including details of entries in official, bridge, scrap/rough and engine-room log books, data log printout, computer printouts, course and engine speed recorder, radar log, etc. Details of communications made between vessel and radio stations, SAR centres and control centres, etc., with transcript of tape recordings where available Details of any injuries/fatalities Voyage data recorder information (if fitted) for analysis 1.7 Assistance after the incident
14 If assistance was summoned, what form and by what means If assistance was offered or given, by whom and of what nature, and whether it was effective and competent If assistance was offered and refused, the reason for refusal 1.8 Authentication of documents
The master should be asked to authenticate all documents and to sign all copies taken of documents as being true copies, also to authenticate relevant dates and times 1.9 Engine-room orders
In all cases where a collision or a stranding is the subject of an investigation, and the movements of the engine are involved, the master or officer on watch and other persons in a position to speak with knowledge are to be asked whether the orders to the engine-room were promptly carried out. If there is any doubt on the matter, the investigator shall refer to it in his report. 1.10 External sources of information
Investigators should consider independent corroborating information from external sources such as radar or voice recordings from vessel traffic systems, shore radar and radio surveillance systems, marine rescue co-ordination centres, coroners and medical records. 2. 2.1 Additional information required in specific cases Fire/Explosion (Investigators should bear in mind the IMO Fire Casualty Record.) How was the ship alerted to the fire? How was the individual alerted to the fire? Where did it start? How did it start (if known)? What was the immediate action taken? Condition of fire-fighting equipment, supported by dates of survey/examination Extinguishers available: Type available in the vicinity; Types available on the ship; Types used Hoses available/used Pumps available/used Was water immediately available? Were air vents closed off to the space? What was the nature of the material on fire and surrounding the fire? Fire retardant specification of bulkheads surrounding the fire Restrictions caused by (a) smoke, (b) heat, (c) fumes Freedom of access Access availability for fire fighting equipment Preparedness of crew - Frequency, duration, content and locations of fire musters and drills
15 Response by land-based fire-fighting brigades 2.2 Collision (Investigators should bear in mind the IMO Damage cards and intact stability reporting format.) General Local or other special rules for navigation Obstructions, if any, to manoeuvring, e.g. by a third vessel, shallow or narrow waters, beacon, buoy, etc. Circumstances affecting visibility and audibility, e.g. state of the sun, dazzle of shore lights, strength of wind, ship-board noise and whether any door or window could obstruct look-out and/or audibility Geographical plot Possibilities of interaction Name, IMO number, nationality and other details of other vessel For each ship: Time, position, course and speed (and method by which established), when presence of other ship first became known Details of all subsequent alterations of course and speed up to collision by own ship Bearing, distance and heading of other ship, if sighted visually, time of sighting, and subsequent alterations Bearing and distance of other ship, if observed by radar, timing of observations and subsequent alterations of bearing If other ship was plotted and by what method (auto-plot, reflection plotter, etc.), and copy of plot, if available Check performance of equipment Course recorder Lights/day signals carried and operated in ship, and those seen in other ship Sound signals, including fog signals, made by ship and when, and those heard from other ship and when If a listening watch was kept on VHF radio channel 16, or other frequency, and any messages sent, received or overheard Number of radars carried on ship, number operational at time of casualty, together with ranges used on each radar Whether steering by hand or automatic Check that steering was operating correctly Details of look-out The parts of each ship which first came into contact and the angle between ships at that time Nature and extent of damage Compliance with statutory requirement to give name and nationality to other ship and to stand by after collision 2.3 Grounding Details of voyage plan, or evidence of voyage planning Last accurate position and how obtained Subsequent opportunities for fixing position or position lines, by celestial or terrestrial observations, GPS, radio, radar or otherwise, or by lines of soundings and, if not taken, why not Chart datum comparison to WGS datum
16 Subsequent weather and tidal or other currents experienced Effect on compass of any magnetic cargo, electrical disturbance or local attraction Radar/s in use, respective ranges used, and evidence of radar performance monitoring and logging Charts, sailing directions and relevant notices to mariners held, if corrected to date, and if any warnings they contain had been observed Depth sounding taken, when and by what means Tank soundings taken, when and by what means Draught of ship before grounding and how determined Position of grounding and how determined Cause and nature of any engine or steering failure before the grounding Readiness of anchors, their use and effectiveness Nature and extent of damage Action taken, and movements of ship, after grounding (Note: information as in cases of foundering may also be required) 2.4 Foundering (Investigators should bear in mind the IMO damage cards and intact stability reporting format.) Draught and freeboard on leaving last port and changes consequent upon consumption of stores and fuel Freeboard appropriate to zone and date Loading procedures, hull stresses Particulars of any alterations to hull or equipment, since survey, and by whom such alterations sanctioned Condition of ship, possible effects on seaworthiness Stability data and when determined Factors affecting stability, e.g. structural alterations, nature, weight, distribution and shift of any cargo and ballast, free surface in tanks or of loose water in ship Subdivision by watertight bulkheads Position of, and watertight integrity of, hatches, scuttles, ports and other openings Number and capacity of pumps and their effectiveness; the position of suctions Cause and nature of water first entering ship Other circumstances leading up to foundering Measures taken to prevent foundering Position where ship foundered and how established Life-saving appliances provided and used, and any difficulties experienced in their use Pollution resulting from an incident (Investigators should bear in mind IMO reporting of incidental spillages of liquids, 50 tonnes or more, and reporting of information from investigation of incidents involving dangerous goods or marine pollutants in packaged form.) Type of pollutant. UN number/IMO hazard class (if applicable). Type of packaging (if applicable). Quantity on board. Quantity lost. Method of stowage and securing. Where stowed and quantities in each compartment/container. Tanks/spaces breached.
17 Tanks/spaces liable to be breached. Action taken to prevent further loss. Action taken to mitigate pollution. Dispersant/neutraliser used, if any. Restricting boom used, if any. 3. Securing of physical evidence 3.1 Occasions may arise where physical evidence may be available and which will require scientific examination. Some examples are oil, paint/scale, pieces of equipment and machinery, pieces of structure. 3.2 Before removal, such evidence should first be photographed in situ. The sample should then be photographed on a clear background before being placed in an appropriate clean container(s), glass bottle, plastic bag, tin container, etc. The container should be sealed and clearly labelled, showing contents, name of vessel, location from which the evidence was taken, the date and the name of the investigator. For items of equipment and machinery, copies of the relevant certificates should be obtained. 3.3 Where paint samples are being taken for identification purposes in collision cases, a sample of paint from the ship's paint drum should also be obtained if possible. 3.4 Advice should be sought on the correct container to use. For example, plastic bags are suitable for paint samples, but are not suitable in investigations of fires where materials may need to be tested for accelerant, in which case sealable tin cans are preferred. 4. Voyage data recorders Where information from a voyage data recorder (VDR) is available, in the event that the State conducting the investigation into a casualty or serious incident does not have appropriate facilities for readout of the VDR, it should seek and use the facilities of another State, giving consideration to the following: .1 the capabilities of the readout facility; .2 the timeliness of the availability of the facility; and .3 the location of the readout facility. 5. Other sources of information Investigators should bear in mind that other Government agencies, such as customs, quarantine and State Authorities, may have useful information relating to crew lists, the general condition of the ship, stores lists (including alcohol on board), ship certificates, etc. Port authorities and independent surveyors may also hold information of use to an investigation.
18 A 20/Res.849
HUMAN ACTIVITY DATA FORM Investigation: Name: Qualifications Address: Phone: Managers: Phone: Joined ship: Travel time: Rank: Training/Courses: : Facsimile: Facsimile: Place joined: TABLE OF PREVIOUS 96 HOURS ACTIVITY (D-X day of Casualty)
D4 D3 D2 D1 DX (X, Time accident; F, Meal; W, Watch; M, Maintenance work; S, Sleep; C, Cargo Watch; R, Recreation, including time ashore; A, Alcoholic drink) Health Personal Issues : :
GUIDELINES ON INVESTIGATION OF HUMAN FACTORS IN MARINE CASUALTIES AND ACCIDENTS DRAFT ASSEMBLY RESOLUTION THE ASSEMBLY RECALLING Article 15(j) of the Convention on the International maritime Organization concerning the functions of the Assembly in relation to regulations and guidelines concerning maritime safety and the prevention and control of marine pollution from ships, CONSIDERING that practical advice for the systematic investigation of human factors in marine casualties and incidents will promote, where appropriate, effective analysis and preventive action, RECOGNIZING the need for development of practical guidelines for the investigation of human factors in marine casualties and incidents, HAVING CONSIDERED the recommendation made by the Maritime Safety Committee at its […..session], ADOPTS the Guidelines on investigation of human factors in marine casualties and incidents set out in the Annex to the present resolution; APPENDS the Guidelines as an annex to the Code for Investigation of Marine Casualties and Incidents; INVITES Governments concerned to implement the guidelines as soon as practicable, as far as national laws allow;
AUTHORIZES the Maritime Safety Committee to keep the guidelines under review and to amend them as necessary.
ANNEX GUIDEL1NES FOR THE INVESTIGATION OF HUMAN FACTORS IN MARINE CASUALTIES AND INCIDENTS CONTENTS 1 2 Introduction - Purpose of the Guidelines Investigation procedures and techniques
A systematic approach 2.2 2.2.1 2.2.2 2.2.3 2.2.4 2.2.5 General Timing of the investigation The Occurrence Site Witness Statements Background Information The Investigation Sequence
2.2.6 2.2.7 2.2.8 126.96.36.199 188.8.131.52 2.3 2.3.1 2.3.2 2.3.3 2.3.4 2.3.5 2.3.6 2.4 2.5 3 4 Fact Finding Conducting Interview Selection of Interviewees On Site(those newest the incident) Remote from the Occurrence Site Topics to be covered by the investigator People factors Organization on board Working and living conditions Ship factors Shore side management External influences and environment Analysis 2.4.1 Fact-finding and analysis Safety action Reporting procedures Qualifications and training of casualty investigators
APPENDICES APPENDIX 1 APPENDIX 2 APPENDIX 3 APPENDIX 4 The ILO/IMO Process for Investigating Human Factors Human Factors Questionnaire Definitions - Common Human Element Term Selected bibliography of UNCLOS/ILO/IMO requirements and recommendations related to investigations of human factors in marine casualties and incidents.
SECTION 1 INTRODUCTION – PURPOSE OF THE GUIDELINES The purpose of these Guidelines is to provide practical advice for the systematic investigation of human factors in marine casualties and incidents and to allow the development of effective analysis and preventive action. The long term intent is to prevent similar casualties and incidents in the future.* 1.2 Ships operate in a highly dynamic environment; frequently the people on board follow a set routine of shift work disrupted by arrival at, working in, and sailing from port. This is an existence which involves living in the place of work for prolonged periods creating a unique form of working life which almost certainly increases the risk of human error. 1.3 Historically, the international maritime community has approached maritime safety from a predominantly technical perspective. The conventional wisdom has been to apply engineering and technological solutions to promote safety and minimize the consequences of marine casualties and incidents. Accordingly, safety standards have primarily addressed ship design and equipment requirements. Despite these technical innovations, significant marine casualties and incidents have continued to occur.
1.4 Analyses of marine casualties and incidents that have occurred over the past 30 years have prompted the international maritime community and the various safety regimes concerned to evolve from an approach which focuses on technical requirements for ship design and equipment to one winch seeks to recognize and more fully address the role of human factors in maritime safety within the entire marine industry. These general analysis have indicated that given the involvement of the human in all aspects of marine endeavours including design, manufacture management, operations and maintenance, almost all marine casualties and incidents involve human factors. 1.5 One way the maritime community has sought to address the contribution of the human factor to marine casualties and incidents has been to emphasize the proper training and certification of ships' crews. It has become increasingly clear, however, that training is only one aspect of human factors. There are other factors which contribute to marine casualties and incidents which must be understood, investigated and addressed. The following are examples of these factors relevant to the maritime industry: communication, competence, culture, experience, fatigue, health, situational awareness, stress and working conditions. 1.6 Human factors winch contribute to marine casualties and incidents may be broadly defined as the acts or omissions intentional or otherwise which adversely affect the proper functioning of a particular system, or the successful performance of a particular task. Understanding human factors thus requires the study and analysis of the design of the equipment; the interaction of the human operator with the equipment and the procedures the crew and management followed. 1.7 It has been recognized that there is a critical need for guidance for accident investigators which will assist them to identify specific human factors which have contributed to marine casualties and incidents. There is also a need to provide practical information on techniques and procedures for the systematic collection and analysis of information on human factors during investigations. These Guidelines seek to fulfil those needs. They include a list of topics which should be considered by investigators and procedures for recording and reporting the results. *For the purpose of these Guidelines, the term “marine casualties and incidents" includes occupational accidents resulting in loss of life or serious personal injury. 1.8 These Guidelines should result in an increased awareness by all involved in the entire marine industry of the role human factors play in marine casualties and incidents. This awareness should lead to proactive measures by the marine community which in turn will result m the saving of lives, ships, cargo and the protection of the marine environment, improvements to the lives of marine personnel and more efficient and safer shipping operations. 1.9 These Guidelines apply, as far as national laws allow, to the investigation of marine casualties or incidents where either one or more interested States have a substantial interest in a marine casualty involving a ship under or within their jurisdiction.
SECTION 2 INVESTIGATION PROCEDURES AND TECHNIQUES 2.1 A systematic approach
The following is a process that provides a step-by-step systematic approach for use in the investigation of human factors. The process is an integration and adaptation of a number of established human factor
frameworks. The process can be applied to any type of marine casualty and incident and consists of the following steps: 1 2 3 collect occurrence data; determine occurrence sequence; identify unsafe acts (decisions) and unsafe conditions,
and then for each unsafe act (decision), 4 5 6 identify the error type or violation; identify underlying factors; and identify potential safety problems and develop safety actions.
This process is detailed in Appendix 1 A systematic approach to Step 1 is crucial to ensure that critical information is not overlooked or lost and that a comprehensive analysis is possible. Step 2 describes a process involved in organizing the data collected in Step 1 to develop a sequence of events and circumstances. In Step 3, the information gathered and organized is used to initiate the identification of occurrence causal factors, ie., unsafe acts, decisions or conditions. When an unsafe act, decision or condition is identified, the process shifts to determining the genesis of that particular act, decision or condition. Step 4 is initiated for each identified unsafe act or decision in order to specify the type of error or violation involved. In Step 5, the focus is placed on uncovering the underlying factors behind the unsafe act decision or condition. Fundamental to the process is the notion that for each underlying factor, there may be one or more associated unsafe act, decision or condition. The re-examination each step of the process emphasizes the iterative nature of this process in that it may show where further investigation is necessary. Finally, Step 6 requires the identification of potential safety problem and proposed safety action based on the identified underlying factors.
An occurrence may result in serious damage or impact and sometimes all four. The purpose of a marine casualty or occurrence safety investigation is to prevent recurrence of similar occurrences by identifying and recommending remedial action. All minor occurrences of high potential in terms of credible result should be subject of full investigation. Studies have shown that occurrences can have many casual factors and that underlying causes often exist remote from the incident site. Proper identification of such causes requires timely and methodical investigation, going far beyond the immediate evidence and looking for underlying conditions which may cause other future occurrences. Occurrence investigation should therefore be seen as a means to identify not only immediate causes, but also failures in the total management of the operation from policy through to implementation. For this reason investigations, must be broad enough to meet this overriding criteria.
Tuning of the investigation
An investigation should be carded out as soon as possible after an occurrence. The quality of evidence, particularly that relying on the accuracy of human recollection, can deteriorate rapidly with time, and
delayed investigations are usually not as conclusive as those performed promptly. A prompt investigation is also a good demonstration of commitment by all those concerned.
The occurrence site
Where possible, the site of the occurrence should be left unchanged until the investigation team has inspected it. Where this is not possible, for instance to make essential and immediate repairs following serious structural damage, the scene should be documented by photographs audio visual recordings or sketches or any other relevant means available with the object of preserving vital evidence and possibly recreating the circumstances at a later date. Of particular importance is the recording of the position of individuals at the site, the condition and position of equipment supervisory instructions, work permits and recording charts. Damage or failed components should be kept in a secure location to await the arrival of the investigation team who may require detailed scientific examination of certain key objects. Such key objects should be carefully
Once the situation in the immediate aftermath of an occurrence has been stabilised and the threat to people, plant and the environment has been removed, individuals involved should commit their recollections to paper in the form of a written statement to assist in preserving their memory of events.. In the event that local authorities take over responsibility for the investigation, the organisation/company involved should nominate a focal point to liaise with the authorities and to assist in assembling the information they require. Where necessary legal assistance should be provided.
Appropriate background information should be obtained before the occurrence location. Such information might include but is not necessarily limited to: procedures for the type of operation involved; records of instuctions / briefings given on the particular job being investigated; location plans; command structure, and. persons involved; messages, directions, etc., given from base/headquarters concerning the work.; vessel particulars and plans; and any other relevant information that may allow the investigator to understand the context of the incident
The Investigation sequence
The method for fact-finding while conducting an investigation includes but is not necessarily limited to the following activities: inspecting the location; gathering or recording physical evidence; interviewing witnesses taking into account cultural and language differences (on-site and external); reviewing of documents, procedure and records; conducting specialised studies (as required); identifying conflicts in evidence; identifying missing information; and recording additional factors and possible underlying causes
Following the fact-finding a typical marine casualty or incident investigation includes analyses of the facts, conclusions and recommendations.
24 2.2.6 Fact-finding
The objective of this stage of the investigation is to collect as many facts as possible which may help understanding of the incident and the events surrounding it. The scope of any investigation can be divided into five areas: people environment equipment procedures organization
Conditions, actions or omissions for each of these may be identified, which could be factors contributing to the incident or to subsequent injury damage or loss. During the initial stages of every investigation, investigators should aim to gather and record all the facts which may be of interest in determining causes. Investigators should be aware of the danger of reaching conclusions too early, thereby failing to keep an open mind and considering the full range of possibilities. With this in mind, it is recommended that the fact-finding stage of the investigation process itself be kept separate from the complete analysis of the collected evidence leading to conclusions and recommendations, and that a structured methodology he adopted to ensure the effectiveness of that analysis. Having said that, the analysis may well help to identify missing pieces of evidence, or different lines of enquiry that may otherwise have gone undetected. Investigation checklists can be very useful in the early stages to keep the full range of enquiry in mind, but they cannot cover all possible aspects of an investigation, neither can they follow all individual leads bad to basic casual factors. When checklists are used, their limitations should be clearly understood. The initial stages of an investigation normally focus on conditions and activities close to the incident and only primary causes also called "active failures", are usually identified at this stage. However, conditions or circumstances underlying these causes also called “latent failures”, should also be investigated. A factor to consider during an investigation is. recent change. In many cases it has been found that some change occurred prior to an occurrence which, combining with other causal factors already present, served to initiate the occurrence. Changes in personnel, organisation, procedures, processes, and equipment should be investigated, particularly the hand-over of control and instructions, and the communication of information about the change to those who needed to know. The effect of work cycles and work related six could have an impact on individuals’ performance prior to an occurrence. The impact of social and domestic pressures (so-called error enforcing conditions) related to individual’s behaviour should not be overlooked. Information should be verified wherever possible. Statements made by different witnesses may conflict and further supporting evidence may be needed. To ensure that all the facts are uncovered, the broad questions of “who?, what?, when?, where?, why?, and how?” should be asked.
An interview should start with the introduction of the interviewing party, the purpose of the investigation and of the interview, and the possible future use of the knowledge and material obtained during the interview. Investigators must be guided by the requirements of national law regarding the presence of legal advisers or other third parties during an interview.
People should be interviewed singly and be asked to go step-by-step through the events surrounding the occurrence, describing both their own actions and the actions of others. The interviewer should take into account the culture and language of the interviewee. Notwithstanding; any previously made written statements the value of a witness’s statement can be greatly influenced by the style of the interviewer, whose main task is to listen, to the witness's story and not to influence him. If the investigation is a team effort care must be taken not to make a witness feel intimidated by too many interviewers. Experience has shown that interviews can be effectively conducted by two interviewers and if appropriate, the witness could be accompanied by an independent "friend". It should be remembered that an investigation team is often seen in a prosecuting role, and there may be reluctance to talk freely if people think they may incriminate themselves or their colleagues. An investigator is not in the position to give immunity in return for evidence, but must try to convince interviewees of the purpose of the investigation and the need for frankness. In addition to requiring both patience and understanding, successful interviewing requires the existence of a "no-blame” atmosphere in which the witness can be made to feel comfortable and is encouraged to tell the truth. It is not the role of the interviewer, or indeed the investigation team, to apportion blame. Their role is to establish the facts and to establish why the occurrence happened. At the end of an interview the discussion should be summarised to make sure that no misunderstandings exist. A written record may be made of the interview and this may be discussed with the witness to clarify any anomalies. Subject to any national law, it may be possible to provide the interviewee with a copy of the written record.
Selection of interviewees
Established marine casualty and incident investigation procedures should be taken into account when determining whom to interview following a marine casualty. Safety concerns should be paramount in the scheduling of interviews. The emphasis must always be to get the investigation team to the site of the occurrence as soon as possible and to interview those most closely involved, which in the marine sense will always be the ship first. When that is not possible due to external factors such as the geographical location of the occurrence or other political factors, it may be possible to nominate a local representative to carry out an interim investigation. From an investigation management point of view, it should still be possible to start the process by carrying out at least some of the interviews of individuals ashore. It may not be possible to speak directly with Port or Pilotage Authorities in some parts of the world. Where that is so then every effort should be made to obtain at least a transcript of the Pilot’s statement if one is involved. In the event of a collision in enclosed waters, evidence from the operators of shore based electronic surveillance equipment can be particularly useful. Thee are no “hard and fast” rules for selecting who to interview and the following is offered as an example only:
184.108.40.206 On site (those nearest the incident)
Generally it is beneficial to begin the interview process with the ship management team including the Master and Chief Engineer who typically can provide an overview of the occurrence..
First hand witnesses present at the occurrence site at the time of the occurrence itself, regardless of rank/position in the organisation; First hand witnesses present at the occurrence site at the time of the occurrence itself, but from outside the organisation. Examples could be berthing or mooring assistants or visiting personnel such as agents or contractors; First hand witnesses present at the time of the occurrence but not at the occurrence location itself. Examples could be ship’s staff on the bridge of a ship witnessing a mooring occurrence on the main deck below; First hand witnesses present at the time of the occurrence but not at the occurrence location itself and. from outside the organization. Examples could be a pilot on the bridge witnessing a mooring occurrence on the main deck below; Those not involved with the occurrence itself but involved in the immediate, aftermath of an occurrence especially those engaged in the recovery process. Examples could be those involved in damage control, shipboard fire-fighting or first-aid medical treatment; Tug, mooring boat or pilot cutter crews; Search & Rescue personnel including helicopter crews; Shore-based fire-fighters; Jetty/Terminal Staff; Other vessels in the immediate vicinity; and Operators of Vessel Traffic Services (VTS) or Monitoring Systems.
220.127.116.11 Remote from occurrence site
2.3 Designated Person under the ISM Code; Ship Operators ashore; Technical Superintendents ashore; Company General Managers ashore; Specialists Consultants (relevant to the occurrence); Port State Inspectors; Flag State Inspectors; Regulatory authorities; Classification Societies Representatives; Safety committee members including am representatives; and Designers, shipbuilders, manufacturers and repairers. Topics to he covered by the investigator**
The diagram below shows a number of factors that have a direct or indirect impact on human behaviour and the potential to perform tasks.
The headings; in the diagram are expanded below: _______________________________________________________________________
**Appendix 2 provides appropriate areas of inquiry and appendix 3 provides definitions of common human element terms. 2.3.1
ability, skills, knowledge (outcome of training and experience) personality (mental condition, emotional state) physical condition (medical fitness, drugs and alcohol, and fatigue) activities prior to accident/occurrence assigned duties at time of accident/occurrence actual behaviour at time of accident/occurrence attitude
Organization on board
division of tasks and responsibilities composition of the crew (nationality/competence) -manning/level
workload/complexity of tasks working hours/rest hours procedures and standing orders communication (internal and external) on board management and supervision organization of on board training and drills teamwork including resource management planning (voyages, cargo, maintenance)
Working and living conditions
level of automation ergonomical design of working, living and recreation places and equipment adequacy of living conditions opportunities for recreation adequacy of food level of ship motion, vibrations, heal and noise
design state of maintenance equipment (availability, reliability) cargo characteristics including securing, handling and care -certificates
Shore side management
policy on recruitment safety policy and philosophy (culture, attitude and trust) management commitment to safety scheduling of leave periods general management policy port scheduling contractual and/or industrial arrangements and agreements assignment of duties ship-shore communication
External. Influences and environment
weather and sea conditions port and transit conditions (V1S, pilots etc) traffic density ice conditions organizations representing shipowners and seafarers regulations, surveys and inspections (international, national, port, classification societies, etc)
Once facts are collected, they need to be analyzed to help establish the sequence of events in the occurrence, and to draw conclusions about safety deficiencies uncovered by the investigation. Analysis is a disciplined activity that employs logic and reasoning to build a bridge between the factual information and the conclusions.
The first step in analysis is to review the factual information to clarify what is relevant, and what is not, and to ensure the information is complete. Thus, this process can give guidance to the investigator as to what additional investigation needs to be carried out. In normal investigation practice, gaps in information that cannot be resolved are usually filled in by logical extrapolation and reasonable assumptions. Such extrapolation and assumptions should be identified and a statement of the measure of certainty provided. Despite best efforts, analysis may not lead to firm conclusions. In these cases, the more likely hypotheses should be presented. 2.4.1 After fact finding and analysis it should be possible to give a description of the occurrence, its background, tuning, and the events leading to it The description should include such factual items as: the weather conditions; the operation(s) involved; the equipment in use, its capabilities, performance and any failures; the location of key personnel and their actions immediately before the incident; the pertinent regulations and instructions; uncontrolled hazards; changes of staff, procedures, equipment or processes that could have contributed to the occurrence; what safeguards were or were not in place to prevent the incident; response to the occurrence (first-aid, shut-down, fire-fighting, evacuation, search and rescue); medical treatment actions taken to mitigate the effects of the occurrence and the condition of injured parties, particularly if disabling injuries or death ensured; damage control including salvage; inventory of all consequences of the occurrence (injury, loss, damage or environmental damage); and general ship's condition.
It should also be possible to identify active and underlying factors such as: operational deviations; design aspects of hull structural failure; defects m resources and equipment; inappropriate use of resources and equipment; relevant personnel skill levels and their application; physiological factors (eg. fatigue, stress alcohol, illegal drugs, prescription medicine); why safeguards in place were inadequate or failed; role of safety programmes; problems relating to the effectiveness of regulations and instructions; management issues; and communication issues.
The ultimate goal of a marine investigation is to advance maritime safety and protection of the marine environment. In the context of these guidelines, this goal is achieved by identifying safety deficiencies through a systematic investigation of marine casualties and incidents, and then recommending or effecting change in the maritime system to correct these deficiencies.
In a report that clearly lays out the facts relevant to the occurrence, and then logically analyzes those facts to draw reasoned conclusions including those relating to human factors, the required safety action may appear self-evident to the reader. Recommended safety actions in whatever form should clearly identify what needs to be done, who or what organization is the agent of change, and, where possible, the urgency for completion. SECTION 3 REPORTING PROCEDURES 3.1 To facilitate the flow of information from casualty investigations, each report should conform to a basic format as outlined in IMO Assembly resolution A. 849(20) - Code for the Investigation of Marine Casualties and Incidents. 3.2 Reports should be made to IMO in accordance with established procedures***.
3.3 Persons and/or organizations with a vested interest in a report should be given the opportunity to comment on the report or relevant parts thereof before the report is finalized. The final report should be distributed to relevant parties involved and preferably be made public. ***MSC/Circ.827, MUC/Circ.333 of 9 December 1997 reports on marine casualties and incidents, inter alia.
31 SECTION 4
QUALIFICATIONS AND TRAINING OF INVESTIGATORS
4.1 Many and varied contributory factors can play a significant part in the events preceding a marine casualty or incident. The question of who should be charged with the responsibility for investigating and analysing human factors therefore becomes important The skilled marine casualty and incident investigator generally is the person best suited to conduct all but the most specialized aspects of human factor investigation. 4.2 An investigator should have appropriate experience and formal training in marine casualty investigation. The formal training should include specific training in the identification of human factors in marine casualties and incidents. 4.3 In some cases, a human factors specialist may be of significant value in the investigation.
THE IMO/ILO PROCESS FOR INVESTIGATING HUMAN FACTORS The following is a process that provides a step-by-step systematic approach for use in the investigation of human factors. The process is an integration and adaptation of a number of human factor frameworks SHEL (Hawkins, 1987) and Reason’s (1990) Accident Causation and generic error-modelling system (GEMS) frameworks, as well as Rasmussen’s Taxonomy of Error (1987). The process can be applied to both types of occurrences, i.e., accidents and incidents. The process consists of the following steps: 1) 2) 3) collect occurrence data; determine occurrence sequence; identify unsafe acts (decisions) and ~e conditions;
and then for each unsafe act (decision), 4) 5) 6) identify the error type or violation; identify underlying factors; and identify potential problems and develop actions.
Steps 3 to 5 are useful to the investigation because they facilitate the identification of latent unsafe conditions. Step 6, the identification of potential safety problems is based extensively on what factors were identified as underlying factors. At times, an unsafe condition may be a result of a natural occurrence; in that case the investigator may jump from Step 3 to Step 6. At other times, an unsafe act or decision may result from an unsafe condition which itself was established by a fallible decision; in such a case, the investigator should proceed through Steps 3 to 6. Step 1 – Collect Occurrence Data The first step in the human factors investigation process is the collection of work-related information regarding the personnel, tasks, equipment and environmental conditions involved m the occurrence. A systematic approach to this step is crucial to ensure that a comprehensive analysis is possible and that the logistical requirements of collecting, organizing and maintaining a relevant occurrence related database are met. For complex systems, where there are numerous interactions between the component elements, there is constant danger that critical information will be overlooked or lost during an investigation. Use of the SHEL model as an organizational tool for the investigator's workplace data collections helps avoid downstream problems because: i) it takes into consideration all the important work system elements; ii) it promotes the consideration of the interrelationships between the work system elements; and iii) it focuses on the factors which influence human performance by relating all peripheral elements to the central liveware element At this step, the process attempts to answer the more simplistic questions concerning “what, who, and when” and then moves to more complicated questions of "how and why”. The resulting data becomes, for the most part, a collection of events and circumstances comprised of acts and conditions. Some of these will be of interest as unsafe acts and unsafe conditions.
There are four components to the SHEL model: Liveware - L Hardware - H Software - S Environment - E The SHEL Model is commonly depicted graphically to display, not only the four components, but also the relationships, or interfaces, between the Liveware and all the other components. Figure 1 attempts to portray the fact that the match or mismatch of the interfaces is just as important as the characteristics of the block themselves. A mismatch can be a source of human error and identification of a mismatch may be the identification of a safety deficiency in the system. Figure 2 also depicts how this model can be applied to a complex system where multiple liveware, hardware, software and environmental element exist
Figure 1. (Adapted from Hawkins, 1987) SHEL Model Liveware (Central Component) The most valuable and flexible component; m the system is the human element, the Liveware, placed at the centre of the model. Each person brings his or her own capabilities and limitations, be they physical, physiological, psychological, or psychosocial. This component can be applied to any person involved with the operation or in support of the operation. The person under consideration interacts directly with each one of the four other elements. The person and each interaction, or interface constitute potential areas of human performance investigation. Liveware (Peripheral) The peripheral Liveware refers to the system’s human-human interactions, including such factors as management, supervision, crew interactions and communications. Hardware Hardware refers to the equipment part of a transportation system. It includes the design of workstations, displays, controls, seats, etc. Software
Software is the non-physical part of the system including organizational policies, procedures, manuals, checklist layout, charts, maps, advisories, and increasingly, computer programs. Environment Environment includes the internal and external climate, temperature, visibility, vibration, noise and other factors which constitute the conditions within which people are working. Sometimes the broad political and economic constraints under which the aviation system operates are included in this element. The regulatory is a part of the environment in as much as its climate affects communications, decision making control, and coordination. Step 2 - Determine Occurrence Sequence As the investigator moves to addressing questions of "how and why", there is a need to link the data identified in the first step of the process. Reason's (1990) model of accident causation, utilizing a production framework, can he used by an investigator as a guide to developing an occurrence sequence. As well, Reasons model facilitates further organization of the work system data collected using the SHEL model, and an improved understanding of their influence on human performance. The occurrence sequence is developed by arranging the information regarding occurrence events and circumstances around one of five production elements, i.e., decision makers, line management, preconditions, productive activities, and defences. The production elements themselves are basically aligned m a temporal context. This temporal aspect is important organizing factor since the events and circumstances that can lead to an accident or incident are not necessarily proximate in time nor in location to the site of occurrence. By establishing a sequential ordering of the data, Reasons (1990) concept of active versus latent factors is introduced. Active factors are the final event or circumstances which led to an occurrence. Their effect is often immediate because they occur either directly in the system’s defences (e.g, disabled warning system) or at the site of the productive activities (i.e., the integrated activities of the work system’s liveware, software and hardware elements), which would indirectly result in the breaching of the system’s defences (e.g., use of the wrong procedure). Underlying factors may reside at both the personal and the organizational levels; they may be present in the conditions that exist within a given work system (referring to the preconditions element in the model). Examples of underlying factors include inadequate regulations, inadequate procedures, insufficient training, high workload and undue time pressure. In practice, Steps 1 and 2 may not be mutually exclusive. As the investigator begins the data collection step, it would be only natural that attempt be made to place the information, albeit often fragmentary in the preliminary stages of an investigation, into the context of an occurrence sequence. To facilitate this concurrent activity, the SHEL and Reason models can be combined as illustrated in Figure 2.
Figure 2. SHEL and Reason Hybrid Model The data collected during an investigation (i.e. events and circumstances) can be organized, using multiple components of the modified SHEL model, into a framework surrounding an occurrence template (in this case the occurrence scenario), based upon the Reason model. Causal factors, i.e., the unsafe acts/decisions and conditions are thereby identified Steps 3 – 5 - An Overview Steps 3 to 5 are based upon the GEMS framework. The framework provides "pathways" that lead from the identification of the unsafe act/decision (Step 3) to the identification of what was erroneous about the action or decision (Step 4) and finally to its placement within, a behavioural context (i.e., a failure mode within a given level of performance in Step 5). The GEMS framework illustrated in Figure 3 is particularly useful in exploring hypothetical reconstructions of the occurrence facts. Step 3 - Identify Unsafe Acts/Decisions and Conditions In Step 3 of the process, the investigation takes on a reductionist nature where the information gathered and organized using the SHEL and Reason frameworks is used to initiate identification of occurrence causal factors, i.e., unsafe acts/decisions and conditions. An unsafe act is defined as an error or violation that is committed in the presence of a hazard or potential unsafe condition. Decisions, where there are no apparent resultant actions but which have a negative impact on safety, should also be considered as unsafe
acts. An unsafe condition, or hazard as noted above, is an event or circumstance that has the potential to result in a mishap. There may be several acts, decisions and/or conditions which are potential unsafe candidates, thus necessitating assessments of the occurrence facts. The SHEL and Reason hybrid tool (refer to Figure 2) can provide a useful base for conducting such iterative assessments. When an unsafe act, decision or condition is identified, the focus shifts to determining the genesis of that particular act or condition. Further investigation and/or analysis may reveal other unsafe acts/decisions or conditions antecedent to the causal factor that was initially identified. As noted earlier, several unsafe acts and decisions may be identified throughout Steps 1 and 2 of the process. The last unsafe act precipitating the occurrence often provides a convenient starting point for reconstruction of the occurrence. This last act or decision differs from the others, in that, it can be viewed as the definitive action or decision which led to the occurrence, i.e., the last act or decision that made the accident or incident inevitable - the primary cause of the initial event. Although it is usually an active failure the last unsafe act or decision can be embedded in a latent unsafe condition, such as a flawed design decision which led to a system, failure. Step 4 - Identify Error or Violation Type This portion of the process, i.e., Step 4, is initiated for each unsafe act/decision by posing the simple question, “what is erroneous or wrong about the action or demon that eventually made it unsafe?" The identification of the type of error or violation involves two sub-steps (see Figure 3):
Figure 3. The GEMS Framework (Adapted from Reason, 1990) Unintentional or Intentional Action
First it is necessary to determine whether the error or violation was an unintentional or intentional action. "Did the person intend action”? If the answer to that question is no, then it is an unintentional action. Unintentional actions are actions that do not go as planned; these are errors in execution. If the answer to the question “Did the person intend the action”? is yes, then the action is intentional. Intentional actions are actions that are carried out as planned but the actions are inappropriate; these are errors in planning 2) Error Type or Violation
The second subset is the selection of the error type or violation that best describes the failure, keeping in mind the decision regarding intentionality. There are four potential error/violation categories, i.e., slip, lapse, mistake and violation. A slip is an unintentional action where the failure involves attention. These are errors in execution. A lapse is an unintentional action where the failure involves memory. These are also errors in execution. A mistake is an intentional action, but there is no deliberate decision to act against a rule or plan. These are errors in planning. A violation is a planning failure where a deliberate decision to act against a rule or plan has been made. Routine violations occur everyday as people regularly modify or do not strictly comply with work procedures, often because of poorly designed or defined work practices. In contrast, an exceptional violation tends to be a one-time breach of a work practice, such as where safety regulations are deliberately ignored to carry out a task. Even so, the goal was not to commit a malevolent act but just to get the job done. Step 5 - Identify Underlying Factors The designation of separate activities implied by Steps 4 and 5 may be somewhat arbitrary in terms of what actually occurs when an investigator attempts to reveal the relationship between the occurrence errors/violations and the behaviours that lead to them. In simplest terms, a behaviour consists of a decision and an action or movement. In Step 3, the action or decision (i.e., unsafe act or decision) was identified. In Step 4, what was erroneous regarding that action or decision was revealed. In Step 5, the focus is now placed on uncovering the underlying causes behind the act or decision of an individual or group. To do so it is important to determine if there were any factors in the work system that may have facilitated the expression of the given failure mode (and hence the error/violation and the unsafe act). These factors have been termed underlying factors. These factors can be found by examining the work system information collected and organized using the SHEL or Reason frameworks in Steps 1 and 2. The re-examination of these data again emphasizes the iterative nature of this investigative process where it may even be deemed necessary to conduct further investigations into the occurrence. Step 6 - Identify Potential Safety Problems and develop Safety Actions The identification of potential safety problems is based extensively on what factors were identified as underlying factors. Once again this underscores the importance of the application of a systematic approach to Steps 1 and 2 of the process which sets the foundation for the subsequent analysis steps. Where appropriate, the potential safety problems can be further analysed to identify the associated risk to the system and to develop safety actions. References Edwards, E (1972). Man and machine: Systems for safety. In Proceedings of the BALPA Technical Symposium London. Hawkins, F.H. (1987). Human factors in flight. Aldershot, UK: Gower Technical Press.
Nagel, D.C. (1988). Human error in aviation operations. In E.L. Weiner and D.C. Nagel (Eds.), Human factors in aviation (pp. 263-303). San Diego, CA: Academic Press. Norman, D.A (1981). Categorization of action slips Psychological Review, 88 (1), 1-15. Norman, D.A (1988). The psychology of everyday things. New York: Basic Books. Rasmussen, J. (1987). The definition of human error and a taxonomy for technical system design. In J. Rasmussen, & Duncan, and J. Leplat (Eds.), New technology and human error. Toronto: John Wiley & Sons. Reason, J (1990). Human error. New York: Cambridge University Press.
APPENDIX 2 AREAS OF HUMAN FACTOR INQUIRY The following questions are designed to aid the investigator while investigating for human factors. Skilful questioning can help the investigator eliminate irrelevant lines of inquiry and focus on areas of greater potential significance The order in which the questions should be asked will depend on who is being interviewed and on his or her willingness and ability to describe personal behaviour and personal impressions. Also, it may be necessary to verify, cross-check or augment information received from one person by interviewing others on the same points. These areas of inquiry can be used in planning interviews. The following questions are not intended as a checklist, and some may not be relevant in the investigation of a particular accident ' 1 .1 .2 .3 .4 .5 .6 .7 2 .1 .2 .3 Safety Policy Does the company have a written safety policy? Is there a designated person for shipboard safety matters in the company? When did a company Representative last visit the vessel or when were you last in contact with the company? When were you last provided safety training? What was the training and how was it provided? When was the last emergency drill (e.g., fire, abandon ship, man-overboard, pollution response, etc) and what did you do during the drill? Was appropriate personal protective equipment provided and did you use it? Are you aware of any personal accidents which occurred on board in the period prior to the accident? Activities prior to incident (If the ship was leaving port at the time of the accident) In general, how did you spend your time while the ship was in port? (If the ship was approaching port or at sea at the time of the accident) How long has the ship been on passage since its last port or terminal operation? What were you don immediately to coming on watch or reporting for duty, and for how long? Recreational activity? Physical exercise? Sleeping? Reading? Watching T.V.? Eating? Paperwork? Travelling to vessel?
.5 .6 .7 3 .1 .2 .3
Specifically what were you doing approximately 4 hours,……1 hour,……….30 minutes……..before the accident?
What evolution was the ship involved m when the accident occurred? What was your role during that evolution? Immediately prior to the accident, what were you thinking about? At any time before the accident, did you have any indication that anyone was tired or unable to perform their duty? Duties at the time of accident Where were you on the ship when the accident occurred? What specific job or duty were you assigned at the time? By whom? Did you understand your assignment? Did you receive any conflicting orders? How often have you performed this job in the past (on the specific ship involved in the accident)?
4 .1 .2 .3 5 .1 .2 .3 .4 .5 6 .1 .2 .3 7 Actual behaviour at time of accident Precisely where were you located at the time of the accident? What specific task were you performing at the time of the accident? Had you at any time since reporting for duty found that you could not concentrate (focus your attention/keep your mind) on a task you were trying to perform? Training/Education/Certification/Professional Experience How long have you been assigned to this ship? Have you requested that your assignment be lengthened or shortened? How long have you filled your crew position? What other crew positions have you held on this ship? How long have you held the certificate indicating your qualifications? Before being assigned to this ship, did you work on other ships? If so, what crew positions have you held? What is the longest time you have been to sea in a single voyage? How long have you been at sea on this passage? What was your longest single passage Physical condition Were you feeling ill or sick at any time in the 24 hours immediately before the accident. If so, what symptoms did you have? Did you have a fever, vomit, feel dizzy, other? Also, did you tell anyone? What do you believe the cause was? When was the last meal you had prior the accident? What did you eat? Was it adequate? Do you exercise regularly while on board? When did you last exercise (before the accident)? How long was the session? Psychological, emotional mental condition and employment conditions When was the last time you felt cheerful or elated on board the ship, and what were the circumstances that generated this emotion? When was the last time you were sad or depressed or dejected, on board the ship? Why? Did you talk about it with anyone else? Have you had to make any difficult personal decisions recently? Have you had any financial or family worries on your mind recently? Have you been criticized for how you are doing your work lately? By whom? Was it justified? What was the most stressful situation you had to deal with on the voyage (prior to the accident)? When did the situation occur? How was it resolved? What are the contractual arrangements for all crewmembers? Have there been any complaints or industrial action in the last (12) months? Workload/Complexity of Tasks What is the shipboard organization? Is the shipboard organization effective? What is your position in the shipboard organization (i.e., who do you work for, report to or assign duties to)? What is the nature of your work? Sedentary? Physically demanding? Was anyone involved in the accident impaired due to heavy workload? Work-period/rest-period/recreation pattern
.2 .3 .4 .5 .6 .7 8 .1 .2 .3 .4 .5 9
.1 .2 .3 .4 .5 .6 .7 .8 10 .1 .2 .3 .4 .5 .6 .7 .8 .9 What is your normal duty schedule? Are you a day worker or a watchstander? What was your duty schedule on the day before the accident and during the week before the accident? Were you on overtime at the time of the accident? How long had you been on duty, or awake performing other work, at the time of the accident? When was your last period of sleep? How long did it last? How often did you awaken during your last sleep period? Did you awaken refreshed? If not, what would have made your sleep period more restful? How do you normally spend your off-duty time while on board? Play cards? Read? Listen to music? Watch T.V.? Other? When was your last extended period of off duty time when your were able to rest? Relationship with other crewmembers and superiors/subordinates Who among the crew would you consider to be a friend? Do you find any members of the crew unpleasant to be with? Do you have difficulty talking with any of the crewmembers because of language barriers? Have any new crewmembers recently joined the ship? Have you had a chance to get acquainted with them? Did you have any argument recently with another crewmember? In an emergency, would you trust your fellow crewmembers to come to your assistance? Has another crewmember ever offered to take your place on watch or perform a duty for you to let you get some extra rest? What was the subject of your last conversation with another crewmember before reporting for duty (when the accident occurred)? Have you talked with any other crewmembers since the accident. If so, what was the subject of your conversation? Have you talked with anyone else about the accident prior to being interviewed? Living conditions and shipboard environment Do you consider your personal area on board the ship to be comfortable? If not, how would you like it to improved? Prior to the accident, did you have any didifficulty resting as a result of severe weather, noise levels, heat/cold, ship's motion, etc.? Manning levels Is the manning level sufficient in your opinion for the operation of the vessel? Master's standing orders Are there written standing orders to the whole crew complement from the Master? Did the Master/Chief Engineer provide written or verbal standing orders to the watchkeeping personnel? Were the orders m conflict with the company safety policy? Level of automation/reliability of equipment In your opinion, was the system reliable? Were them earlier failures in the system? Were the failures repaired by the crew or shore-based workers?
11 1 .2 12 .1 13 .1 .2 .3 14 .1 .2 .3
Ship design, motion/cargo characteristics Did you observe anything out of the ordinary on this passage concerning the ship design, or motion or cargo characteristics? SHORESIDE MANAGEMENT
Questions 16-24 16 .1
Scheduling of work and rest periods What is the company's work schedule and relief policy?
Manning level .1 18 .1 .2 19 .1 20 .1 21 .1 22 .1 23 .1 24 .1 .2 25 How is the manning level determined for your fleet? Watchkeeping practices Do you require the master to stand watch? Do you leave the watchkeeping practices to the discretion of the Master? Assignment of duties Do you leave this matter to the Master? Shore-ship-shore support and communications How do you support the vessel’s Master? Management policies Does the company have a written safety policy? Voyage planning and port call schedules How does the Master plan the voyages? Recreational facilities Are welfare/recreational services and facilities provided on board? Contractual and/or industrial arrangements and agreements What are the contractual agreements for all crewmembers? Have there been any complaints or industrial action m the last (12) months? National/international requirements
.1 Are the management/Master complying with the requirements and recommendations of the applicable international conventions and Flag State regulations?
APPENDIX 3 DEFINITIONS COMMON HUMAN ELEMENT TERMS Human error A departure from acceptable or desirable practice on the part of an individual or group of individuals that can result in unacceptable or undesirable results. Diminished human performance: Emotional: A physiological state of agitation or disturbance which can affect an individual’s normal ability to perform required tasks. Panic: Anxiety A sudden overpowering fear that reduces the ability to perform required tasks. A state of uneasiness and distress about future uncertainties which may reduce the ability to properly focus on a required task.
Personal problem: A problem which preoccupies the emotions and reduces the ability to perform required tasks. Examples include physical disabilities, death or illness in the family, marital and other relationship problems, health concerns, financial problems, anger, or poor interactions with shipmates. Mental impairment Diminished mental ability tat can reduce or impede an individual’s normal ability to perform the mental pan of required tasks. Alcohol use: Consumption of alcoholic beverages which diminishes an individual’s abilities to perform required tasks. Examples include drinking on or too close to duty which can impede an individual’s abilities; drunkenness on duty; drinking off duty which results poor performance while on duty; and excessive drinking over a longer period of time which results in a permanent decrease in mental abilities. Use of medicine or a narcotic which effects an individual’s abilities to perform required tasks There are many different effects on mental and physical capabilities that can result from the use of legal and illegal drugs, such as extreme drowsiness to a false sense of competence to hallucinations. Mental abilities of the user may also be distracted by the constant need to obtain additional drugs. In addition, individuals may not be aware of the “side-effects” of legal drugs and may take them while on duty or forget to report taking them. The loss of attention, notice or regard; neglect. Examples include failing to monitor displays; not maintaining a proper lookout; forgetting to perform an assigned duty. Inattention may also be the result of other causes such as a personal problems fatigue, drugs, boredom, or hearing problems. Physical damage to the body which causes a decrease in mental or physical abilities. Examples include a head injury and injuries such as a smashed finger or a severe burn where pain causes distraction and a loss of mental ability.
Mental illness: Psychotic or erratic behaviour; depression; hallucinations; unexplainable, or other forms of abnormal behaviour. Physical illness: Sickness which produces a decrease in mental or physical abilities but, not generally termed as mental illness. Examples include: the general disability accompanying colds
and flu; hallucinations due to high fever; migraine headaches: seasickness; and even severe indigestion and exposure to toxic substances. Diminished Motivation: Lack of will or desire to perform well resulting in a decrease of an individual’s normal performance of required tasks. Deliberate misaction: Purposely taking an incorrect action or purposely failing to take the correct action. Examples include dereliction of duty; refusal to obey commands; sabotage, theft or ignoring procedures. Fatigue: A reduction in physical and/or mental capability as the result of physical, mental or emotional exertion which may impair nearly all physical abilities including: strength; speed; reaction time; co-ordination; decision making or balance. A problem with individual or group motivation as shown by reduced willingness, confidence, or discipline to perform assigned tasks. Examples/causes may include interpersonal conflict amongst the crew, officers with poor interpersonal skills, lack of a strong corporate or shipboard safety culture, excessively long tours of duty.
Lack of self-discipline: Inadequate ability of an individual to control personal conduct. Examples include loss of temper, or unprofessional behaviour. Visual problem: A reduced visual, acuity due to a specific physical disability. Causes may include eye injury causing total or partial blindness; not wearing prescribed glasses or contacts; inability to adequately adapt to darkness. Excessive workload: Diminished physical or mental capability as the result of the sum total of all the mental and physical tasks a human must perform within a prescribed time resulting in a diminished job performance. Marine environment Hazardous natural environment: A situation in which the natural environment causes required tasks to become more difficult than usual. Examples include storms; high waves; shallow water; severe shoaling; strong currents or tides; ice; rocks; submerged wrecks, severe eddies, ship traffic, wind; fog; mist; rain; snow; sleet; haze; dust; airborne debris. Poor design of the ships, its subsystems, its environmental controls, or its human-machine interfaces, which results in an increased difficulty to perform shipboard tasks. Examples of poor human factors engineering design include inadequate lighting; excessive noise; excessive vibration; inadequate heating, cooling, or ventilation systems; hazardous deck stair, ladder, bulkhead, or work surfaces; inadequate provision for foul weather or degraded mode operations; inadequate restraints, guards, or hand-holds; poor workstation orientation in regard to ship dynamics; poor hull seakeeping characteristics; controls whicvh allow accidental actuation; illegible or ambiguous control markings; illedgible or ambiguous displays or display labels; poor layout, sizing, and colouring of controls and displays; inadequate design for operational or maintenance access; inadequate design for safety.
Poor human factors engineering design:
Poor operations: A situation in which individuals or groups of individuals degrade the shipboard environment making the performance of some required tasks more difficult. Examples include ship manoeuvres (e.g. increased speed, change in course, erratic manoeuvres) impact ship dynamics causing balance and restraint difficulties, when personnel performing one task interfere with those performing another; or where storage of cargo impedes access or transit. Failure to keep any part of the ship or its equipment in the condition it was designed to function within a designated lifetime or operational period, thus degrading the shipboard environment and making the performance of some required tasks more difficult. Examples of poor maintenance impacting on required tasks are; inadequate replacement parts, tools to perform proper maintenance that are the result of a lack of commitment from management.
Safety administration: Inadequate technical knowledge:
Not knowing due to inadequate experience and/or training, the general knowledge which is required for the individual’s job on board. Examples are navigation, seamanship, propulsion systems, cargo handling, communications, or weather. Not knowing, due to inadequate experience, lack of communication/co-ordination, and/or training, the current status of the ship, its systems, or its environment. Examples include lack of knowledge of location, heading or speed or lack of knowledge of status of ongoing maintenance on board. Not making use of all the available information sources to determine current status. This may be the result of a lack of initiative on the part of the individual or a lack of initiative and/or cooperation on the part of others. Examples of poor communication/coordination include: poor communication between bridge officers, poor communication with pilots, or poor deck to engine room coordination. Lack of knowledge resulting from inadequate experience, a failure ship to know regulations, an inadequate knowledge of procedures, inadequate training, and/or being unaware of your role/task responsibility. Examples of areas where you might lack knowledge are: Navigation, seamanship, propulsion systems, cargo handling, communications, or weather. Lack of knowledge or understanding or required regulations due to inadequate experience and/or training. Examples of possible regulations; company policies and standards, national and international regulations, other port State’s maritime regulations, local jurisdiction regulations, shipboard regulations, cautionary notices, charts notations, or labelling. Not knowing due to inadequate experience and/or training the shipboard and company policies requiring adequate knowledge of your own ship’s operation. Examples include emergency
Inadequate situational communication/awareness:
Lack of communication of co-ordination:
Inadequate knowledge of operations:
Inadequate knowledge regulations/standards:
Inadequate knowledge of ship procedures:
procedures, maintenance procedures, administrative procedures, and safety system procedures. Unaware of role/task responsibility: Inadequate knowledge of the specific job required of an individual. Examples include a lack of understanding of command responsibilities, communications responsibilities, safety responsibilities, maintenance responsibilities and emergency responsibilities. A lack of primary language skills necessary to communicate and perform duties as required. This includes total or partial inability to speak, read or comprehend the primary language and/or other required language sufficiently to understand all shipboard commands, instructions, procedures, labels, warnings, and regulations. Failing to ensure that personnel submit to authority, regulations and procedures. Examples include: tolerating unqualified or inept personnel, not enforcing regulations and procedures, tolerating inappropriate insubordination. Mistakes in giving commands. Examples of faulty command include: proper command not given, proper command not given at the appropriate time or out of sequence with other commands, incorrect commands, conflicting commands. Inadequate oversight of activities of personnel under an individual’s supervision. Examples of faulty supervision include: not checking to see that a job was performed in a timely and correct manner, not providing proper resources to problems brought to the attention of supervising individual, unequal treatment of personnel. Failure to communicate and coordinate to address issues, problems, and tasks both aboard ship and ashore. Examples include: poor communication between bridge officers, poor communication with pilots, poor communication with home office, poor deck to engine room coordination. Poor management of physical resources which ensure that people have the tools, equipment, supplies, facilities, food, water, fuel, etc to perform their required tasks. Examples of faulty management of physical resources include: absence of physical resources, shortage of physical resources, inappropriate physical resources, physical resources stored improperly, physical resource difficult to obtain when needed. Failing to ensure that all required tasks aboard ship can be properly performed and that adequate personnel of the proper skill level, physical and mental ability, experience, certification, and inclination to properly perform those tasks.
Inadequate language skills:
Management: Failure to maintain discipline:
Failure of command:
Inadequate co-ordinator or communication:
Inadequate management of physical resources:
Inadequate manpower available: Poor job design Not assigning and assuring availability of adequate personnel with appropriate skill levels to a ship, or to a specific task aboard the ship to ensure safe and efficient operation. Specifying job or task requirements which are unreasonable, inefficient, impossible, excessive, or impractical. Examples include: excessive watch duration or frequency, requiring a single person to simultaneously monitor displays that are spastically separated, requiring exposure to hazardous materials without proper protective gear. Any problem with standards, regulations, policies, procedures, or practices. For example: standards, regulations, policies, procedures, or practices may be conflicting, inaccurate, inadequate, do not provide sufficient detail, or outdated. The application of standards, regulations, policies, procedures, or practices at an incorrect time or in an inappropriate circumstance
Poor regulations, policies procedures, or practices:
Misapplication of good regulations, policies, procedures, or practices: Mental action:
Lack of situational awareness: An incorrect understanding of the current situation winch can lead to a faulty hypothesis regarding a future situation or a situation which is based upon incorrect beliefs leading to compounded errors that can substantially increase the risk to the ship. Examples include arriving at a hypothesis without confirmation of which direction an oncoming ship will steer incorrect interpretation of alarms on board ship (e.g. seawater contamination of a fuel system during high seas). Lack of perception: When an individual does not properly understand that a problem or situation exists. Examples include misreading a dial, mishearing a command, misunderstanding a garbled radio message, thinking you smell engine oil when its actually crude, not noticing a list to starboard. overestimating the distance to die dock. Incorrect recognition: The misdiagnosis of a particular situation or problem once it has been perceived. It may be perceived that a problem or situation exists, however, the identification is incorrect. Examples include misdiagnosis of a sounded alarm that sounds similar to other alarms on board ship, incorrect recognition of a visual display alarm on the bridge. Incorrect identification: The incorrect identification of a problem or hazard once it has been recognized that the problem or hazard exists. The alarms on a display panel may have identified a particular hazard to the ship (e.g. low fuel oil pressure), however, the individual may have misinterpreted the alarm and identified the problem incorrectly.
Quick Check Lists for Field Investigators for Various Types of Accidents
The questions contained in the next few pages were developed by the New Zealand MSA. They are not all inclusive but as these questions are asked and answered, they will ultimately lead to others. It is suggested that laminated copies be made available to the investigators.
1 2 Name, address, telephone number, date of birth, qualifications and experience. What was the passage plan? (Ask about courses, times, weather, way points, intentions, distances on each leg, dangers on passages & why, critical points on passage) What were the night orders? What were you told? What were the standing orders? from both master to others and from company to ship. Ask to see the chart and log book used? Was a Nautical Almanac used or tide tables? Take copies of charts and logbooks. What was the position fixing method and how often was the position fixed? What was the last fix plotted before the vessel grounded? What were the courses and speeds over ground that were steered? What were times of course alterations? Were you steering by hand or by auto pilot? What was the Gyro/compass error and the allowance/correction? See compass error book.
3 4 5 6 7 8 9 10 11
12 13 14 15 16 17 18 19 20
Do you have a compass correction certificate? What was the deviation on the course steered? What was the weather like, leeway? What was the tidal stream? What was the visibility like? (fog?, moon?, how they determined it) Where there any decklights impairing visibility? How was the radar performing? Was there clutter? Do they know how to use it? What was the radar range in use? Was the echo sounder in use and used in comparison with the chart? Was there an alarm set? Does it work on the plane? Is it affected by speed? What were your rest/work periods for the previous week? Had you consumed any alcohol? What were the orders (regarding courses, speeds, way points) that were left at the change over of watch? Before taking over the watch did you verify the vessel’s position? By what means? What time did the vessel ground? What speed do you estimate the vessel grounded at? How many people were on the bridge at the time of grounding? What was everybody else doing? What was the position of the grounding? Did you check the vessel damage, water ingress, propeller damage? Was any pollution caused? What was the vessel’ draft? Has the vessel a course recorder? What setting were the engines at when the vessel grounded? Was the gear tested prior to arrival/departure? What was the height of tide? Did any alarms sound before contact? Can I see your accident register?
22 23 24 25 26 27 28 29
Stability 1 2 3 Full names, addresses (and nationalities if not NZ) of witnesses with contact telephone numbers. Age and date of birth. All sea going qualifications (including country of issue if not NZ). Ascertain, as fully as possible, precisely what instructions (written, verbal and practical) each witness has received, when and from whom on stability. (As an example, the holder of a CLM certificate should know what is meant by 'good stability" and "poor stability" and recognise the warning signs of the latter.) In addition, he should be able to describe the effect on stability of: • • • • • • Raising & lowering weights Freely suspended weights Free fluid surface Low freeboard Obstructed freeing ports Rolling period. Rolling faster or slower than normal.
For details of the stability knowledge that holders of a Coastal Master Certificate, Mate and Skipper of a Deep Sea Fishing Boat should have - the syllabuses are available from Seafarer Licensing. 4 How long at sea, date of joining the vessel and previous seafaring background of witnesses. How long on this vessel. What training have you received on stability and free surface effect? Particulars of the vessel should include: • • • • • • • • • • • • • Name & port of registry Type & category of vessel Official number Present ship location Owners and/or agents addresses & contact phone numbers Registered & overall length Maximum breadth When & where the vessel was built Gross & net tonnage Draughts of vessel Summer deadweight & draughts on summer deadweight Freeboard on summer deadweight TPC at load draught
• • • • • • • • • • • •
• • • 6
Number & location of all watertight doors, watertight/non watertight bulkheads, hopper tanks and cofferdams Number, location capacity and dimensions of all double bottom tanks (void, water ballast, fresh water & fuel oil) Number, location (including height above the keel), dimensions and capacity of all wing tanks, day tanks & service tanks (void, water ballast, fresh water, lube oil, machinery oil and fuel oil) Number, location & capacity of all water ballast and bilge pumps Number, location & height above bottom of tank/hull plating of all bilge/ballast suctions including whether fitted with high bilge alarm. Volume in cubic metres of cargo holds/fish holds/freezer spaces Dimensions of cargo holds/fish holds/freezer spaces Number & position of all air pipes to ballast fuel oil tanks and manner of blanking off Number & position of all ventilators (including accommodation, engine room, fish & cargo holds) and manner of blanking off Details of all other closing appliances at weather deck level, including their manner of securement, e.g., fish holds and cargo holds Number, location & dimensions of all freeing ports Details of all substantial fixed weights above main deck level to include height above the keel and weight and date when fitted, e.g., on fishing vessels, such things as 'A' frames and booms, truck decks and net rollers (including warp wires and nets) How were the tank soundings determined:- by manual soundings and/or automatic system? What was the purpose of the voyage? Navigational information eg. auto pilot/hand steering
Obtain copies of the following documents from the vessel: • • • • • • • • • • • • • Stability booklet Stability cross curves Hydrostatic curves Bonjean curves TPC and displacement curves GZ Curves Load line certificate Tonnage certificate General arrangement plan Capacity plan Pumping arrangement plan Shell expansion plan Cargo stowage plan
Ascertain the distribution/weight and height above the keel of all moveable weights on the vessel at the time of accident/incident, i.e., cargo, stores, fuel, oil/lubricants, fresh water and ballast water. In respect of ballast, fuel oil and fresh water tanks, ascertain which of these were empty, full or partly full. Ascertain the GM of the vessel, if this is possible. Ascertain which, if any, weights were moved or were in the process of being moved, when or shortly before the accident/incident happened, including when this was done, from where and to which point the weight was being moved, the amount of weight being moved, the reason why and the type of weight being moved, e.g., ballasting/deballasting tanks, moving cargo, landing fish on deck. Ascertain details of the weather, to include height of sea/swell and duration between wave/swell crests. Clarify the extent to which, if at all, any seas were being shipped on board and if so where and in what quantity the extent to which this was remaining on the deck and the times at which this occurred in relation to the accident/incident. Did you kow hatches were shut? How did you know? Ascertain the extent to which the vessel was rolling, i.e., in degrees and whether the vessel was rolling quickly or slowly. Do you understand the significance of this? Ascertain whether the vessel was listed at all before the accident/incident and if so, when and to what extent. Ascertain how cargo both on and below deck was secured, e.g., by lashing, shoring/pound boards. Ascertain to what extent, if at all, the vessel was hogged or sagged. Ascertain precisely what steps the crew took to prevent the accident/incident occurring, e.g., by lowering weights, ensuring weights were properly secured, pressing up slack tanks to reduce free surface effect, minimising rolling of vessel/water being shipped on deck (e.g., by reducing speed/turning into the weather, vessel hove to, etc.) securing watertight doors and all openings at weather deck level. What was the disposition of the cargo/fish at the time? Do you understand what is meant by free surface effect (FSE)? How was FSE established? How was it applied in your calculations and what practical effect did it have? Have you had a similar disposition of weights on other voyages or was this unusual?
11 12 13 14
18 19 20 21 22 23 24 25 26
Have there been any modifications to the hull or equipment recently? What are they? What was the draught when you left? What displacement does this draught correspond to? What valves were left open? Do you know if they function adequately as non return valves? When were they last cleaned? How often do you check the level in the fish hold? How frequently did you have to operate the bilge pump? Describe the fuel transfer procedure. Was it adhered to? What is there to prevent the seawater inlet valve for the deck service line back flooding? How much weight (fish) can be landed on deck before the vessel's stability will be compromised? How do you know this? How do you decide how much of the load to pick at once? Who calculates the maximum bending moments allowed? How does he/she do it? Who sets the standard? Were the standards exceeded on this occasion?
Personnel Injury 1 2 3 4 5 6 7 Name, address, phone number, date of birth, qualifications. What is your position on board (skipper, deckhand etc.)? How many years of experience do you have in the industry? How long have been on board vessel? Is the vessel surveyed? What SSM Company? How many crew are employed on board? What were the events of the accident? (Take time to ask for clarification on tasks and procedures, events leading up to the accident, and establish times! Also find out what happened afterwards regarding the emergency procedures.) How efficient were the emergency procedures? Was the seafarer told to clean/use the machinery/equipment or undertake the task on this particular occasion? If so, by whom? What initial training was the crew member given before undertaking this task? What are the main tasks of the victim on board? When did he/she last undertake safety training? Was the crew member fit to undertake duties? Had the person cleaned/used/maintained the machinery, or undertaken the task before? How often? Did he/she take precautions or follow procedures in the past? Was the crew member taking any short cuts or not using the equipment correctly? If so, why? What instructions were given regarding the operation of machinery, or the performance of the task? (Ask both the person in charge and the victim.) Were regular checks made that any person, using the machinery/equipment, or undertaking the task, was taking precautions as instructed? Who was operating the controls? Was any other seafarer assisting in the task? Did the equipment have emergency stops. When were they last tested? Were the controls within easy reach of the operator? If equipment or machinery was involved, who was the manufacturer? How old was the model? Have replacement designs been subsequently introduced to the industry which have eliminated the hazard? Have any modifications been made to the equipment? Had controls been modified or over ridden? When was the equipment last examined? Were there any guards in place? Were these sufficient?
11 12 13
Had guards been asked for yet not supplied? Are all running nips guarded? 15 Have other injuries or close calls occurred under the same circumstances? (i.e., associated with the same equipment/ machinery/procedures / task? ) Have any other crew had problems or suffered injury as a result? If so, had the injury or near miss been recorded in the accident register? Were they discussed at safety meetings? Are these mishaps reviewed, investigated and monitored? How often is the accident register reviewed? Is it necessary to do the task in the way it was done on this particular occasion? Could it be done in another way? Safer? Had this particular task/equipment/machinery/procedure/ substance been identified as a hazard to the crew? Are there any notices on board the vessel to warn seafarers about the hazard? Have any notices been erected since the accident? What has been done to prevent a similar accident from occurring? Has comprehensive hazard identification been carried out on the vessel? What method was used? (Items analysis, task analysis, process analysis) Was a checklist used? Were significant hazards identified and then controlled. Was priority given firstly to elimination and then by isolation or minimisation? Have the hazards been managed? Give examples. What training have the seafarers received with regards to all hazards on board the ship? Are there any procedures that have to be followed on board? Are these documented? Are you aware of any similar accidents occurring on any other (similar) vessels in the industry?
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
32 33 34 35
What personal protective equipment is available to the crew? Has training been given to the use of the personal protective equipment? Is there an induction programme for new crew members who work on board? How is information about safety on board vessels communicated to the (e.g. notices, manuals, meetings, etc.) crew?
To the employer: Are you aware of the responsibilities under the [specify the national legislation]? (To identify, assess and control significant hazards, Ensure every seafarer is given information about emergency procedures and all identified hazards, provide appropriate training and supervision and involve seafarers in the development of health and safety procedures.) To the seafarer: Are you aware of your responsibility as a seafarer under the [specify the national legislation] that all practicable steps must to taken to ensure your own safety and the safety of others. And that you must not knowingly expose yourself or others to harm?
Collision 1 2 Name, address, telephone number, date of birth. All sea - going qualifications (including country of issue if not NZ) and when obtained. This to include any ancillary certificates such as radar simulator, navigation control, electronic navigational systems and bridge resource management. Rank on board the vessel at the time of the collision and date of first attaining that rank. How long have you been at sea, what date did you join the vessel, and what is your previous seafaring background (in brief). What are the particulars of vessel (include): • • • • • • • • • • • • • • • • • Name and port of registry Type & Category of vessel (including whether laden or ballast) Official number Present ship location Owners and/or agents addresses & contact phone numbers Registered length & overall length Maximum breadth Distances from bridge to bow and bow to stern Height of bridge above the waterline When & where the vessel was built Gross tonnage Deadweight Draughts of vessel at the time of collision Make & type of main engine with details of propulsion power Maximum sea speed of vessel & direction of revolution of propeller (e.g., right or left turning, fixed or CPP) Turning circle and stopping information of vessel, if available (usually displayed on bridge) Manoeuvring data, if available (usually displayed on bridge), including corresponding revolutions & speeds at full, half, slow and dead slow ahead and astern, plus emergency full astern.
Particulars of bridge and navigational aids to include: • Number and type of compasses and repeaters - check if gyro repeaters are correctly aligned with master compass with details of gyro error and magnetic deviation - see deviation card on vessel. Check chart for details of variation
• • • • • •
• • •
Number & types of radar (e.g., relative motion and/or true motion together with type of display being used at the time of collision, such as "north up" or "ship's head up" and whether stabilised or unstabilised, range scales available on the radars, whether fitted with VRM and the type of bearing cursor), whether there are any blind sectors on the radars, and if so, their extent and location. Whether the vessel is fitted with an ARPA Type of log fitted, e.g., doppler (check for accuracy) Number & type of echo sounders (e.g., digital or graph paper) Type of position fixing equipment (other than radar) e.g., GPS/DGPS, whether corrected to agree with NZ geodetic data Type of steering gear apparatus - manual, automatic hydraulic, electric Type of communication equipment such as VHFs (fixed and hand held) including number of channels, SSB and whether H/F or M/F, portable aldis lamp and/or fixed light signalling equipment, whistle and whether it's manual/automatic or both Course recorder trace, if fitted Details of the navigational chart(s) in use at the time and whether corrected and up to date The position of all of the above equipment within the wheelhouse / chartroom. This should be noted on a sketch plan with photographs and any defects noted. The plan should also note the number and position of windows/doors within the wheelhouse, whether these were open/closed at the time of the collision and details of any blind sectors caused by the existence of cranes or other structures on the fore deck.
Where the vessel was proceeding from and to at the time of the collision, with type of cargo carried The names and ranks of the master, pilot (if any) and crew who were on the bridge, on deck and in the engine room at the time of the collision. Ascertain where master ,pilot and each crew member was at the time of the collision and what they were doing in the 2-3 minutes immediately preceding the collision. The originals of all deck and engine log books, main engine print out sheets/bell books, course recorder trace, echo sounding traces, radio traffic messages, weather reports/facsimile sheets, gyro/compass error books, crew list, officers' certificates (if not NZ), working charts, master/pilot/crew reports/sketches of the collision, masters/company standing orders/instructions and masters night orders must be obtained and considered before any interview and then used as a cross reference when interviewing each witness. Details of the weather conditions, range of visibility and tidal data at the time of the collision and the extent to which, if at all, these were causative of or contributed towards the collision.
10 11 12 13 14 15 16
Get information on the extent of damage to both vessels, details of any crew injury and risk of pollution from cargo/bunkers. How did you ascertain if a risk of collision existed? Did you find that a collision risk existed? Whose responsibility was it to give way? Whose responsibility was it to stand on? How did you exercise that responsibility? (Give times of course and/or speed alterations and their effects) The time, relative bearing, distance course, speed, closest point of approach (CPA) and time of CPA (to your vessel) of the other vessel when it's echo was first observed by radar (if applicable) – when obtaining the time, get the source of this i.e. Ship's clock or watch and its accuracy The course, speed and position of your vessel at the time the other vessel was first observed by radar. The time, relative bearing, distance, course, speed and the configuration of the navigational light(s) exhibited by the other vessel when she was first observed visually . The course, speed and position of your vessel at the time the other vessel was first observed visually Whether any plots were made of the other vessel - if so, ascertain from which source these plots were made i.e. Radar or by hand and by whom they were made. They should be checked for accuracy. Details of the navigational aids that were in operation, whether or not these had any defects and the crew who were on duty on the bridge and in the engine room of your vessel at the time the other vessel was first observed by radar/visually. Details of the changes in the course, speed, relative bearing, distance, CPA and time to CPA and the configuration of the navigational lights of the other vessel and the times at which these occurred between the time she was first observed by radar and/or visually and the time of the collision. Details of the changes in the course and speed of your vessel (this should include the helm orders/action and telegraph orders/action that occurred), the reasons for these changes and the times at which they occurred from the time the other vessel
was first observed by radar/visually and the time of the collision. 24 Full details of any aural/visual warning signals that were made by your/the other vessel, the times that these occurred and the relative bearing and distance of the other vessel when they were made. If any contact was made over the VHF/SSB get details of what was said, the time this occurred and what action, if any, was taken as a result. The time the collision occurred and its position - this should include who obtained this information, the manner in which it was obtained e.g. GPS and its accuracy. Ascertain the angle of blow between the two vessels at the time of impact, the parts of each vessel that initially and subsequently came into contact, the heading and speed of both vessels on collision and whether the two vessels were on a steady course or swinging when this occurred. Get details if the master, pilot, crew were alert/sober - go through work/sleep pattern over last 72 hours to determine if master, pilot crew were fatigued - in this regard check the quality of sleep which may have been impaired by noise, personal concerns or interruptions. Check whether the collision was witnessed by any other vessel. If so get as much information as you can on her identity so that follow up action can be taken. Check with the engineers on duty for the time of collision and confirmation of engine manoeuvres. Note that the crew can assist you/themselves by drawing sketch plans of the events leading up to the collision - ship models are also a useful aid.
28 29 30
Fire 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 How was the fire detected? When was the fire detected? Where was it thought to be? What action was taken to extinguish the fire (alarms, stations, etc.)? What fire fighting equipment was available (CO2, portable, hoses, BA sets)? Did the equipment work? When was the equipment last inspected? What did the fire fighting parties do? Was it effective? If not, why not? Was the fire electrical, spontaneous combustion, conduction, convection, radiation? How recent were the equipment overhauls? Were they while in drydock or new installations? How frequent are fire drills on the vessel? Are there log book entries of fire drills? Does the vessel have a fire fighting plan? Were the fire service called? Was the vessel stopped? Was the course altered? Where was the seat of the fire? What was the ignition source? Are there any photographs or video evidence of the fire?
22 23 24 25 26 27 28 29 30 31 32 33 34
What was the combustible material involved in the fire? Did the fire give off any gas/smoke, and if so, what colour was it? How were any burns or smoke inhalation treated? How many of the crew have fire fighting certificates? Has there been a fire on board the vessel before? Can I see your accident register? With hindsight, how could you have dealt with it better? Were there fuel remote trips? Ventilation flaps? Fan trips? Pump trips? Were the fire dampers, fuel shut offs, fire doors used? Did they work? How often were they tested? Was any use made of BA gear? Who had been given training in the use of this equipment? Were standard procedures followed What training do the crew get? (courses, drills, videos)
Machinery Failure 1 2 3 Name, address, telephone number, date of birth, qualifications and experience. Establish, what, where and when. What was the mechanism of the failure, in as much detail as possible: • • • • • • • • 4 What machinery and which part Any collateral damage Resulting circumstances Had there been any signs of impending failure? What was done about them? Try, if possible, to collect up and save damaged parts. Take lots of photos Get/make sketches or line diagrams
When did it happen?: • • Time of damage, as near as possible When and how it was noticed
Actions taken when the damage became apparent: • Who did what, and why, when & how?
Once the circumstances of the actual accident/failure have been established, there are a number of questions you can ask, and actions you can take, that will be a significant help to the inquiry. Questions such as: 6 7 8 9 10 11 12 13 Had there been any concerns about this machine? To whom were these expressed? Were they raised at safety meetings? Is there a record? Has this happened before? How many times? Have any trends been identified Were procedures in place to prevent/mitigate this happening again? Are these procedures documented? Can you show that these procedures were followed? What is the maintenance period for this machine?
When was the machine last overhauled? Is there a record?
The following documents should be collected or photocopied (as appropriate): • • • • • • • 16 17 18 19 20 Machinery manuals Engineering drawings Piping diagrams Log books Any other official records that may be useful, such as maintenance records and planned maintenance schedules Letters/Reports that may refer Data log records
Are manuals in a language understood by all ship staff? Are there warning signs on the machinery that failed? Would warning signs have prevented the failure? Did fatigue play a part? What would you do to stop a recurrence?
MAIIF - Contacts
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Objectives Charter Resolutions Code Manual Guidelines Comments Contacts Newsletters Meetings Related sites Home
OFFICE HOLDERS MEMBERS HONORARY MEMBERS
OFFICE HOLDERS Chairman Captain C W Filor Deputy Director Surface Investigations & Inspector of Marine Accidents Australian Transport Safety Bureau PO Box 967 Civic Square ACT 2608 AUSTRALIA First Deputy Chairman Mr D Rabe Chief - Marine Investigation Division United States Coast Guard Headquarters 2100-2nd Street South West Washington DC 20593-0001 USA Fax: +61 2 6274 6699 Phone: +61 2 6274 7165 E-mail: Kit.Filor@atsb.gov.au
Fax: +1 202 267 1416 Phone: +1 202 267 1430 E-mail: DRabe@comdt.uscg.mil
MAIIF - Contacts
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Second Deputy Chairman Mr M Heikkilä Chief Accident Investigator Accident Investigation Board Yrjönkatu 36 00100 Helsinki FINLAND MEMBERS ANTIGUA & BARBUDA Captain B Lerdon (Bernd) Department of Marine Services and Merchant Shipping (ADOMS) Am Patentbusch 4 26125 Oldenburg GERMANY Captain S Ottinger (Siegfried) Department of Marine Services and Merchant Shipping (ADOMS) Alter Fährweg 27568 Bremerhaven GERMANY AUSTRALIA Captain C W Filor (Kit) Deputy Director Surface Investigation & Inspector of Marine Accidents Australian Transport Safety Bureau PO Box 967 Civic Square ACT 2608 AUSTRALIA Mr N Rutherford (Nick) Surface Safety Investigation Group Australian Transport Safety Bureau PO Box 967 Civic Square ACT 2608 AUSTRALIA BAHAMAS Captain S Clinch (Steve) Deputy Director Bahamas Maritime Authority 2nd Floor, Latham House
Fax: +358 9 1825 7811 Phone: +358 9 1825 7638 Mobile: +358 405 219 343 E-mail: email@example.com
Fax: +49 441 93 95 9 -20/29 Phone: +49 441 93 95 90 E-mail: firstname.lastname@example.org
Fax: +49 471 419 24 22 Phone: +49 471 419 24 19 E-mail: email@example.com
Website: http://www.atsb.gov.au Fax: +61 2 6274 6699 Phone: +61 2 6274 7165 E-mail: Kit.Filor@atsb.gov.au
Fax: +61 2 6274 6699 Phone: +61 2 6274 7665 E-mail: Nick.Rutherford@atsb.gov.au
Fax: +44 0207 264 2575 Phone: +44 0207 264 2579 E-mail: firstname.lastname@example.org
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16 Minories London EC3N 1EH UK BELIZE Mr A Mouzouropoulos (Angelo) Director General International Merchant Marine Registry of Belize Marina Towers, Suite 204 Newtown Barracks Belize City Belize CENTRAL AMERICA Libardo Brú, MSc Head of Technical Department International Merchant Marine Registry of Belize Marina Towers, Suite 204 Newtown Barracks Belize City Belize CENTRAL AMERICA BERMUDA Captain G P A Nawaratne (Pat) Registry of Shipping PO Box HM 1628 Hamilton HM GX BERMUDA BRAZIL Mr Paulo Eduardo MEIRELLES Freire Directorate of Ports & Coasts Rua Teofilo Otoni No 4 Centro Rio De Janeiro RJ BRAZIL CANADA Captain F Perkins (Fred) Director - Marine Investigation Branch Transportation Safety Board of Canada Place du Centre, 4th Floor 200 Promanade du Portage Hull Quebec K1A 1K8 Fax: +55 21 216 5202 Phone: +55 21 216 5204 Phone: +55 21 490 2702 E-mail: email@example.com Fax: +1 441 295 3718 Phone: +1 441 295 7251 Phone: +1 441 295 7306 Fax: +501 223 5048 Phone: +501 223 5026 E-mail: firstname.lastname@example.org E-mail: email@example.com
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Website: http://www.tsb.gc.ca Fax: +1 819 953 1583 Phone: +1 819 953 1398 E-mail: Fred.Perkins@tsb.gc.ca
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CANADA CHILE Commander R Böke (Ricardo) Head. International Affairs Department Chilean Maritime Administration AV Errazuriz 537 Valparaiso CHILE Lt Commander R Marticorena (Rene) AV Errazuriz 537 Valparaiso CHILE Lt Commander O Mrugalski Meiser (Otto) AV Errazuriz 537 Valparaiso CHILE CHINA Captain Hu Xi-chen China Maritime Safety Administration 11 Jianguomennei Avenue Beijing 100736 PEOPLE'S REPUBLIC OF CHINA Wang Hongsheng Xiaman Maritime Safety Administration 19 Haicang Avenue Xiaman 361026 PEOPLE'S REPUBLIC OF CHINA Shen Jianbin China Shanghai Maritime Safety Administration 725 Wai Ma Road Shanghai 200010 PEOPLE'S REPUBLIC OF CHINA Captain Ningbo Assistant Investigator of Navigation Department China Maritime Safety Administration Shenzheni 11 Jianguomennei Avenue Beijing 100736 PEOPLE'S REPUBLIC OF CHINA CYPRUS Fax: +86 10 6 529 2882 Phone: +86 10 6 529 2895 E-mail: firstname.lastname@example.org Website: http://www.directemar.cl Fax: +56 32 20 8085 Phone: +56 32 20 8 -200/000 E-mail: email@example.com
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Fax: +86 10 6 529 2882 Phone: +86 10 6 529 2896 E-mail: Boning@btamail.net.cn
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Captain N Economides (Nick) Marine Surveyor A Department of Merchant Shipping PO Box 6193 -CY 3305 Limassol CYPRUS Mr Michael A Michaelidis Marine Surveyor-Consul Consul-Maritime Affairs The Cyprus Maritime Office Consul General of the Republic of Cyprus 13 East 40th Street New York NY 10016 USA DENMARK K S Eriksen (Knud Skaaereberg) Danish Maritime Safety Authority Investigation Division Vermundsgade 38 c 2300 Copenhagen Ø DENMARK ESTONIA T Linikoja (Taidus) Estonia Maritime Administration Vaige 4 11413 Tallinn ESTONIA R Silm (Rein) Estonia Maritime Administration Vaige 4 11413 Tallinn ESTONIA FIJI Captain J Rounds (John) Senior Marine Officer Marine Department Regulatory Section GPO Box 326 Suva FIJI
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FINLAND Dr T Karppinen (Tuomo) Finnish Maritime Administration Porkkalankatu 5 00180 Helsinki FINLAND Mr M Heikkilä (Martti) Chief Accident Investigator Accident Investigation Board Yrjönkatu 36 00100 Helsinki FINLAND Captain R Repo (Risto) Accident Investigator Accident Investigation Board Yrjönkatu 36 00100 Helsinki FINLAND FRANCE Rear Admiral Rtd J L Guibert (Jean Louis) Bea-mer / METL Arche Sud 92055.La Défense Cedex 04 FRANCE J M Schindler (Jean-Marc) MAE/DAEF 37 Quai d'orsay 75007 Paris SP FRANCE GERMANY Mr D Graf Federal Bureau of Maritime Casualty Investigation Bernhard-Nocht-Str 78 20359 Hamburg GERMANY Dr K Grensemann (Klaus) Head Maritime Safety Division Federal Ministry of Transport Postfach 20 01 00 D-53175 Bonn GERMANY
Website: http://www.onnettomuustutkinta.fi Fax: +358 204 484 336 Phone: +358 204 484 1
Fax: +358 9 1825 7811 Phone: +358 9 1825 7638 Mobile: +358 405 219 343 E-mail: Martti.Heikkila@om.fi
Fax: +358 9 1825 7811 Phone: +358 9 1825 7817 Mobile: +358 405 028 714 E-mail: Risto.Repo@om.fi
Fax: +33 1 4081 3842 Phone: +33 1 4081 3824 E-mail: Bea-Mer@equpement.gouv.fr Fax: +33 143 1789 51 Phone: +33 143 1781 64 E-mail: Jean-Marc.Schindler@diplomatie.gouv.fr
Fax: +49 40 31 90 50 00 Phone: +49 40 31 90 50 00 E-mail: Miriam.Hinz@bsh.d400.de
Fax: +49 228 300 1454 Phone: +49 228 300 4630 E-mail: Klaus.Grensemann@bmvbw.bund.de
MAIIF - Contacts
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Captain J Erhardt (Jan) Executive Officer Federal Ministry of Transport Postfach 20 01 00 D-53175 Bonn GERMANY GREECE Captain (HCG) Constantinos Brilakis Director - Civil Emergency Planning Directorate Hellenic Ministry of Mercantile Marine 150 Gr Lambraki Street 18518 GR Piraeus GREECE HONG KONG Captain S Anand (Suresh) Chief, Marine Accident Investigation Marine Department 21st Floor Harbour Building 38 Pier Road Central HONG KONG Wing Fai Leung Marine Department The Government of the Hong Kong Special Administrative Region Marine Accident Investigation Section 21st Floor Harbour Building 38 Pier Road Central HONG KONG Captain Lee Kai Leung Chief, Marine Accident Investigation Marine Department 24th Floor Harbour Building 38 Pier Road Central HONG KONG ICELAND Captain J A Ingolfsson (Jon) Director Rannsoknarnefnd Sjoslysa Flugstodin 340 Stykkisholmur
Fax: +49 228 300 1454 Phone: +49 228 300 4636 E-mail: Jan.Erhardt@bmvbw.bund.de
Fax: +30 1 412 -8150/7843 Phone: +30 1 422 0795 E-mail: email@example.com
Fax: +852 2542 4841 Phone: +852 2852 4603 E-mail: firstname.lastname@example.org
Fax: +852 2542 4841 Phone: +852 2852 4603 E-mail: email@example.com
Fax: +852 2542 4841 Phone: +852 2852 4603 E-mail: firstname.lastname@example.org
Fax: +354 551 5152 Phone: +354 552 5105 Mobile: +354 893 2629 E-mail: email@example.com
MAIIF - Contacts
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ICELAND INDONESIA Mr Yudustar Head of Guard and Rescue Division Port Administration of Tanjung Priok Jin. Palmas No.1 Tg Priok Jakarta INDONESIA Rachmat Sasraatmadja Directorate General of Sea Communication JL. Merdeka Barat No.8 Jakarta 10110 INDONESIA ISLE OF MAN Captain D Howell (Desmond) Principal Surveyor Marine Administration Isle of Man Government Peregrine House Peel Road, Douglas Isle of Man IM1 5EH UK Captain B McGrath (Barry) Principal Surveyor Marine Administration Isle of Man Government Peregrine House Peel Road, Douglas Isle of Man IM1 5EH UK ITALY Dott Pierfrancesco PERSIANI Ministry of Transport & Navigation Department of Maritime & Internal Navigation Directorate General for Maritime & Internal Navigation - NAVIG Viale dell' Arte 16 00144 ROME(EUR) ITALY JAMAICA Fax: +39 06 5908 4282 Phone: +39 06 5908 4273 Mobile: +39 349 159 1797 E-mail: firstname.lastname@example.org Fax: +62 21 492 214 Phone: +62 21 492 214
Fax: +62 21 350 5687 Phone: +62 21 345 8835 Mobile: +62 811 841 730
Website: http://www.gov.im/dti/shipping Fax: +44 1624 688 501 Phone: +44 1624 688 500 E-mail: Desmond.Howell@shipping.dti.gov.im
Fax: +44 1624 688 501 Phone: +44 1624 688 500 E-mail: Barry.McGrath@shipping.dti.gov.im
MAIIF - Contacts
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Captain N Robin Lee Director Training & Safety Maritime Authority of Jamaica Dyoll Building, 40 Knutsford Blvd Kingston 5 JAMAICA JAPAN Mr T Yamamoto (Tetsuya) Judge Yokohama Marine Accidents Inquiry Agency Kasumigaseki 2-1-2 Chiyoda-ku Tokyo 100-8918 JAPAN Captain T Fujie (Tetsuzo) Manager of International Affairs Team High Marine Accidents Inquiry Agency Kasumigaseki 2-1-2 Chiyoda-ku Tokyo 100-8918 JAPAN LIBERIA Mr M Davies-Sekle (Michael) Vice President Marine Investigation & Assistant General Counsel The Liberian International Ship & Corporate Registry 99 Park Avenue Suite 1700 New York NY 10016-1601 USA MALAYSIA Mr J B Yusuf (Jamaludin) Marine Department Headquarters Peninsular Malaysia PO Box 12 42007 Port Klang Selangor MALAYSIA Captain Mohamad H Bin Ahmed (Halim) Enforcement Unit Marine Department Headquarters
Fax: +1 876 754 7256 Phone: +1 876 929 2201 Phone: +1 876 754 7260/5 E-mail: email@example.com
Fax: +81 3 5253 1680 Phone: +81 3 5253 8824 E-mail: firstname.lastname@example.org
Fax: +81 3 5253 1680 Phone: +81 3 5253 8821 E-mail: email@example.com (Also Mr Nagata)
Fax: +1 212 697 5655 Phone: +1 212 697 3434 Phone: +1 703 251 2407 direct Email: firstname.lastname@example.org
Fax: +60 3 3368 5289 Phone: +60 3 3346 7777 E-mail: Jamaludin@marine.gov.my
Fax: +60 3 3368 5289 Fax: +60 3 3368 4454 Phone: +60 3 3368 6616
MAIIF - Contacts
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Peninsular Malaysia PO Box 12 42007 Pelabuhan Klang Selangor Darul ehsan MALAYSIA Mr Abdul Samad Shaik Osman Maritime Control Division Marine Department of Peninsula Malaysia PO Box 12 42007 Pelabuhan Klang Selangor Darul ehsan MALAYSIA MALTA Mr L C Vassallo (Lino) Executive Director Merchant Shipping Directorate Malta Maritime Authority Maritime House Lascaris Wharf Valletta VLT 01 MALTA Captain J Zerafa (Joe) Technical Manager Merchant Shipping Directorate Malta Maritime Authority Maritime House Lascaris Wharf Valletta VLT 01 MALTA Mr S Mifsud (Sean) Merchant Marine Diretorate Malta Maritime Authority Maritime House Lascaris Wharf Valletta VLT 01 MALTA Mr K Thomas Ghirxi (Kevin) Merchant Shipping Directorate Malta Maritime Authority Maritime House Lascaris Wharf
E-mail: email@example.com E-mail: firstname.lastname@example.org
Fax: +60 4 3168 5289 Phone: +60 4 3169 5100 E-mail: email@example.com E-mail: firstname.lastname@example.org
Fax: +356 21 241 460 Phone: +356 21 250 350 Mobile: +356 21 9494 316 E-mail: email@example.com
Fax: +356 21 241 460 Phone: +356 21 250 360 Phone: +356 21 250 352 direct Mobile: +356 21 9494 318 E-mail: Joe.Zerafa@mma.gov.mt
Fax: +356 21 241 460 Phone: +356 21 250 352 E-mail: firstname.lastname@example.org
Fax: +356 21 241 460 Phone: +356 21 250 352 Mobile: +356 21 9494 318 E-mail: Kevin.Ghirxi@mma.gov.mt
MAIIF - Contacts
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Valletta VLT 01 MALTA Mr D Kerr (David) Malta Maritime Authority Maritime House Lascaris Wharf Valletta VLT 01 MALTA MARSHALL ISLANDS Mr D L Crede (Dave) Deputy Commissioner of Maritime Affairs Republic of the Marshall Islands 11495 Commerce Park Drive Reston Virginia 20191-1507 USA THE NETHERLANDS Mr K M van der Velden (Mart) Senior Investigator Shipping Raad voor de Transportveiligheid Dutch Transportation Safety Board PO Box 95404 2509 CK The Hague NETHERLANDS G Th Koning (Thom) Investigator Shipping Dutch Transportation Safety Board PO Box 95404 2509 CK The Hague NETHERLANDS Mr H Zieverink (Henk) Secretary of the Chamber Shipping Dutch Transportation Safety Board PO Box 95404 2509 CK The Hague NETHERLANDS NEW ZEALAND Mr M Eno (Mike) Maritime Safety Authority PO Box 27006 Wellington 6036 Fax: +64 4 473 8111 Phone: +64 4 494 1232 Mobile: +64 25 481 267 E-mail: email@example.com Fax: +31 70 333 7078 Phone: +31 70 333 7000 Phone: +31 70 333 7037 direct E-mail: K.Vandervelden@rvtv.nl Fax: +1 703 476 8522 Phone: +1 703 620 4880 ext 385 E-mail: firstname.lastname@example.org Fax: +356 21 241 460 Phone: +356 21 250 360 E-mail: David.Kerr@mma.gov.mt
Fax: +31 70 333 7078 Phone: +31 70 333 7038 direct E-mail: G.Koning@rvtv.nl
Fax: +31 70 333 7078 Phone: +31 70 333 7035 direct E-mail: A.Groenin'tWoud@rvtv.nl E-mail: H.Zieverink@rvtv.nl
MAIIF - Contacts
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NEW ZEALAND Trasnport Accident Investigation Commission Captain J Mockett (John) Transport Accident Investigation Commission PO Box 10-323 Wellington 6036 NEW ZEALAND NORWAY Kristin Asgard Kleven Norwegian Maritime Directorate PO Box 8123 Dep N-0032 Oslo NORWAY Dag Erik Danielsen Norwegian Maritime Directorate PO Box 8123 Dep N-0032 Oslo NORWAY PAKISTAN Captain M Nouman Alvi Karachi Port Trust Plot 40-A BL-4Lalazar Karachi PAKISTAN PANAMA Mr F Perez Salamero (Francisco) Director of Department of Maritime Safety Directorate of Consular & Maritime Affairs Republic of Panama 6 West 48th Street, 10th Floor New York NY 10036 USA PANAMA CANAL Captain D Porras (Diego) Senior Canal Operations Captain - Pacific Panama Canal Authority ACP-MRTC Miami Florida 33102-5543 Fax: +507 272 4212 Phone: +507 272 4212 E-mail: email@example.com Fax: +1 212 575 2285 Phone: +1 212 869 6440 E-mail: FPSalamero@segumar.com Fax: +47 22 45 47 90 Phone: +47 22 45 45 84 E-mail: Kristin.Kleven@sjofartsdir.dep.no Website: http://www.taic.org.nz Fax: +64 4 499 1510 Phone: +64 4 473 3112 Pager: +64 26 100 101 Mobile: +64 25 425 548 E-mail: firstname.lastname@example.org
Fax: +47 22 56 87 80 Phone: +47 22 45 44 08 E-mail: Dag.Danielson@sjofartsdir.dep.no
MAIIF - Contacts
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USA Captain M F Rodriguez (Miguel) Chairman - Board of Inspectors Panama Canal Authority Building 996 La Boca Panama REPUBLIC OF PANAMA or ACO-MRXI PO Box 025543 Miami Florida 33102-5543 USA PHILIPPINES Commander R A Campos PN (Ruben) Coast Guard Intelligence & Investigation Force Headquarters Philippine Coast Guard 139 25th Street Port Area Manila PHILIPPINES Administrator Maritime Industry Authority PPL Building UN Avenue Ermita Manila 1000 PHILIPPINES Mr R C Areco (Roberto) Regional Director Northern Luzon Maritime Regional Office Maritime Industry Authority PPL Building UN Avenue Ermita Manila 1000 PHILIPPINES PORTUGAL Mr P Correia (Paulo) Instituto Maritimo Portuário Edifico Vasco Da Gama Rua General Gomes Araujo 1399-005 Liboa PORTUGAL Fax: +351 21 397 9794 Phone: +351 21 391 4643 E-mail: PauloLDCorreia@hotmail.com Fax: +63 2 527 3883 Phone: +63 2 527 3885 Fax: +507 272 3548 Phone: +507 272 3403 E-mail: email@example.com
Phone: +63 2 523 86 -51/60
Phone: +63 2 523 86 -51/60
MAIIF - Contacts
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REPUBLIC OF KOREA Mr Oh Gonggyun Investigator General Korean Maritime Safety Tribunal 139 Chungjong-No 3 Seodaemun-Gu Seoul 120-715 REPUBLIC OF KOREA Mr Park Youngsun Senior Investigator Korean Maritime Safety Tribunal 139 Chungjong-No 3 Seodaemun-Gu Seoul 120-715 REPUBLIC OF KOREA Mr In-Chul Kim Korean Maritime Safety Tribunal 139 Chungjong-No 3 Seodaemun-Gu Seoul 120-715 REPUBLIC OF KOREA Dr Choi Jeong-seop Commissioner Incheon Maritime Safety Tribunal 25 Jun-Dong Chung-Gu Incheon 400-190 REPUBLIC OF KOREA Captain Suh Sung-ki Chief Investigator Mokpo Maritime Safety Tribunal 2-4 Hang-dong, Mokpo-shi Jeonnam REPUBLIC OF KOREA Mr Jo Byeongyong Senior Investigator Busan Maritime Safety Tribunal 1116-1Chwacheon-Dong Dong-Gu Busan 601-053 REPUBLIC OF KOREA Mr Lee Changyong Assistant Investigator Korean Maritime Safety Tribunal 139 Chungjong-No 3 Seodaemun-Gu Seoul 120-715 REPUBLIC OF KOREA Fax: +82 2 3148 6239 Phone: +82 2 3148 6236 E-mail: firstname.lastname@example.org
Fax: +82 2 3148 6230 Phone: +82 2 3148 6236 E-mail: email@example.com
Fax: +82 2 3148 6239 Phone: +82 2 3148 6236 E-mail: firstname.lastname@example.org
Fax: +82 32 763 3522 Phone: +82 32 762 3826 E-mail: email@example.com
Fax: +82 61 242 9812 Phone: +82 61 242 1765
Fax: +82 51 646 4094 Phone: +82 51 647 0092 E-mail: Joby@momaf.go.kr
Fax: +82 2 3148 6239 Phone: +82 2 3148 6236 E-mail: firstname.lastname@example.org
MAIIF - Contacts
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ROMANIA Ion Mircea Inspectorate of Civil Navigation 8700 Constanta Port Nanlomar Building ROMANIA Serban Berescu Inspectorate of Civil Navigation 8700 Constanta Port Berth 0 ROMANIA SINGAPORE Captain I G Sangameswar Assistant Director - Shipping Division Maritime & Port Authority of Singapore 460 Alexandra Road #21-00 PSA Building SINGAPORE 119963 SOUTH AFRICA Captain R Zanders (Robert) Principal Officer South African Maritime Safety Authority Private Bag X54309 Durban 4000 SOUTH AFRICA Captain T Wilson (Tom) Deputy Principal Officer South African Maritime Safety Authority Private Bag X7025 Roggeby Capetown 8012 SOUTH AFRICA Captain T Clarke (Tony) South African Maritime Safety Authority Suite 1401 Kingsfield Place, 30 Field Street Durban 4001 SOUTH AFRICA Mr P van Gysen (Peter) South African Maritime Safety Authority 19th Floor, No 2 Long Street Fax: +27 31 306 4983 Phone: +27 31 307 1501 Fax: +65 375 6231 Phone: +65 375 6205 E-mail: Irinjalakuda_G_Sangameswar@mpa.gov.sg Phone: +40 241 60 22 29 Email: Ion.Mircea@inc-constantza.ro Email: email@example.com
Fax: +40 24 1618 299 Phone: +40 24 4312 299 Email: SerbanBerescu@inc-constanto.ro
Fax: +27 21 419 0730 Phone: +27 21 421 6170 E-mail: firstname.lastname@example.org
Fax: +27 31 306 4983 Phone: +27 31 307 1501
Fax: +27 21 419 0730 Phone: +27 21 421 6170 E-mail: PvanGysen@samsa.org.za
MAIIF - Contacts
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Capetown 8000 SOUTH AFRICA SPAIN Mr P Lopez Mauriz (Pedro) Direccion General de la Marina Mercante C/Ruiz de Alarcon No.1 28071 Madrid SPAIN SWEDEN Captain S Anderson (Sten) Maritime Safety Inspectorate Swedish Maritime Administration SE-601 78 Norrköping SWEDEN Board of Accident Investigation Ms L Svenaeus (Lena) Director General Board of Accident Investigation PO Box 12538 SE-102 29 Stockholm SWEDEN Mr S E Sigfridsson (Sven-Erik) Board of Accident Investigation PO Box 12538 SE-102 29 Stockholm SWEDEN Captain H Rosengren (Hans) Board of Accident Investigation PO Box 12538 SE-102 29 Stockholm SWEDEN Mr P Lindemalm (Per) Lindemalm CoPAB Igelokottsvägen 23 16756 Bromma SWEDEN UNITED KINGDOM Rear Admiral S Meyer (Stephen) Fax: +44 2380 232 459 Fax: +43 915 979 120 Phone: +43 915 979 273
Website: http://www.sjofartsverket.se E-mail: email@example.com Fax: +46 11 239 934 Phone: +46 11 191 269 E-mail: Sten.Anderson@sjofartsverket.se
Website: http://www.havkom.se Fax: +46 8 441 3821 Phone: +46 8 441 3820 E-mail: firstname.lastname@example.org
Fax: +46 8 441 3821 Phone: +46 8 441 3823 E-mail: email@example.com
Phone: +46 480 470 801 E-mail: Karin_rosengren@swipnet.se
Phone: +46 8 735 8535 E-mail: Per.Lindemalm@swipnet.se
MAIIF - Contacts
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Chief Inspector of Marine Accidents Marine Accident Investigation Branch Carlton House Carlton Place Southampton Hants SO15 2DZ UK UNITED STATES OF AMERICA Mr D Rabe (Doug) Chief - Marine Investigation Division United States Coast Guard Headquarters 2100 2nd Street South West Washington DC 20593 USA Mr T Farley (Timothy) Senior Marine Casualty Analyst United States Coast Guard Headquarters 2100 2nd Street South West Washington DC 20593 USA Ms M Murtagh (Marjorie) Director - Office of Marine Safety National Transportation Safety Board 490 L'Enfant Plaza East SW Washington DC 20594 USA Mr D J Tyrrell (Don) Chief - Major Investigation Branch Office of Marine Safety National Transportation Safety Board 490 L'Enfant Plaza East SW Washington DC 20594 USA Captain J H Scheffer (James) Senior Marine Accident Investigator Major Investigation Branch Office of Marine Safety National Transportation Safety Board 490 L'Enfant Plaza East SW Washington DC 20594 USA Mr M E Jones (Michael)
Phone: +44 2380 395 528 E-mail: Stephen.Meyer@dft.gsi.gov.uk
Fax: +1 202 267 1416 Phone: +1 202 267 1430 E-mail: DRabe@comdt.uscg.mil
Fax: +1 202 267 1416 Phone: +1 202 267 1430 E-mail: TFarley@comdt.uscg.mil
Fax: +1 202 314 6454 Phone: +1 202 314 6450 E-mail: firstname.lastname@example.org
Fax: +1 202 314 6454 Phone: +1 202 314 6455 E-mail: email@example.com
Fax: +1 202 314 6454 Phone: +1 202 314 6459 E-mail: firstname.lastname@example.org
Fax: +1 202 314 6454
MAIIF - Contacts
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Senior Human Performance Investigator Office of Marine Safety National Transportation Safety Board 490 L'Enfant Plaza East SW Washington DC 20594 USA Mr T Roth-Roffy (Thomas) Senior Marine Accident Investigator Technical Services Branch Office of Marine Safety National Transportation Safety Board 490 L'Enfant Plaza East SW Washington DC 20594 USA Mr R Henry (Robert) National Transportation Safety Board 490 L'Enfant Plaza East SW Washington DC 20594 USA VANUATU Dr D J Sheetz (Don) Deputy Commissioner of Maritime Affairs Republic of Vanuatu 42 Broadway 12th Floor Suite 1200-18 New York NY 10004 USA Captain C H Grainger Deputy Commissioner of Maritime Affairs Success TOTSUKA Building #303 4893 Totsuka-cho Totsuka-ku Yokohama 244-0003 JAPAN HONORARY MEMBERS Dr W H Lampe Birkenweg 9 22880 Wedel bei Hamburg GERMANY
Phone: +1 202 314 6417 E-mail: JonesMi@ntsb.gov
Fax: +1 202 314 6454 Phone: +1 202 314 6494 E-mail: email@example.com
Fax: +1 202 314 6454 Phone: +1 202 314 6490 E-mail: firstname.lastname@example.org
Fax: +1 212 425 9652 Phone: +1 212 425 9600 E-mail: email@example.com
Fax: +81 45 866 1167 Phone: +81 45 866 1164 E-mail: firstname.lastname@example.org
Phone: 04103 8 29 44
MAIIF - Contacts
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Captain B D Thorne (Brian) 12 Dunvegan Road Ottawa Ontario K1K 3E9 CANADA Captain W A Chadwick (Bill) 400 Chesapeake Drive PO Box 100 Great Falls Virginia 22066 USA Captain J Palmgren (Johannes) Brunstrop SE 523-99 Hokerum SWEDEN Captain P B Marriott (Peter) Hazlemere 6 Mill Meadow Milford on Sea Hants SO41 0UG UK Mr R H Musker 29 Monk's Orchard Road Petersfield Hampshire GU32 2JD UK Captain K M Varghese Assistant Director - Shipping Division Marine Department 22nd Floor Harbour Building 38 Pier Road Central HONG KONG Captain T Legge (Tony) Unit 2/148 Evans Bay Parade Roseneath WELLINGTON Dr D Steinicke (Dietrich) Assistant Secretary Head of the Maritime Safety Division Federal Ministry of Transport Postfach 20 01 00 D-53175 Bonn
Fax: +1 613 745 0504 Phone: +1 613 745 4521 E-mail: email@example.com
Fax: +1 703 759 4896 Phone: +1 703 759 9259
Fax: +46 321 80321 Phone: +46 321 80275 E-mail: firstname.lastname@example.org Phone: +44 1590 642 300
Phone: +44 1730 267 807 E-mail: email@example.com
Fax: +852 2854 9416 Phone: +852 2852 4404 E-mail: firstname.lastname@example.org
Phone: +64 4 385 2844 E-mail: email@example.com
Fax: +49 228 300 1454 Phone: +49 228 300 4630 E-mail: Dietrich.Steinicke@bmvbw.bund.de
MAIIF - Contacts
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GERMANY Rear Admiral J Lang (John) Wangfield House Martyr Worthy Winchester Hants SO21 1AR UK Mr A Paquet Conseiller Technique Ministere des Transports Commissariat aux Affaires Maritimes 19-21 Blvd Royal L-2938 LUXEMBOURG E-mail: firstname.lastname@example.org
Fax: +352 465 753 Phone: +352 478 4452
New Zealand Accident Investigation Manual
This Appendix contains a number of tips extracted from the NZMSA Accident Investigation Manual for Maritime Safety Inspectors along with an edited version of Captain Tony Legge’s introduction.
This manual has been designed for Maritime Safety Inspectors as an aid to the investigation of accidents. The contents of the manual have been the subject of training seminars which Maritime Safety Inspectors have attended over the past four years. It is not a procedure manual but rather a tool to help with your investigations document. It will…be updated as circumstances dictate. Included in the manual are a selection of interviewing techniques which you might like to consider. Take note of the taping tips. A good quality transcript can save a lot of time and angst. Once your evidence has been collected, you need to analyse it to find the contributing factors and cause. I have provided summaries of two accident causation models to help your analyses. These are the SHEL model and James Reason’s theory. They are not mutually exclusive. Finally, the last and most time consuming job in the investigation process is for you to write the report. The last section of this manual explains the difference between Key Events and Key Conditions and gives an example of a basic causal factors diagram which I have always found very helpful. Tony Legge February 1999
Purpose of Investigation
1. To collect information which will enable you to build a reconstruction of the sequence of events which occurred prior to the accident 2. To collect information which will allow you to make suppositions about the factors which may have contributed to the accident occurring 3. To collect information which will support the recommendations you make and MSA’s further action 4. To collect other statistical information for analytical purposes at head office. Information can be collected in two ways: Hardware evidence and interviews.
Hardware evidence includes: • charts • ship log books • pieces of equipment, materials, wreckage etc. • photos • video recordings • company records and logs • maintenance records • certificates and licences • personnel or training records • company manuals or operating procedures • weather forecasts • medical records & post-mortem results • VHF radio recordings • Reports from external consultants, manufacturers, designers, analysts, divers, scientists etc.
Who should be interviewed?
Interviews need to be conducted with people both directly and indirectly involved with the accident. These might include, for example, victim, skipper, other crew members, vessel owner or manager, survivors, passengers, eyewitnesses, next of kin, friends, colleagues, manufacturer/boat builder/designer, stevedore, Harbourmaster etc. Interviewing a selection of people will help to confirm, clarify or supplement information received from other sources.
First of all, you need to know the circumstances of the accident and then plan the interview. Choose a venue which is free of interruptions and distractions. You may interview people on their own but you must advise the witness of their right to have a lawyer present. If the accident occurs within Harbour Limits, you may like to invite the Harbourmaster to assist in the investigation providing there is no conflict of interest. The flag state may also wish to participate. If so, written consent is required from either the Director of Maritime Safety or the Chief Investigator of Accidents. However, you must maintain control of the questioning and exercise the right to prohibit certain people from attending when their attendance could inhibit an effective interview. This prohibition particularly applies to owners and their lawyers. You may offer to interview the owner separately on their own, but their lawyers cannot participate in anything other than interviews involving their own clients. Prepare a list of points that need to be covered in the interview.
Interviews should be conducted as soon as possible after the incident. If there is a delay, details may be forgotten or distorted and evidence at the scene may be tampered with. Give yourself plenty of time and avoid rushing the interview. If people are reluctant to talk, be patient and give them reassurance.
How well the interview goes and the quality of information you obtain will often depend on the rapport you establish. You should introduce yourself and explain the purpose of the interview. Put the person at ease by spending some time in general conversation. Assess the person and decide on the best way to deal with them. Be considerate and courteous, but maintain control of the interview.
You should try and minimise your own input and concentrate on listening. Although you have to direct the interview and keep it going, it is important to be actively listening to what is being said so that subsequent questions can relate directly to the witness’s experience. Listening can be a very tiring experience. Take frequent breaks so that you and the witness can refresh yourselves.
While listening to what is being said, also study body language and look for discrepancies. Listen for verbal cues which may indicate whether or not the person is telling you the truth. Non-verbal communications may be divided into vocal and non-vocal. Vocal Intonation (certainty, doubt, embarrassment) Rhythm (relaxed, tense) Speed, pitch (stress, anxiety, excitement, relief) Volume (aggressive, defensive, assertive) Laughter (amusement, nerves, scorn) Sighing (resignation, exasperation) Yawning (tired, nervous, lying) Ums, ahs (buying time, pause for thought) Non-vocal Body language- use of hands - touching face, hair or body - scratching - facial expression - leg movement - feet Distance - when seated does he/she try to move back or closer Orientation - sitting face to face may create anxiety that can be reduced by sitting at right angles.
Silent pauses may emerge after a question is asked. This might be due to the person not fully understanding the question or that they are thinking through their answer or they may be nervous and need more time to think. You should refrain from speaking to fill in the pause as the person will usually fill it in themselves. Take advantage of the silence pause to note body language, think up further questions and make a mental check on what you already know.
Once the interview is underway, it is often best to start with a ‘free recall’ question where the witness can tell their story without interruption. From here you can ask questions in more detail.
The following are some points to remember when questioning: • Use plain language and simple words • Keep the questions brief • Be sure you convey the meaning you intend when using certain words in a question • Be sure that the person understands your pronunciation • Use familiar words and examples • Avoid ambiguous words or sarcasm An ‘open ended’ question can be non-threatening and the least leading as it allows the individual to answer in their own way and tell what s/he knows. For example, “I don’t know very much about long line tuna fishing, could you tell me about the processes involved?” Occasionally, the expected answer is not received so a supplementary question may be required to redirect the witness. Be careful not to be too specific in questioning so as to be leading and pressurise a witness into remembering something they may not have known or observed. Try and avoid using ‘closed’ questions which evoke a yes/no response as they produce limited information. For example, “Did the first mate have problems working with the master?” is the type of question which will elicit a ‘yes’ or ‘no’ response and you will have to attempt another question to get a more complete response. Similarly try and avoid using ‘negative’ questions such as “You don’t remember which way the wheel turned?”.
Closing the interview
The last 10% of the interview is often the most important as this is when the greatest amount of information, per unit of time, is exchanged. You should ask the person if there is anything else they want to tell you or if they have any questions. When closing, the witness should be assured that the interview has been valuable. Thank them and tell them what will happen now. They should be encouraged to contact the investigator at a later date if they want to provide additional information or wish to enquire about the progress of the investigation.
Appendix 6 of the MAIIF Manual gives examples of questions which should be used as a guide when interviewing witnesses involved in accidents such as groundings, loss of stability, personnel injuries, collisions, fires and machinery failures.
Tips For Getting Good Quality Transcripts
Before Starting the Interview 1 Check the sound quality of the tape by recording yourself talking into the tape recorder and then play it back to check if it sounds okay. Also, remember to place the tape recorder at the same distance from each person in the room. You should do another check, with all people in the room talking (one at a time) to see how the tape picks up their voices. Ask the interviewee(s) to speak more slowly than usual, louder and clearly so that the tape recorder picks up their voice. They should also be told to speak one at a time. Ensure that all mobile phones, pagers etc., are turned off during the interview.
Post a "Quiet Please" notice on the door. Try to hold the interview away from any background noises, such as fans, air conditioning, traffic, typing, paper rustling, telephones, doors slamming. The tape tends to pick up noises (other than voices) very clearly.
Starting the Interview 1 Before you start reading the preamble or beginning the interview, you should start with the following: Today's date is [Day] [Date] [Month] [Year]. I have here with me today, [Person's name] the [Insert title, i.e. Master of vessel’s name] in relation to the [accident, incident, mishap] on board[Insert name of vessel] on [Day] [Date] [Month] [Year]. This helps me determine who is being interviewed, and also helps with putting a heading at the top of the page. Also include the names and titles of anyone else who may be in the interview, i.e. Lawyers, Owner representatives etc. Just in knowing they are present at the beginning of the interview is helpful. 2 Then read the preamble for a full investigation or begin the interview.
First Six Questions I recommend that you begin by asking the following six questions immediately after reading the preamble or at the beginning of your interview. 1 2 3 4 5 6 Name (also ask them to spell it if you think they need to) Contact address (ask them to spell street and place names if needed) Contact telephone number(s) Age and Date of Birth Any qualifications they may hold Sea going experience
During the Interview 1 2 3 4 Try not to interrupt. It is difficult trying to transcribe two people at the same time. If you must interrupt in order to bring the interviewee back on track, make it decisive. Stop the tape if they/you need to refer to charts, notes, speak to lawyers etc., but make a reference to why you have stopped and again when you resume, make an audio reference. If they begin to speak too quickly, mumble, or speak quietly, remind them to speak slowly, loudly and clearly. If your tape recorder does not give an indication that it has reached the end of one side, keep checking it. This is quite easy to do during the interview. The micro cassettes are generally sold as 60 minutes tapes, which is half an hour on each side. However, on long play it would be one hour each side. Therefore, depending on whether you have the tape recorder on normal or long play, keep an eye on the time to give you an indication of when the tape will reach the end. Ask them to spell place names or vessel names if necessary.
The Finished Product When I have transcribed the interview and returned it to you, you may find it has some dotted lines in it. To help clarify what these mean: ......................... A series of dots, like this, means that I could not decipher the word. If I can't decipher it the first time, I listen to it 3 or 4 more times (and sometimes even ask others to listen) and if I still can't decipher it, then in go the dots. However, if you or the person you interviewed can remember what was said, please feel free to put the word(s) in. Three spaced dots like this will always appear at the end of a sentence/paragraph when the person speaking at the time was either interrupted or trailed off without finishing the sentence. You should not complete the sentence. It accurately represents what happened. This means exactly what it says.
When you send the tapes, please indicate whether you would like me to e-mail the document to you (so you can make appropriate changes) or send the hard copy to you. If you would like the hard copy posted to you, could you also please indicate if you require any copies of the transcript. Also, when you send the tapes to Head Office, please label them. They do come with labels, but if you don't have them, write on a post-it or piece of paper the name of the vessel involved, the name of the person(s) interviewed on the tape, and the date of the interview. Head Office currently has a standard letter that goes out with the transcripts when they are sent for signature. Generally, the original transcript and a copy are sent to the person concerned. We ask them to send back the original (which we stamp with an "original" stamp) initialled on each page and the declaration that it is a true and accurate account of the interview on the final page signed and dated, and the copy (which is also stamped with a "copy" stamp) is for them to keep. Attached to this document is a copy of the standard letter that we send with the transcripts.
Accident Causation Models - An aid in analysis
The SHEL model
The SHEL model is a simple interactive model which focuses on the importance of human interaction and the use of written information and symbology. There are four components of the model. These are Software, Hardware, Environment and Liveware - hence the name SHEL! The liveware, or the human element, is in the centre of the model since this is the pivotal component which interacts directly with each of the other components. (Source: The SHEL model (adapted from Hawkins 1975) ICAO Circular, Montreal Canada.) As you can see from the displayed model, the component blocks are not straight. They are jagged and other blocks have to be carefully matched to them in order to fit well. An accident occurs where the blocks are not matched well and the investigation of human factors has to identify where the mismatches occur. That is, what was the breakdown between the components which contributed to the accident? The investigation has to examine each of the components in order to find where the weak links occur at the interfaces. The central liveware component, the individual, can be broken down into four categories. These are physical, physiological, psychological and psychosocial.
Firstly, the physical factors deal with the physical capabilities and limitations of the person and include their physical condition and strength, their motor skills and various senses. A useful question to put in this regard would be whether the person was physically capable of performing their required task(s). The physiological aspect of a human involves his/her general health, level of stress, degree of fatigue, their tendency to smoke, drink or take drugs, and considers the individuals general lifestyle. The psychological element of the human is complicated as it involves an individual’s past knowledge and experience, such as training, and their mental capabilities such as perceptions, information processing, attention span, personality, mental and emotional states, attitudes and moods. Questions surrounding this psychological aspect would include - Was the training, knowledge and experience sufficient? Was there any misperceptions about the task, or did the level of attention needed exceed the individual’s limitations? What were the person’s attitudes towards work and other employees, and how did these attitudes influence motivation, judgement and quality of work? Psychosocial factors deal with influences external to the work environment which distract or stress the individual. A death in the family, financial troubles or relationship problems are examples of this type of factor. It could be found that the death of a close relative contributed to the amount of fatigue experienced by the person. The liveware-liveware interface denotes the relationship between the individual and other persons in the same workplace. This relationship can be between fellow workers, staff and management or superiors and subordinates. Human interaction, verbal and non verbal communications and visual signals all need to analysed. Had interactions with others influenced the individual’s performance? How did the crew work together as a team? Did visual signals support verbal information? Were management policies regarding working conditions sufficient given the circumstances? These are the types of questions which should be considered when investigating this interface. The relationship between the human and the machine is represented by the liveware-hardware interface and factors included here are the configuration of the work place, display and control design etc. These are the physical features which could have been factors in the accident. The liveware-software interface represents the relationship between the individual and the supporting systems in the workplace, such as regulations, manuals, standard operating procedures etc. A breakdown in the match of these components could be due to the manuals, checklists etc. not being readily available, adequate, incomprehensible, or perhaps they have not been consulted. The relationship between the person and the internal and external environments is described as the liveware-environment interface. The immediate work area includes factors such as temperature and noise variations, lighting and ventilation. This is the internal environment while the weather, terrain, infrastructure, political and economic situation and constraints, denote the external environment. This final interface is relevant in the maritime industry as weather conditions can often be a contributory factor in an accident. However, economic pressures have also shown to hold a strong influence, especially on time constraints in shipping, or the amount of fish caught in the fishing industry. A systems approach to the investigation of human factors in accidents allows a better understanding of how various components of the system interact and integrate to result in an accident. By adopting a systematic approach to the investigation of accidents the investigator can identify the underlying causes. In addition to the SHEL model above, this interactive approach has been proposed by many other theorists. Another model and theory by James Reason will be discussed next.
The basic proposition of the Reason model is that industrial accidents are the end-results of long chains of events that start with decisions at management level. As a general framework for accident causation Reason
considers the basic elements of production to be: Decision makers, Line management, Preconditions, Productive activities and Defences. Decision-makers incorporate the architects and the upper management or senior executives. They are responsible for setting the goals for managing available resources (money, equipment, people and time) to achieve not only the goal of punctual cost-effective fishing and transportation of passengers and cargo for example, but also the goal of safety. The second key element is line management. This is where the decisions which have been made by upper management are implemented. The strategies of the decision makers are implemented in each of the operation spheres such as operations, training, maintenance, finance, safety, engineering support etc. However, for these upper management decisions and line management actions to be effective and productive there has to be certain preconditions existing. Equipment has to be reliable and available and the workforce has to be skilled, knowledgeable and motivated. Another required precondition is a safe environment. For productive activities there needs to be a good co-ordination between the mechanical and human activities to produce the right task at the right time. Finally, the element at the end of the complex productive system are the defences. Productive activities involve exposure to hazards and safeguards should be in place for the human and the mechanical components to prevent foreseeable injury, damage or costly interruptions of service. (Source: James Reason, Human Error, 1990. United Kingdom: Cambridge University Press) James Reason’s model of accident causation shows the various human contributions to the breakdown of a complex system. He believes that accidents rarely originate from the errors made by front-line operators or from major equipment failures but result from interactions of a series of failures or flaws already present in the system. These failures are not readily obvious and usually have delayed consequences. An active failure is an error made by the operational personnel, such as the ship’s crew, which has an immediate adverse effect. The skipper inadvertently switching the bridge control switch to engine room control while the engine room control was at off is an example of this failure type. A latent failure is the result of a decision or action made well before the accident and usually has been lying dormant for a long time. Such a failure is usually initiated by someone far removed from the event in both time and space who is the decision maker in the line management level. The failure can then be introduced at any time into the system by the human element. For example, upper management make the decision to put a new roster system for pilots into place which is organised by line management. However, the new system brings with it longer working hours which results in a lack of motivation and fatigue. An actual maritime accident occurred in Zeebrugge when the overworked and undermanned crew of the Herald of Free Enterprise left harbour with the bow doors open. This was an oversight caused by a combination of active failures (Sheen 1987), but it was also compounded by strong management pressures to meet the binding schedule for the Dover docking. Latent failures can then interact to create a “window of opportunity” for the front line operator to make an active error or failure. When all the defences of the system are inadequate then an accident will ultimately result. Those at the human-machine interface are the inheritors of system defects which are created by poor design, conflicting goals, defective organisation and bad management decisions. In effect, the part played by the front line operators is to create the conditions under which these latent failures can reveal themselves. Although latent and active failures will interact they will not result in an accident when defences work and the system is well guarded. In this instance the “window of opportunity” is not lined up. This approach to the investigation of human factors encourages the investigator to go beyond the unsafe acts of the front line operator and look for hazards already existing in the system.
Writing the Report
A good way to start the written report and analysis is to separate the key events of the accident from the key conditions. Accidents are the result of a set of successive events that produce unintentional harm. The accident sequence occurs during the action of some work activity. Every accident involves a sequence of events or happenings that occur during a work activity and there are identifiable beginning and ending points in the sequence of events. Then, there are conditions which are relevant to the accident but which do not fall into the sequence of events. Contributory factors emerge in the accident causation analysis as the sequential events interact with the existing conditions. As an analytical aid, the use of diagrams or charts are useful in separating the events from the conditions. A causal factors diagram helps in evaluating the evidence during an investigation as well as assisting in the analysis. Firstly, the investigator should break the accident’s sequence into a logical flow of events, from the development of the accident to the end. Then the relevant conditions, which affect the events, need to be added to the diagram, where they surround the events. Each event should describe an occurrence or happening and usually a time can be fixed to it. Therefore, a good rule to follow in determining when a fact is an event rather than a condition is whether a time can be fixed to it within the accident sequence. Conditions differ from events in that they describe states or circumstances rather than occurrences or happenings and are usually passive rather than active. Events are best arranged chronologically, either from left to right if developing a diagram, or from the earliest event to the last event when writing a sequence of events in a report form. The event needs to be accurately described, eg. “Chief Engineer pulled main engine switch to on position” rather than “Chief Engineer turned engine on.” Additionally, each event needs quantifying when possible. Therefore, instead of stating “The helm was turned to port” one should write “The helm was turned 20° to port.” Once the key events and key conditions have been identified, it will then be easier to identify specific contributory factors which can then be narrowed down to a root or immediate cause. This is when the use of an accident causation model comes into play. The following paragraph is a summary of an accident which actually occurred. A Port of Tauranga pilot suffered a serious mishap when disembarking from Union Rotorua to the pilot launch Tauranga II using a pilot ladder. He fell about 2 metres onto the deck of the launch and landed on the safety rail fitted above the safety harness track. He had been unable to retain his grip on the manropes which were of a large diameter and wet and slippery from heavy rain. A deckhand hooked a safety line to the pilot’s belt to take him on board. He was taken to hospital with cracked ribs and compressed vertebrae. The accident report is written in the following way. Look at how the report divides the events from the conditions. Also take note of the numbering system used for each sentence and section. Each of your written reports should be written according to this format.
1.1 At 1642 hours, the pilot boarded MV Union Rotorua 1.2 At 1705 hours, all lines were clear and the vessel left Sulphur Point berth. 1.3 At 1749 hours, the pilot disembarked the vessel using the pilot ladder on the port side, with the ship heading approximately 330°T. 1.4 The ship provided a lee for the pilot boat, and the boat was heaving and pitching to give a bow motion of about half a metre.
1.5 While disembarking from MV Union Rotorua, using the pilot ladder and manropes, the pilot fell about 2 metres onto the deck of the pilot launch Tauranga II. 1.6 He landed on the safety rail fitted above the safety harness track while still holding the manropes. He then pitched forward. 1.7 The boat’s deckhand hooked the safety line to the pilot’s belt and he was taken inside the boat. 1.8 The pilot went to hospital with serious injuries. He stayed for two nights.
2.1 The wind observed at the Tauranga signal station was: 1600 hours NE 40 knots, 1714 hours ENE 60 knots, 1826 hours NE 65 knots, 2000 hours N 25 knots. 2.2 Two ships had departed shortly before MV Union Rotorua. These were MV Grand Honest at 1657 hours and MV Wisteria at 1706 hours. The two pilots were on the launch at the time. 2.3 There was heavy rain and conditions deteriorated rapidly before the accident. 2.4 The pilot said that the port ladder and manropes were rigged before the ship left the berth, and that the ropes were wet and slippery. He said that there was a lot of water at the side of the deck and it was flowing over the side as the ship rolled, and that he had considered remaining on board the ship which was bound for Auckland. 2.5 The boat’s crew confirmed that water was flowing over the side. 2.6 The pilot’s feet were over 2 metres above the deck of the boat when he lost control. 2.7 He suffered cracked ribs and a compressed vertebrae. 2.8 He was off work until 17 August and off pilotage duties for five to six weeks. Contributing Factors 3.1 Water on deck flowing over the sheer strake. 3.2 The water may have been oily from cargo handling vehicles working on deck. Causes 4.1 Heavy rain made the manropes wet and slippery 4.2 The manropes were of a large diameter, possibly 42 mm. Opinions and Recommendations 5.1 The Port of Tauranga senior pilot is assessing various sizes of manrope in order to recommend the most suitable size. The Shipping (Pilot Ladders) Rules 1974 specifies a minimum size of 20mm. 5.2 Manropes should be stowed in a dry area and rigged shortly before the pilot disembarks. In Tauranga, manropes are used only when disembarking. 5.3 Ships should ensure that scuppers are clear so that water is not trapped by the sheer strake and deck camber. 5.4 MSA should circulate to ships’ agents advice for rigging pilot ladders which should be forwarded to ships arriving in New Zealand. The circular should recommend a maximum diameter for manropes, and should draw attention to the recommendations of the International Marine Pilots Association, which includes directing the light forward and not fitting a tripping line to the bottom of the ladder.
The following is a basic causal factors diagram of the accident. It will aid in analysis and prompt further questions to analyse deficiencies in the management system.
Weather deteriorating Pilot ladder and manropes rigged previously Heavy rain Water on deck
Vessel leaves berth
Pilot disembarks by way of pilot ladder
Vessel rolls heavily
Pilot falls onto deck
Large diameter ropes Wet and slippery ropes
Wind ENE 60 knots
Hanging two metres above deck oily deck from cargo operations
In summary, the written report, which is finally sent to Head Office, must be written according to the following sections which employs the numbering system illustrated in the example:
Key Events Key Conditions Contributing Factors Causes Opinions and Recommendations.
Your report should be accompanied with all the evidence which you collected during the investigation so that a full file can be held at Head Office.
An accident means an occurrence that involv-es a ship and in which (a) A person is seriously harmed as a result of (i) Being on the ship; or (ii) Direct contact with any part of the ship including any part that has become detached from the ship; or (iii) Direct exposure to the wash of the ship or interaction (other then direct contact) between 2 ships; or
Being involved in the salvage of any ship - except where the injuries are self inflicted or inflicted by other persons or when injuries are to stowaways hiding outside the areas normally available to passengers and crew; or (b) The ship sustains damage or structural failure that(i) Adversely affects the structural strength, performance or seaworthiness of the ship; or (ii) Would normally require major repair or replacement of the affected component; or (iii) Poses a threat to the safety of people on board the ship; or (c) There is a complete or partial failure of machinery or equipment that affects the seaworthiness of the ship; or (d) There is a loss of, or damage to, or movement of, or change in the state of, the cargo of the ship which poses a risk to the ship or other ships; or (e) There is a significant loss of, or significant damage to, property (not being the cargo carried by the ship) or the property of any person (whether or not on board the ship), whether or not the loss or damage arises from an interaction between 2 ships; or (f) There is a loss or escape of any substance or thing that (i) May result or has resulted, in serious harm to any person; or (ii) May pose a risk, or has resulted in damage to the ship or other ships; or (iii) May pose a risk, or has resulted in damage to any property (whether or not on board the ship); or (g) A person is lost at sea (whether or not subsequently found) or is missing: or (h) The ship is foundering, capsizing, being abandoned, stranding, missing or has foundered, capsized, been abandoned, stranded, been in a collision, or has had a major fire on board. An incident means any occurrence, other than an accident, that is associated with the operation of a ship and affects or could affect the safety of operation. A mishap means an event that (a) Causes any person to be harmed; or (b) In different circumstances, might have caused any person to be harmed. Serious Harm means1. Death; or 2. Any of the following conditions that amounts to or results in permanent loss of bodily function, or temporary severe loss of bodily function: respiratory disease, noise-induced hearing loss, neurological disease, cancer, dermatalogical disease, communicable disease, musculoskeletal disease, illness caused by exposure to infected material decompression sickness, poisoning, vision impairment, chemical or hot metal burn of eye, penetrating wound of eye, bone fracture, laceration, crushing. 3. Amputation of body part. 4. Burns requiring referral to a specialist registered medical practitioner or specialist outpatient clinic. 5. Loss of consciousness from lack of oxygen. 6. Loss of consciousness, or acute illness requiring treatment by a registered medical practitioner, from absorption, inhalation, or ingestion, of any substance. 7. Any harm that causes the person harmed to hospitalised for a period of 48 hours or more commencing within 7 days of the harm's occurrence. A Seafarer a) Means any person whoi) Is employed or engaged on any ship in any capacity for hire or reward; or
ii) Works on any ship for gain or reward otherwise than under a contract of employment; but b) Does not include a pilot or any person temporarily employed on a ship while it is in port A Ship means every description of boat or craft used in navigation, whether or not it has any means or propulsion; and includesa) A barge, lighter, or other like vessel: b) A hovercraft or other thing deriving full or partial support in the atmosphere from the reaction of air against the surface of the water over which it operates: c) A submarine or other submersible