INCIDENT INVESTIGATION

1. Which of the following definitions is that of a “blame culture”?

a) One where people look no further than “human error”
b) One where investigators seek to blame as many people as possible
c) One which seeks to avoid apportioning any degree of blame
d) One in which the level of responsibility of each person involved in an incident is allocated as a percentage
2. Which of the following are possible consequences of accidents, incidents and near-misses? (Select all applicable
answers).
a) Personal injury
b) Material damage
c) Lost time
d) Adverse publicity
e) Loss of reputation
f) Low morale and poor attitude amongst the workforce
g) Enhanced reputation
h) Positive impact through publicity
3. If accidents are investigated and the information obtained is constructively fed back into the system, which of the
following might reasonably be anticipated?
a) A reduction, or even elimination of such accidents in the future
b) An increased likelihood of the repetition of such accidents in the future
c) A reduction in personal injuries, matched by a corresponding increase in incidents involving material damage
d) A more efficient system will be developed for the purposes of allocating blame
4. This program featured a study conducted by the North of England P&I Club which used the example of a man and a
ladder alongside the accident pyramid. What relationship did this illustration suggest?
a) That the severity of accidents depends on the degree of hazard
b) That the observed severity of a series of connected incidents is inversely proportional to the number of incidents in the
series
c) That a rectangular shape is more practical for the purposes of illustrating accident and incident statistics than a pyramid or
circular pie-chart
d) That such studies are more valuable and accurate when physical injury is involved
5. What broad rule is often referred to by safety investigators when explaining the selective investigation of reported
incidents?
a) The 80 / 20 rule
b) The 20 / 20 rule
c) Bernhard’s principle of Selective Accident Investigation
d) The Accident Pyramid
6. Which piece of international legislation directly resulted from the sinking of the “Herald of Free Enterprise”?
a) The International Safety Management (ISM) Code
b) The International Convention for the Safety of Life at Sea (SOLAS)
c) The Guidelines on Places of Refuge for Ships in Distress
d) The Global Integrated Maritime Information System (GISIS) Guidelines
e) The Code for the Investigation of Marine Casualties and Incidents
7. Which maritime Code requires shipping companies to provide for safe practices in ship operation and a safe working
environment, establish safeguards against all identified risks and to continuously improve safety management skills
of personnel ashore and aboard ships, including preparing for emergencies related both to safety and environmental
protection?
a) The International Safety Management (ISM) Code
b) The International Convention for the Safety of Life at Sea (SOLAS)
c) The International Ship and Port Facility Security (ISPS) Code
d) The International Convention for the Prevention of Pollution from Ships (MARPOL)
8. Within the context of this training module, which of the following is the definition of an “incident”?
a) An uncontrolled development in the course of an operation which has resulted in unintended harm or damage, or
the potential for legal action, or is not consistent with acceptable standards
b) An unforeseen event that has resulted in unintended harm or damage
c) A planned event that has resulted in deliberate damage
d) A situation where personnel have been injured as a result of failure to comply with the operating requirements of the
company’s Safety Management System
9. Within the context of this training module, which of the following is the definition of a “near-miss”?
a) An unintended or unwanted event, or uncontrolled development in the course of an operation, that almost
resulted in unintended harm or damage, or potential for legal action, or is not consistent with acceptable
standards
b) An intended or desired event, or controlled development in the course of an operation, that inadvertently resulted in
unintended harm or damage
 c) An occurrence in which personnel are found not to have been operating in compliance with the Safety Management
System
d) An operation, or phase in an operation, in which personnel, the ship, its equipment or cargo, or the environment, are
assessed as being exposed to risk
10. Which safety initiative, launched by the Oil Companies International Marine Forum in 1993, takes the form of a risk-
assessment tool for charterers, ship operators, terminal operators and government bodies and was intended to
address concerns over sub-standard shipping?
a) The SIRE Programme
b) The CDI Programme
c) The International Risk Assessment Guide for Ship and Terminal Operators
d) The Operator Voluntary Audit Scheme
11. As described in this training program, an accident is generally caused by contact with which of the following? (Select
all applicable answers).
a) A source of energy
b) A substance above the threshold limit of the body concerned
c) A material at or below the threshold limit of the body concerned
d) A body within which all energy has been contained during an impact
e) A body capable of generating a disproportionately high level of energy
12. In terms of investigation, which of the following may be considered as the results or effects of an accident?
a) The loss experienced at the end of a sequence of events
b) The elements in a sequence of events prior to the point of contact
c) Serious material damage, but not any physical injury
d) Visible costs in material replacement and repair only
13. Which of the following are examples of “hidden” costs? (Select all applicable answers)
a) Lost time
b) Reduced capacity
c) Increased premiums
d) Reduced profits
e) Loss of future business
f) Injuries
g) Material damage
h) Pollution
14. Which of the following are examples of “latent factors” behind an accident? (Select all applicable answers)
a) Design
b) Incorrect installation
c) Faulty maintenance
d) Management decision
e) Inadequate procedures
f) Unsafe acts
g) Substandard practices
15. The maximum safe working load of a crane has been exceeded. When the operator attempted the lift, the retaining
bolts at the foot of the crane mounting sheared and the crane toppled over. Which of the following may be
considered as evidence of “fallibility” in this situation? (Select all applicable answers).
a) Incompetence
b) Recklessness
c) Negligence
d) Lack of monitoring
e) Lack of communication
f) Ongoing management failure
g) Inadequate design
h) Faulty maintenance
16. A Junior Engineer is injured during the replacement of a main engine cylinder liner. Immediately before the accident,
which two distinct types of actions, referred to in this training program, may have been performed by the 1st
Engineer, who was supervising the operation and by the other members of the maintenance team?
a) Omission
b) Commission
c) Remission
d) Deletion
e) Prevention
f) Solution
17. Following an incident, the situation may develop in one of two ways. What are they?
a) It may continue to deteriorate
b) It may be recovered
c) It may be considered of no importance to the overall operation
d) It will not be possible to investigate the accident in compliance with the company Safety Management System
18. An investigator arrives on board to conduct an inquiry into an incident involving some damaged containers, several
of which have collapsed and fallen forward onto the back of the forecastle deck. Which of the following will he
initially seek to identify?
a) The transfer of energy
b) Where the biggest impact has taken place
c) How the greatest damage was caused
d) The sequence of events leading to the incident
19. Which of the following are examples of transfer of energy by contact?
a) Seafarer struck and injured when cradle collapses and a number of empty nitrogen cylinders are spilled onto
deck
b) Chief Cook slipping and falling down ladder from galley to refrigerator flat
c) Pumpman caught by chemical under pressure when he attempts to release the bolts holding a flange
d) Damage to spare parts in storage cabinet sustained when work bench broke loose in the electrician’s workshop
during heavy weather
e) Steward opens locker door and is hit by falling crockery as ship rolls
f) Mental stress due to fatigue and inadequate training
g) Improper system activities being present in the procedure in progress
h) Wear and tear on the shaft of a sledge hammer, resulting in the head working loose
20. Drag and drop the methods onto the questions, to show the techniques that an investigator will use at the
corresponding stages of an incident investigation.
a) Observation">What?
b) Evidence>What?
c) Analysis">Why?
d) Reasoning>Why?
21. Which of the following are examples of substandard practices? (Select all applicable answers)
a) Operating equipment without authority
b) Over-riding or bypassing safety devices
c) Operating at an improper or unsafe speed
d) Failure to use personal protective equipment
e) Inadequate or missing guards or barriers
f) Inadequate or defective warning systems
g) Defective tools, equipment or materials
h) Exposure to excessive high or low temperatures
22. Which of the following are examples of substandard conditions? (Select all applicable answers)
a) Inadequate, improper or missing personal protective equipment
b) Congested or restricted work area
c) Inadequate or defective warning systems
d) Exposure to excessive high or low temperatures
e) Working under the influence of alcohol or drugs
f) Operating equipment at an improper or unsafe speed
g) Failure to secure
h) Willfully ignoring legitimate orders or instructions
23. Which of the following are examples of abnormal behavior? (Select all applicable answers)?
a) Removing a “nitrogen tag” from the lid of a cargo tank, unclipping the securing dogs, opening the lid and
climbing inside
b) Allowing a colleague to walk along a poorly-lit catwalk, towards an area where the gratings have been lifted for
maintenance on a pump underneath and no protective barriers have been erected, without issuing a warning
c) Commencing the overhaul of a ballast valve, without first checking that it has been properly isolated and the
appropriate warning notices put in place in the control room
d) Operating a workshop drill without using eye protection
e) Operating a manifold crane on which no training and familiarization has been delivered
f) Wearing footwear with steel-toecaps during storing
g) Carrying out a risk assessment and completing a “Permit to work aloft” form before repairing a floodlight on the front of the
accommodation
24. Basic causes are generally divided into which two of the following categories?
a) Personal factors
b) Job factors
c) Substandard acts
d) Substandard conditions
e) Fundamental causes
f) Intermediate factors
g) Resultant causes
25. Immediate causes are generally divided into which two of the following categories?
a) Substandard acts
b) Substandard conditions
c) Personal factors
 d) Job factors
e) Circumstantial evidence
f) Underlying factors
g) Resultant conditions
26. Below is a list of six “personal factors”. Three of them may be categorized under inadequate physical / physiological
capability and three under mental and physical stress. Drag and drop the examples onto the applicable
corresponding personal factor:
a) Inadequate orientation or briefing">Lack of knowledge
b) Lack of experience>Lack of knowledge
c) Inadequate updating or refresher training">Lack of knowledge
d) Lack of incentives>Lack of proper motivation
e) Improper example set by supervisor>Lack of proper motivation
f) Excessive frustration>Lack of proper motivation
27. Below is a list of six “job factors”. Three of them may be categorized under inadequate tools or equipment and three
under wear and tear. Drag and drop the examples onto the applicable corresponding job factors.
a) Inadequate assessment of operational requirements">Inadequate tools or equipment
b) Inadequate standards and specifications">Inadequate tools or equipment
c) Improper recycling or disposal of used components">Inadequate tools or equipment
d) Inadequate planning for utilization of equipment">Wear and tear
e) Improper loading">Wear and tear
f) Inadequate maintenance practice">Wear and tear
28. Which of the following may be categorized under the general factor described as “mental or physiological stress”?
(Select all applicable answers)
a) Fatigue due to mental task load
b) Reaching or approaching the limit of sound judgment or decision making
c) Routine or monotony
d) Exposure to an environment within which the subject is not comfortable or confident
e) Conflicting instructions or demands
f) Frustration
g) Blood sugar deficiency
h) Limited ability to sustain body position
29. Which of the following may be categorized under the general factor described as “inadequate or improper work
standards”? (Select all applicable answers).
a) Inadequate development of standards, including risk assessment, coordination with process design, lack of
employee involvement and inconsistent procedures and rules
b) Inadequate or improper communication of standards, including publication, distribution, translation and
reinforcement with color codes, signs and other visual aids
c) Inadequate maintenance of standards, including monitoring and updating
d) Inadequate preventative maintenance, including assessment, servicing, adjustment, cleaning and / or documentation
e) Inadequate or improper repair procedures, including assessment and communication of requirements, scheduling of work,
replacement of parts and / or documentation
30. What is it that starts the process of cause and effect and ultimately results in the “loss” evidenced in the incident?
a) Lack of control
b) Lack of equipment
c) Lack of training
d) Improper risk assessment
e) Intentional abuse
f) Insufficient feedback
31. Drag and drop the tasks into the correct sequence to be adopted to produce “good control” in the context of this
program.
a) Accurately measure performance">1
b) Carefully evaluate results">2
c) Assess needs">3
d) Apply corrective and development measures">4
32. What are the three common reasons for lack of control?
a) An inadequate system
b) Inadequate standards
c) Inadequate compliance with standards
d) Poor communication
e) Insufficient investment in training
f) Lack of personnel
g) Excessive paperwork
h) Inadequate design
33. Which of the following factors may be evidence of a failing in loss control? (Select all applicable answers).
a) There are too few system activities
b) There are irrelevant activities present
 c) Inaccurate and out-of-date activities are observed
d) Incomplete activities are found
e) There are improperly arranged activities
f) Training standards are excessively high
g) Performance standards are too specific
34. If control is assessed as inadequate, which of the following factors may be representative of inadequate performance
standards? (Select all applicable answers).
a) The standards are not specific enough
b) The standards are unclear
c) The standards are assessed as not high or demanding enough
d) The standards are assessed as not low or easy enough
e) The standards state exactly what is required
f) There are too few system activities found
35. Which of the following should be declared in performance standards? (Select all applicable answers).
a) What action is expected
b) When an action is expected
c) Who an action is expected from
d) Where results are to be recorded
e) Why only accredited personnel can measure performance standards
36. Which of the following best explains the purpose of an investigation into an accident, incident or near miss on board
ship?
a) The establishment of facts and the determination of corrective action, aimed at the prevention of a recurrence of
the incident. It is not the allocation of blame
b) Primarily the allocation of blame, but also the identification of relevant contributory factors. It may suggest corrective
action
c) The drawing up of corrective action, including disciplinary procedures where appropriate. The applicable contributory
factors may not necessarily be identified
d) The completion of the necessary forms, so that an incident is on record and an auditor can see that a system for
selectively documenting certain incidents exists
37. There has been an outbreak of food poisoning on board your vessel. The suspicion is that the source can be traced
to a portable hose, previously used to transfer sewage while a pump was under repair in the engine room. There are
two inspectors attending the vessel. They ask permission to take samples from the domestic fresh water tanks. What
should be the action of the Master and Chief Engineer? (Select the most correct answer).
a) The Master should check with the company before releasing any samples. He should clearly establish what he is
to release and who he is authorized to release it to
b) The Master and Chief Engineer should at all times be fully cooperative with all inspectors following an incident, including
releasing any papers, samples and reports that are asked for
c) Neither the Master nor Chief Engineer should cooperate in any way with any inspectors. The gangway security watch
should be doubled and all shore side personnel should be refused admission to the ship
38. There has been an incident on board the vessel, resulting in two injured crewmembers and damage to a cargo
loading arm. A reporter from a union newspaper approaches the seaman on duty at the gangway and asks him to
explain what happened. He offers the man €100 if he will “assist with confirming some details”. How should the
seaman be trained to react to such an approach?
a) He should not enter into any discussion relating to the incident. He should refuse admission to the reporter
b) He should accept the money and politely answer the reporter’s questions
c) He should call the Bosun on his radio and ask him to come and talk with the reporter
d) He should freely answer all the reporter’s questions, but ask him to write his name in the visitor’s log book
39. Which of the following is the best definition of “evidence”, as described in this program?
a) Something that demonstrates proof
b) Something that demonstrates guilt
c) Information collected for an investigation report
d) The verbal statements of witnesses interviewed during an investigation
40. Which of the following is the definition of “circumstantial evidence”, as understood by this module?
a) Something that may reasonably be inferred as a fact relevant to an incident
b) Something found in physical objects, which cannot often be disputed
c) Information obtained through a third party
d) Accounts told by witnesses
41. Which of the following is an example of direct, or real, evidence?
a) A broken hydraulic jack
b) A photograph of a broken hydraulic jack
c) A description of a broken hydraulic jack, made by a witness who saw it break.
d) A test certificate relating to a hydraulic jack, which broke in the incident
e) A description of a broken hydraulic jack, told to the person you are now interviewing
f) An opinion on the condition of the hydraulic jack under investigation by an expert metallurgist
42. If an officer is instructed to investigate an incident which involved a broken wire on a mooring winch and he is
supporting his inquiry with photographs, how should he try to photograph the wire?
a) In place, still on the winch drum
b) In the forecastle store, having been removed from the winch drum.
c) Ashore, having been removed from the vessel
d) He should not take photographs of the broken wire
43. Which of the following may be an indication that entries in a log-book have been added, or amended, at a later stage?
(Select all applicable answers).
a) A missing page as indicated by a break in the numerical sequence
b) The application of “liquid paper” (Tipex)
c) An entry between others in a different handwriting style
d) An entry between others using a different pen
e) An entry made by someone who was not on watch at the time
f) An entry found to have been made by the Chief Engineer
44. You are investigating an accident on the deck of a chemical tanker. You want to take some photographs in support of
your investigation. Which of the following must be confirmed before this? (Select all applicable answers).
a) All necessary atmosphere tests have been done, incompliance with the applicable safety procedures and that the
appropriate risk assessment form and permits have been completed
b) The Master has given permission for photographs to be taken
c) Where fitted, the date / time facility must be correctly set and activated
d) That the camera to be used meets the specifications laid down in the ISPS Code
e) That the ship’s deck lights have been switched off
45. Which of the following will commonly be amongst an investigator’s aims when planning a series of interviews as part
of the inquiry procedure? (Select all applicable answers).
a) To establish and confirm the sequence of events
b) To understand how the witness was involved in the incident
c) To identify the principal elements and contributing factors in the incident
d) To determine areas of the operation that require attention in order to prevent a recurrence of the accident or
incident
e) To determine if the witness is to blame for the incident
f) To see if a witness has lost his nerve following the incident
g) To determine if the witnesses have “arranged a story” between them
46. The Chief Officer has been appointed to investigate an incident in the engine room workshop. He is planning to
interview a number of crewmembers. Which of the following should he do, prior to commencing the interviews?
(Select all applicable answers).
a) Analyze the evidence already secured
b) Identify evidence still to be secured
c) Run through the sequence of events and review the principal elements and contributing factors known to that
point in the investigation
d) Draw up a list of those to be interviewed
e) Consider the approach to be taken with each witness
f) Work out beforehand who is lying and how to trap them in the interview
g) Compile questions which will deliver evidence to support his ideas of what happened
47. The Superintendent is going on board to conduct an investigation into an accident in which a crewmember was
seriously injured during the securing of the hatch cover on number 3 hold. Which of the following should he
particularly try to interview? (Select all applicable answers).
a) The person in charge of closing the hatches at the time of the accident
b) Any eye witnesses
c) Any person who can contribute to the understanding of the events leading up to, and the prevailing conditions at
the time of, the accident
d) Any person who can provide additional evidence, relevant to the investigation
e) All crewmembers
f) A representative from the manufacturer of the hatch covers
48. The ship’s Safety Officer is conducting an on-board investigation into a minor incident involving a lifeboat access
platform. A Seaman who was working nearby at the time is being interviewed and is having difficulty in remembering
some of the details. How might the Safety Officer assist him to remember? (Select all applicable answers).
a) He might talk through the incident with the Seaman
b) He might work through a list of potentially relevant items, asking the Seaman to include or reject them
c) He must get firm with the Seaman and tell him how important it is that he remembers
d) He should ask the Seaman to say anything, even if he is not absolutely sure of the facts, so that he can include some
testimony from the Seaman in the investigation report
49. Which of the following is the definition of an “impartial” witness, within the context of this program?
a) One who has no personal interest and nothing to gain, or lose
b) One with a personal interest in the outcome of the inquiry
c) One who is displaying suppressed hostility, loyalty to colleagues or fear.
d) One with whom there is a language-based communication problem
 e) One who has a problem with authority and feels threatened by the interview
50. Which of the following is the definition of a “negative” witness, within the context of this program?
a) One who “saw nothing, heard nothing, knew no-one involved and remembers nothing anyway”.
b) One with a personal interest in the outcome of the inquiry
c) One who is biased and hostile
d) One with whom there is a language-based communication problem
e) One who has a problem with authority and feels threatened by the interview
f) One who “saw and heard everything, knew everyone involved and remembers everything clearly”
51. Which of the following are common interview techniques, as explained in this program? (Select all applicable
answers).
a) Question and answer
b) Free recall
c) Conversational approach
d) Trick questions
e) Numerical assessment
52. Which of the following terms is that generally applied to the “signs” displayed in a person’s gestures, the way that
they sit or stand and the way they look at you?
a) Body language
b) Mental perception
c) Overt display
d) Concealed language
e) Subconscious exhibition
53. As a quality measure following an interview, an investigator should perform which of the following checks? (Select
all applicable answers).
a) Review his notes
b) Determine whether anything significant has been missed
c) Analyze whether the conduct and outcome of the interview were satisfactory
d) Assess whether the character of the witness has any bearing on the evidence he has given
e) Modify his notes to reflect his general assumptions of the causes behind the incident, taking selective evidence from the
interview he has just conducted
f) Analyze whether the evidence from the interview supports the general idea of whom is to blame
54. Which of the following are standard parts of an Incident Investigation report? (Select all applicable areas).
a) A summary outline of the incident and known results
b) The identity and general particulars of the vessel
c) Basic details on the personnel involved in the incident and those who have additionally contributed to the
investigation
d) A more detailed narrative explaining the circumstances of the incident
e) Analysis and comment on the elements of the incident
f) Recommendations aimed at prevention of a repetition of the incident
g) The names and signatures of any injured shore personnel
h) References to similar incidents on other vessels
55. Which of the following best describes the form that the narrative section of an Incident Investigation Report should
follow?
a) A simple, orderly description of the events leading up to the accident, incident or near miss, the circumstances
of the accident, incident or near miss itself, the consequences and the post-incident actions, written in a neutral
way, without opinion or judgment
b) A random description of the events preceding an incident, or near miss and the corrective actions necessary to prevent a
recurrence, written in a neutral way, but including the investigator’s summary assessment
c) A complex and detailed account of the accident, incident or near miss only, reflecting, so far as possible, the investigator’s
understanding of the circumstances and including recommendations for the attention of management
56. The following 2 incidents involve Seamen A and B -- carrying a box of stores on ladders Seaman A – Young, fit, full
protective clothing, slips from lower part of ladder, slight sprain on left ankle. Seaman B – Older, unfit, no protective
clothing, falls from upper part of ladder, breaks ankle, wrist and has a concussion on the head. What is the essential
difference here, in terms of control?
a) The severity of the outcome was affected by the height from which the man fell, the protective clothing he was
wearing and his ability to react to the fall.
b) The potential for an accident was affected by the height from which the man fell, the protective clothing he was wearing
and his ability to react to the fall.
c) Nothing could have been done in either case to minimize injury, because you can never legislate for chance.
57. Identify the United Nations Convention and the major IMO Convention which outline the requirements for Flag States
to investigate and report marine casualties and pollution incidents.
a) The United Nations Convention on the Law of the Sea (UCLOS)
b) The International Convention for the Safety of Life at Sea (SOLAS) 1974
c) MARPOL 1974
d) The International Ship and Port Facility Security Code.
e) The United Nations Convention on Maritime Pollution (UNCMP)
 f) The IMO Casualty Investigation Committee 5th Assembly
58. For the purposes of communication, who is the nominated representative of the Owner of the vessel?
a) The Master
b) The Ship’s Safety Officer
c) The boarding agent
d) The Ship’s Security Officer
e) The P&I Surveyor
f) The Port Security Officer