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 to the safety investigation of marine casualties and incidents, and also to promote co-operation between States in identifying the contributing factors leading leading to marine casualties. The result of this 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 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 marine casualties. This may be facilitated 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 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 ca sualty 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 de termine responsibility or blame.
6 .4
.5
.6
.7
.8
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 information should not be barred by reason 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 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 substantially interested 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 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 Responsibiliti es 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 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 flag State of a ship involved in 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 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 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.
11
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. 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 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 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 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 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 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 facilitate the flow of information information from casualty investigations, 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. 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 investigation is being conducted. In particular, cooperating investigators must be guided by the requirements of national law over issues such as: -
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.
1.
Information generally required in all cases
1.1
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) 1.2
Documents to be produced
( Note: Note: Any An y documents that may have relevance to the investigation should be b e produced. p roduced. Where possible original documents should be retained, otherwise authenticated and dated photocopies should be taken in accordance with with 9.1.2 of the Code. A number of these documents will contain details sought under 1.1 of these Guidelines.) 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 the se 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 wha t 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.
Additional information required in specific cases
2.1
Fire/Explosion ( Investigators Investigators should bear in mind the IMO Fire Casualty Record.) 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 da tes 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, hea t, (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 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 listening watch was kept on VHF radio 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 tog ether 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
( Investigators 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 difficulties experienced in their use
2.5
Pollution resulting from an incident ( Investigators 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.) 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.
Foundering
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, oil, paint/scale, pieces of equipment and machinery, pieces of structure.
3.2 Before removal, such evidence should first be photographed in situ. 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 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 Time accident; F, Meal; Meal; W, Watch; M, Maintenance Maintenance work; work; S, Sleep; Sleep; C, Cargo Cargo Watch; R, Recreation, including time ashore; ashore; A, Alcoholic drink) Health Personal Issues
: :
19
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
General
2.2.1 2.2.2 2.2.3 2.2.4 2.2.5
Timing of the investigation The Occurrence Site Witness Statements Background Information The Investigation Sequence
20 2.2.6 2.2.7 2.2.8 2.2.8.1 2.2.8.2
Fact Finding Conducting Interview Selection of Interviewees On Site(those newest the incident) Remote from the Occurrence Site
2.3
Topics to be covered by the investigator
2.3.1 2.3.2 2.3.3 2.3.4 2.3.5 2.3.6
People factors Organization on board Working and living conditions Ship factors Shore side management External influences and environment
2.4
Analysis 2.4.1 Fact-finding and analysis
2.5
Safety action
3
Reporting procedures
4
Qualifications and training of casualty investigators
APPENDICES
APPENDIX 1 APPENDIX 2 APPENDIX 3 APPENDIX 4
The ILO/IMO ILO/IMO Process for Investigating Investigating Human Factors Human Factors Questionnaire Definitions - Common Common Human Element Term Selected bibliography bibliography of UNCLOS/ILO/IMO UNCLOS/ILO/IMO requirements and and recommendations 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 is to prevent similar casualties casualties and incidents in the the future.* 1.2 Ships operate in a highly dynamic environment; frequently the people on board follow a set routine of shift work disrupted disrupted by arrival at, working in, and sailing 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 technical perspective. The conventional wisdom wisdom has been to apply engineering engineering and technological solutions solutions to promote safety and minimize the consequences of marine casualties and incidents. Accordingly, safety standards have have primarily addressed ship design and equipment requirements. Despite these technical innovations, innovations, significant marine casualties and incidents incidents have continued to occur.
21 1.4 Analyses of marine casualties and incidents that have occurred over the past 30 years have prompted the international international maritime community community and the various safety regimes 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 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 increasingly clear, however, that training is only 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 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 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 practical information on techniques techniques and procedures for the systematic collection and analysis analysis of information on human factors during investigations. 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 marine community which in in turn will result m the saving 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 integration and adaptation of a number number of established human factor factor
22 frameworks. The process can be applied to any any type of marine casualty and incident 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 is the notion that for each underlying underlying factor, there may be one or more associated unsafe act, decision decision or condition. The re-examination each step 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.
2.2
General consideration
An occurrence may result in serious serious damage or impact and sometimes sometimes all four. The purpose of a marine casualty or occurrence safety investigation is to prevent recurrence 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 which may cause other future occurrences. Occurrence investigation should 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. implementation. For this reason investigations, must be broad enough to meet this this overriding criteria.
2.2.1
Tuning of the investigation
An investigation should should be carded out as soon as possible possible after an occurrence. The quality of evidence, particularly that relying on the the accuracy of human recollection, recollection, can deteriorate rapidly with time, time, and
23 delayed investigations are usually usually not as conclusive as those performed promptly. A prompt investigation is also a good demonstration of commitment by all those concerned.
2.2.2
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 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 components should be kept in a secure secure location to await the arrival arrival of the investigation team who may require detailed scientific scientific examination of certain key objects. Such key objects should be carefully
2.2.3
Witnesses
Once the situation in the immediate aftermath of an occurrence has been stabilised and the threat to people, plant and the environment environment has been removed, individuals individuals involved should 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 organisation/company involved should nominate a focal point to liaise with the authorities and to assist in assembling the information they require. require. Where necessary legal assistance assistance should be provided.
2.2.4
Background information
Appropriate background information information should be be obtained before the occurrence location. 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
2.2.5
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 surrounding it. The scope of any investigation 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 determining causes. Investigators should 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 possible aspects of an investigation, investigation, neither can they follow follow all individual leads leads bad to basic casual factors. factors. When checklists are used, used, their limitations should 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 investigation is. recent change. change. In many cases it has been found that that some change occurred prior to an occurrence which, combining with other causal factors already present, served to initiate the occurrence. occurrence. Changes in personnel, organisation, organisation, procedures, processes, 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 (so-called error enforcing conditions) related to individual’s behaviour should not be overlooked. Information should be verified wherever possible. possible. Statements made by different witnesses may conflict and further supporting evidence evidence may be needed. To ensure that all the facts are uncovered, uncovered, the broad questions of “who?, what?, when?, where?, why?, and how?” should be asked.
2.2.7
Conducting interviews
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 requirements of national law regarding the presence of legal advisers or other third parties during an interview.
25 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; Notwithstanding; any previously made written written statements the value value of a witness’s statement 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 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 people think they may incriminate incriminate themselves or their colleagues. 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, interviewer, or indeed the the investigation team, to apportion 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 provide the interviewee with a copy of the written record.
2.2.8
Selection of interviewees
Established marine casualty and incident investigation procedures should be taken into account when determining whom to interview following 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 interview those most closely closely involved, which in the marine marine sense will always be the the ship first. When that is not possible due to external factors such as the geographical location 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 point of view, it should still be possible to start the process by carrying out at least some some of the interviews of individuals 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 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:
2.2.8.1 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..
26 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 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 those engaged in the recovery process. Examples could be those 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.
2.2.9.2 Remote from occurrence site -
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.
2.3
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.
27
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
People factors
-
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
2.3.2
Organization on board
-
division of tasks and responsibilities responsibilities composition of the crew (nationality/competence) (nationality/competence) --
manning/level
28 -
workload/complexity 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)
2.3.3
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
2.3.4
Ship factors
-
design state of maintenance equipment (availability, reliability) cargo characteristics including securing, handling and care -certificates
2.3.5
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
2.3.6
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)
2.4
Analysis
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 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.
29 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 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 reasonable assumptions. Such extrapolation and assumptions should should be identified and a statement of the measure of certainty provided. Despite best efforts, analysis may not lead to firm conclusions. 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 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.
2.5
Safety action
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.
30 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 outlined in IMO Assembly resolution resolution A. 849(20) - Code for the Investigation 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 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 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.
32
APPENDIX 1 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 integration and adaptation of a number 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 R asmussen’s Taxonomy of Error (1987). The process can be applied to both both types of occurrences, i.e., accidents and 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 extensively on what factors were identified as underlying underlying factors. At times, an unsafe condition condition may be a result of a natural occurrence; in that case the investigator investigator may jump from 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 environmental conditions involved 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 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 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 of events and circumstances comprised comprised of acts and conditions. conditions. Some of these will be of interest as unsafe acts and unsafe conditions.
33 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 Liveware and all the other components. Figure 1 attempts to portray the fact that the match or or mismatch of the interfaces is is just as important as the characteristics of the block themselves. themselves. A mismatch can be a source of human human error and identification identification of a mismatch may be the identification identification of a safety deficiency in the system. Figure 2 also depicts how 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, limitations, be they physical, physiological, psychological, psychological, or psychosocial. This component can be applied applied to any person involved with the operation or in support of the operation. The person under consideration interacts interacts directly with each one of the four other elements. elements. The person and each interaction, interaction, or interface constitute potential 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
34 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 conditions within which people are working. Sometimes the broad political and economic constraints under which the aviation 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 utilizing a production framework, can he used used by an investigator as a guide guide to developing an occurrence occurrence sequence. As well, Reasons model facilitates further organization of the work system data collected using the SHEL model, and an improved understanding understanding of their influence 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, activities, and defences. The production elements themselves 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 of active versus latent factors 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 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 mutually exclusive. As the investigator begins 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 context of an occurrence sequence. To facilitate this concurrent activity, the SHEL and Reason models can be combined as illustrated in Figure 2.
35
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. 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 GEMS framework. The framework provides 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 performance in Step 5). The GEMS framework illustrated illustrated in Figure 3 is particularly useful in exploring exploring hypothetical reconstructions reconstructions of the occurrence 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 acts/decisions and conditions. conditions. An unsafe act is defined as an error or violation violation that is committed in in the presence of a hazard or potential 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
36 acts. An unsafe condition, or hazard as noted above, is an event or circumstance circumstance that has the potential potential to result in a mishap. There may be several acts, decisions and/or conditions which are potential potential unsafe candidates, thus necessitating 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. condition. Further investigation and/or and/or analysis may reveal other other unsafe acts/decisions 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 precipitating the occurrence often provides provides a convenient starting starting point for reconstruction of the occurrence. occurrence. This last act or decision decision differs from the others, in that, 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 it is usually usually an active 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
37 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 regarding intentionality. intentionality. There are four potential error/violation error/violation categories, i.e ., slip, lapse, mistake and violation. A slip is an unintentional action action where the failure involves involves attention. These are errors in execution. execution. A lapse is an unintentional unintentional action where the failure involves involves memory. These are also errors 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 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 one-time breach of a work practice, such as where safety regulations regulations are deliberately 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 behaviours that lead to them. In simplest terms, a behaviour consists of a decision and an action or movement. movement. In Step 3, the action or decision (i.e., (i.e., unsafe act or decision) was identified. In Step 4, what was erroneous regarding regarding that action or decision was 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 important to determine if there were any factors in the the work system that may have have facilitated the expression of the given failure mode (and hence the error/violation and the unsafe act). These factors have been termed underlying underlying factors. These factors can be found by examining examining the work system information collected collected and organized using using the SHEL or Reason frameworks in 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 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). (1972). Man and machine: Systems for safety. In Proceedings In Proceedings of the BALPA BALPA Technical Symposium London. Hawkins, F.H. (1987). Human (1987). Human factors in flight. flight. Aldershot, UK: Gower Technical Press.
38 Nagel, D.C. (1988). Human error in aviation aviation operations. In E.L. Weiner and D.C. Nagel (Eds.), Human (Eds.), Human factors in aviation aviation (pp. 263-303). San Diego, CA: CA: Academic Press. Norman, D.A (1981). Categorization Categorization of action slips Psychological slips Psychological Review, Review, 88 (1), 1-15. Norman, D.A (1988). The psychology of everyday things. New York: Basic Books. Books. Rasmussen, J. (1987). The definition definition of human error and a taxonomy taxonomy for technical system design. design. In J. Rasmussen, & Duncan, and J. Leplat (Eds.), New (Eds.), New technology and human error. Toronto: John Wiley & Sons. Reason, J (1990). Human (1990). Human error. New error. New York: Cambridge University University Press.
39 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 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
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?
2
Activities prior to incident
.1
(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?
.2 .3
.4
Specifically what were you doing approximately 4 hours,……1 hour,……….30 minutes……..before the accident?
.5
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?
.6 .7
3
Duties at the time of accident
.1 .2
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)?
.3
40 4
Actual behaviour at time of accident
.1 .2 .3
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?
5
Training/Education/Certification/Professional Training/Education/Certifi cation/Professional Experience
.1
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? passage? What was your longest single single passage
.2 .3 .4 .5
6
Physical condition
.1
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, 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?
.2 .3
7
Psychological, emotional mental condition and employment conditions
.1
.6 .7
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?
8
Workload/Complexity Workload/Complexity of Tasks
.1 .2 .3 .4 .5
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?
9
Work-period/rest-period/recreation Work-period/rest-period/recrea tion pattern
.2 .3 .4 .5
41 .1 .2 .3
.8
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? period? Did you awaken refreshed? If not, what would would have made your sleep period more restful? How do you normally spend your off-duty time while on board? Play cards? Read? R ead? Listen to music? Watch T.V.? Other? When was your last extended period of off duty time when your were able to rest?
10
Relationship with other crewmembers and superiors/subordinates
.1 .2 .3 .4
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 anyone else about the accident prior to being being interviewed?
.4 .5 .6
.7
.5 .6 .7 .8 .9
11
Living conditions and shipboard environment
1
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.?
.2
12
Manning levels
.1
Is the manning level sufficient in your opinion for the operation of the vessel?
13
Master's standing orders
.1 .2 .3
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?
14
Level of automation/reliability automation/reliability of equipment
.1 .2 .3
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?
42
15
Ship design, motion/cargo characteristics
.1
Did you observe anything out of the ordinary on this passage concerning the ship design, or motion or cargo characteristics?
Questions 16-24
SHORESIDE MANAGEMENT
16
Scheduling of work and rest periods
.1
What is the company's work schedule and relief policy?
Manning level
.1
How is the manning level determined for your fleet?
18
Watchkeeping practices
.1 .2
Do you require the master to stand watch? Do you leave the watchkeeping practices to the discretion of the Master?
19
Assignment of duties
.1
Do you leave this matter to the Master?
20
Shore-ship-shore support and communications
.1
How do you support the vessel’s Master?
21
Management policies
.1
Does the company have a written safety policy?
22
Voyage planning and port call schedules
.1
How does the Master plan the voyages?
23
Recreational facilities
.1
Are welfare/recreational services and facilities provided on board?
24
Contractual and/or industrial arrangements and agreements
.1 .2
What are the contractual agreements for all crewmembers? Have there been any complaints or industrial action m the last (12) months?
25
National/internationall requirements National/internationa
.1 Are the management/Master complying with the requirements and recommendations of the applicable international conventions and Flag State regulations?
43 APPENDIX 3 DEFINITIONS COMMON HUMAN ELEMENT TERMS
Human error A departure departure from acceptable or desirable desirable practice on the the part of an individual or group 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 physical disabilities, disabilities, death or illness in the family, 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 drinking on or too close to duty duty which can impede an individual’s abilities; drunkenness on duty; drinking off duty which results poor performance while on duty; duty; and excessive drinking over over a longer period of time which results in a permanent decrease in mental abilities.
Drug use:
Use of medicine or a narcotic which effects an individual’s abilities to perform required tasks There are many different effects on mental mental and physical capabilities capabilities that can result from the use of legal and illegal drugs, such as extreme drowsiness to a false sense of competence to hallucinations. hallucinations. Mental abilities of the the user may also be distracted by the constant need to obtain additional additional drugs. In addition, individuals 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.
Inattention:
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.
Injury.
Physical damage to the body which causes a decrease in mental or physical abilities. Examples include a head injury 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; behaviour; depression; hallucinations; hallucinations; unexplainable, 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 disability accompanying colds
44 and flu; hallucinations due to high fever; migraine headaches: seasickness; and even severe indigestion and exposure to toxic substances. Diminished Motivation: 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 incorrect action or purposely purposely failing 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.
Low morale:
A problem problem with individual or group group motivation motivation as shown shown by reduced reduced willingness, 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: self-discipline: Inadequate ability ability of an individual 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 mental capability capability as the result result of the sum 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. usual. Examples include storms; 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 human factors engineering design:
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. 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 orientation in regard to ship dynamics; 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.
45 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 ship manoeuvres (e.g. increased speed, speed, change in course, erratic manoeuvres) impact ship dynamics causing balance and restraint difficulties, difficulties, when personnel performing performing one task interfere with those performing another; or where storage of cargo impedes access or transit.
Poor maintenance:
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. difficult. Examples of poor maintenance 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 inadequate experience and/or training, training, the general knowledge which is required for the individual’s job on board. Examples are navigation, navigation, seamanship, propulsion propulsion systems, cargo handling, communications, or weather.
Inadequate situational communication/awareness:
Not knowing, due to inadequate inadequate experience, lack of communication/co-ordination, communication/co-ordination, and/or training, the current status of the ship, its systems, or its its environment. Examples include lack of of knowledge of location, heading or speed or lack of knowledge of status of ongoing maintenance on board.
Lack of communication of co-ordination:
Not making use of all the available available information sources sources to determine current status. 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 the part of others. Examples of poor poor communication/coordination communication/coordination include: poor communication between bridge officers, poor communication communication with pilots, pilots, or poor deck to engine room coordination.
Inadequate knowledge of operations:
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 might lack knowledge are: Navigation, seamanship, propulsion systems, cargo handling, communications, or weather.
Inadequate knowledge regulations/standards:
Lack of knowledge or understanding or required regulations due to inadequate experience and/or and/or training. Examples of possible 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.
Inadequate knowledge of ship procedures:
Not knowing due to inadequate inadequate experience and/or training training the shipboard and company policies requiring adequate knowledge of your own ship’s operation. Examples include include emergency
46 procedures, maintenance procedures, procedures, administrative administrative procedures, and safety system procedures. Unaware of role/task responsibility:
Inadequate knowledge of the specific job required of an individual. Examples include include a lack of understanding understanding of command responsibilities, communications responsibilities, safety responsibilities, responsibilities, maintenance responsibilities and emergency responsibilities.
Inadequate language skills:
A lack of primary language skills necessary to communicate and perform duties as required. This includes total or 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.
Management: Failure to maintain discipline:
Failing to ensure that personnel submit to authority, regulations and procedures. Examples include: tolerating tolerating unqualified or inept inept personnel, not enforcing regulations regulations and procedures, procedures, tolerating inappropriate insubordination. insubordination.
Failure of command:
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 supervision:
Inadequate oversight of activities of personnel under an individual’s supervision. Examples of faulty supervision supervision include: not checking checking to see that a job was performed in a timely and correct manner, not providing proper resources resources to problems brought to to the attention of supervising individual, unequal treatment of personnel.
Inadequate co-ordinator or communication:
Failure to communicate and coordinate to address issues, problems, and tasks both aboard ship ship and ashore. Examples include: poor poor communication between bridge officers, poor communication with pilots, poor communication communication with home office, poor poor deck to engine room coordination.
Inadequate management of physical resources:
Poor management of physical resources which ensure that people have the tools, equipment, supplies, facilities, food, water, fuel, etc to perform their required tasks. tasks. Examples of faulty management management of physical resources include: include: absence of physical resources, resources, shortage of physical resources, inappropriate inappropriate physical resources, resources, physical resources stored improperly, physical resource difficult to obtain when needed.
Inadequate manning:
Failing to ensure that all required tasks aboard ship can be properly performed and that adequate personnel personnel of the proper skill skill level, physical and mental ability, ability, experience, certification, and inclination inclination to properly perform those tasks.
47 Inadequate manpower available:
Not assigning and assuring assuring availability of of adequate personnel with appropriate skill levels to a ship, or to a specific task aboard the ship to ensure safe and efficient operation.
Poor job design
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 simultaneously monitor displays that are spastically separated, requiring exposure to hazardous materials without proper protective gear.
Poor regulations, policies procedures, or practices:
Any problem with standards, regulations, policies, procedures, or practices. For example: standards, standards, regulations, policies, procedures, procedures, or practices may be conflicting, inaccurate, inadequate, do not provide sufficient detail, detail, or outdated.
Misapplication of good regulations, policies, procedures, or practices:
The application of standards, regulations, policies, procedures, or practices at an incorrect time time or in an inappropriate circumstance circumstance
Mental action:
Lack of situational situational awareness: awareness: An incorrect understanding of the current 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 compounded errors that can substantially substantially increase the risk to the 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 misreading a dial, mishearing a command, command, misunderstanding 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: recognition: The misdiagnosis misdiagnosis of of a particular particular situation situation or problem once once it has been perceived. It may be perceived that a problem or situation exists, however, the identification is incorrect. Examples include misdiagnosis 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.
Appendix 6 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.
Groundings 1
Name, address, telephone number, date of birth, qualifications and experience.
2
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)
3
What were the night orders? What were you told?
4
What were the standing orders? from both master to others and from company to ship.
5
Ask to see the chart and log book used? Was a Nautical Almanac used or tide tables? Take copies of charts and logbooks.
6
What was the position fixing method and how often was the position fixed?
7
What was the last fix plotted before the vessel grounded?
8
What were the courses and speeds over ground that were steered?
9
What were times of course alterations?
10
Were you steering by hand or by auto pilot?
11
What was the Gyro/compass error and the allowance/correction? See compass error book.
12
Do you have a compass correction certificate? What was the deviation on the course steered?
13
What was the weather like, leeway?
14
What was the tidal stream?
15
What was the visibility like? (fog?, moon?, how they determined it) Where there any decklights impairing visibility?
16
How was the radar performing? Was there clutter? Do they know how to use it? What was the radar range in use?
17
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?
18
What were your rest/work periods for the previous week?
19
Had you consumed any alcohol?
20
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?
21
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?
22
What was the position of the grounding? Did you check the vessel damage, water ingress, propeller damage? Was any pollution caused?
23
What was the vessel’ draft?
24
Has the vessel a course recorder?
25
What setting were the engines at when the vessel grounded?
26
Was the gear tested prior to arrival/departure?
27
What was the height of tide?
28
Did any alarms sound before contact?
29
Can I see your accident register?
Stability
1
Full names, addresses (and nationalities if not NZ) of witnesses with contact telephone numbers.
2
Age and date of birth.
3
All sea going qualifications (including country of issue if not NZ). Ascertain, as fully as possible, precisely 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 h ave you received on o n stability and free surface effect?
5
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
7
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 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.
8
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.
9
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? shut? How did you know?
10
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?
11
Ascertain whether the vessel was listed at all before the accident/incident and if so, when and to what extent.
12
Ascertain how cargo both on and below deck was secured, e.g., by lashing, shoring/pound boards.
13
Ascertain to what extent, if at all, the vessel was hogged or sagged.
14
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.
15
What was the disposition of the cargo/fish at the time?
16
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?
17
Have you had a similar disposition of weights on other voyages or was this unusual?
18
Have there been any modifications to the hull or equipment recently? What are they?
19
What was the draught when you left? What displacement does this draught correspond to?
20
What valves were left open?
21
Do you know if they function adequately as non return valves? When were they last cleaned?
22
How often do you check the level in the fish hold?
23
How frequently did you have to operate the bilge pump?
24
Describe the fuel transfer procedure. Was it adhered to?
25
What is there to prevent the seawater inlet valve for the deck service line back flooding?
26
How much weight (fish) can be landed on deck before the vessel's stability will be compromised? How do you know this? this? How do you decide how much much of the load to pick at once?
27
Who calculates the maximum bending moments allowed? How does he/she do it? Who sets the standard? Were the standards standards exceeded on this occasion?
Personnel Injury
1
Name, address, phone number, date of birth, qualifications.
2
What is your position on board (skipper, deckhand etc.)?
3
How many years of experience do you have in the industry?
4
How long have been on board vessel?
5
Is the vessel surveyed? What SSM Company?
6
How many crew are employed on board?
7
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?
8
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?
9
What are the main tasks of the victim on board? When did he/she last undertake safety training? Was the crew member fit to unde rtake duties?
10
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 eq uipment correctly? If so, why?
11
What instructions were given regarding the operation of machinery, or the performance of the task? (Ask both the person in charge and the victim.)
12
Were regular checks made that any person, using the machinery/equipment, or undertaking the task, was taking precautions as instructed?
13
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?
14
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?
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?
16
If so, had the injury or near miss been recorded in the accident register? Were they discussed at safety meetings?
17
Are these mishaps reviewed, investigated and monitored?
18
How often is the accident register reviewed?
19
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?
20
Had this particular task/equipment/machinery/procedure/ substance been identified as a hazard to the crew?
21
Are there any notices on board the vessel to warn seafarers about the hazard?
22
Have any notices been erected since the accident?
23
What has been done to prevent a similar accident from occurring?
24
Has comprehensive hazard identification been carried out on the vessel?
25
What method was used? (Items analysis, task analysis, process analysis) Was a checklist used?
26
Were significant hazards identified and then controlled. Was priority given firstly to elimination and then by isolation or minimisation?
27
Have the hazards been managed? Give examples.
28
What training have the seafarers received with regards to all hazards on board the ship?
29
Are there any procedures that have to be followed on board?
30
Are these documented?
31
Are you aware of any similar accidents occurring on any other (similar) vessels in the industry?
32
What personal protective equipment is available to the crew?
33
Has training been given to the use of the personal protective equipment?
34
Is there an induction programme for new crew members who work on board?
35
How is information about safety on board vessels communicated to the (e.g. notices, manuals, meetings, etc.)
36
37
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 y ou must not knowingly expose yourself or others to harm?
Collision
1
Name, address, telephone number, date of birth.
2
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.
3
How long have you been at sea, what date did you join the vessel, and what is your previous seafaring background (in brief).
4
What are the particulars of vessel (include): (include): • • • • • • • • • • • • • • •
•
•
5
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 bo w 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 c ollision 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 gy ro 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.
6
Where the vessel was proceeding from and to at the time of the collision, with type of cargo carried
7
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.
8
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 must be obtained and considered before any interview and then used as a cross reference when interviewing each witness.
9
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
Get information on the extent of damage to both vessels, details of any crew injury and risk of pollution from cargo/bunkers.
11
How did you ascertain if a risk of collision existed?
12
Did you find that a collision risk existed?
13
Whose responsibility was it to give way?
14
Whose responsibility was it to stand on?
15
How did you exercise that responsibility? (Give times of course and/or speed alterations and their effects)
16
The time, relative bearing, distance course, speed, closest point of approach (CPA) and time of CPA (to your vessel) v essel) 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
17
The course, speed and position of your vessel at the time the other vessel was first observed by radar.
18
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 .
19
The course, speed and position of your vessel at the time the other vessel was first observed visually
20
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.
21
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.
22
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 occurred between the time she was first observed by radar and/or visually and the time of the collision.
23
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.
25
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.
26
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.
27
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.
28
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.
29
Check with the engineers on duty for the time of collision and confirmation of engine manoeuvres.
30
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.
Fire
1
How was the fire detected?
2
When was the fire detected?
3
Where was it thought to be?
4
What action was taken to extinguish the fire (alarms, stations, etc.)?
5
What fire fighting equipment was available (CO2, portable, hoses, BA sets)?
6
Did the equipment work?
7
When was the equipment last inspected?
8
What did the fire fighting parties do?
9
Was it effective?
10
If not, why not?
11
Was the fire electrical, spontaneous combustion, conduction, convection, radiation?
12
How recent were the equipment overhauls?
13
Were they while in drydock or new installations?
14
How frequent are fire drills on the vessel?
15
Are there log book entries of fire drills?
16
Does the vessel have a fire fighting plan?
17
Were the fire service called?
18
Was the vessel stopped?
19
Was the course altered?
20
Where was the seat of the fire? What was the ignition source?
21
Are there any photographs or video evidence of the fire?
22
What was the combustible material involved in the fire?
23
Did the fire give off any gas/smoke, and if so, what colour was it?
24
How were any burns or smoke inhalation treated?
25
How many of the crew have fire fighting certificates?
26
Has there been a fire on board the vessel before?
27
Can I see your accident register?
28
With hindsight, how could you have dealt with it better?
29
Were there fuel remote trips? Ventilation flaps? Fan trips? Pump trips?
30
Were the fire dampers, fuel shut offs, fire doors used? Did they work? How often were they tested?
31
Was any use made of BA gear?
32
Who had been given training in the use of this equipment?
33
Were standard procedures followed
34
What training do the crew get? (courses, drills, videos)
Machinery Failure
1
Name, address, telephone number, date of birth, qualifications and experience.
2
Establish, what, where and when.
3
What was the mechanism of the failure, in as much detail as possible: • • • • • • • •
4
When did it happen?: • •
5
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
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
Had there been any concerns about this machine?
7
To whom were these expressed? Were they raised at safety meetings?
8
Is there a record?
9
Has this happened before? How many times? Have any trends been identified
10
Were procedures in place to prevent/mitigate this happening again?
11
Are these procedures documented?
12
Can you show that these procedures were followed?
13
What is the maintenance period for this machine?
14
When was the machine last overhauled?
15
Is there a record?
The following documents should be collected or photocopied (as appropriate): • • • • •
• •
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
16
Are manuals in a language understood by all ship staff?
17
Are there warning signs on the machinery that failed?
18
Would warning signs have prevented the failure?
19
Did fatigue play a part?
20
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
Page 1 of 20
Contacts Index z
OFFICE HOLDERS
z
MEMBERS
z
HONORARY MEMBERS
October 2002
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
Fax: +61 2 6274 6699 Phone: +61 2 6274 7165 E-mail:
[email protected]
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: +1 202 267 1416 Phone: +1 202 267 1430 E-mail:
[email protected]
http://www.maiif.net/address.htm
5/27/2003
MAIIF - Contacts
Page 2 of 20
Second Deputy Chairman Mr M Heikkilä Chief Accident Investigator Accident Investigation Board Yrjönkatu 36 00100 Helsinki FINLAND
Fax: +358 9 1825 7811 Phone: +358 9 1825 7638 Mobile: +358 405 219 343 E-mail:
[email protected]
MEMBERS ANTIGUA & BARBUDA
Captain B Lerdon (Bernd) Department of Marine Services and Merchant Shipping (ADOMS) Am Patentbusch 4 26125 Oldenburg GERMANY
Fax: +49 441 93 95 9 -20/29 Phone: +49 441 93 95 90 E-mail:
[email protected]
Captain S Ottinger (Siegfried) Department of Marine Services and Merchant Shipping (ADOMS) Alter Fährweg 27568 Bremerhaven GERMANY
Fax: +49 471 419 24 22 Phone: +49 471 419 24 19 E-mail:
[email protected]
AUSTRALIA
Website: http://www.atsb.gov.au
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
Fax: +61 2 6274 6699 Phone: +61 2 6274 7165 E-mail:
[email protected]
Mr N Rutherford (Nick) Surface Safety Investigation Group Australian Transport Safety Bureau PO Box 967 Civic Square ACT 2608 AUSTRALIA
Fax: +61 2 6274 6699 Phone: +61 2 6274 7665 E-mail:
[email protected]
BAHAMAS
Captain S Clinch (Steve) Deputy Director Bahamas Maritime Authority 2nd Floor, Latham House
http://www.maiif.net/address.htm
Fax: +44 0207 264 2575 Phone: +44 0207 264 2579 E-mail:
[email protected]
5/27/2003
MAIIF - Contacts
Page 3 of 20
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
Fax: +501 223 5048 Phone: +501 223 5026 E-mail:
[email protected] E-mail:
[email protected]
Libardo Brú, MSc Head of Technical Department International Merchant Marine Registry of Belize Marina Towers, Suite 204 Newtown Barracks Belize City Belize CENTRAL AMERICA
Fax: +501 223 5047 Phone: +501 223 5026 E-mail:
[email protected] E-mail:
[email protected]
BERMUDA
Captain G P A Nawaratne (Pat) Registry of Shipping PO Box HM 1628 Hamilton HM GX BERMUDA
Fax: +1 441 295 3718 Phone: +1 441 295 7251 Phone: +1 441 295 7306
BRAZIL
Mr Paulo Eduardo MEIRELLES Freire Directorate of Ports & Coasts Rua Teofilo Otoni No 4 Centro Rio De Janeiro RJ BRAZIL
Fax: +55 21 216 5202 Phone: +55 21 216 5204 Phone: +55 21 490 2702 E-mail:
[email protected]
CANADA
Website: http://www.tsb.gc.ca
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: +1 819 953 1583 Phone: +1 819 953 1398 E-mail:
[email protected]
http://www.maiif.net/address.htm
5/27/2003
MAIIF - Contacts
Page 4 of 20
CANADA CHILE
Website: http://www.directemar.cl
Commander R Böke (Ricardo) Head. International Affairs Department Chilean Maritime Administration AV Errazuriz 537 Valparaiso CHILE
Fax: +56 32 20 8085 Phone: +56 32 20 8 -200/000 E-mail:
[email protected]
Lt Commander R Marticorena (Rene) AV Errazuriz 537 Valparaiso CHILE
Fax +56 32 208 000 Phone +56 32 208 0000 E-mail:
[email protected]
Lt Commander O Mrugalski Meiser (Otto) AV Errazuriz 537 Valparaiso CHILE
Fax: +56 41 384550 or 385136 Phone: +56 41 384550 or 385136 E-mail:
[email protected]
CHINA
Captain Hu Xi-chen China Maritime Safety Administration 11 Jianguomennei Avenue Beijing 100736 PEOPLE'S REPUBLIC OF CHINA
Fax: +86 10 6 529 2882 Phone: +86 10 6 529 2895 E-mail:
[email protected]
Wang Hongsheng Xiaman Maritime Safety Administration 19 Haicang Avenue Xiaman 361026 PEOPLE'S REPUBLIC OF CHINA
Fax: +0592 689 5231 Phone: +0592 689 5278 E-mail:
[email protected]
Shen Jianbin China Shanghai Maritime Safety Administration 725 Wai Ma Road Shanghai 200010 PEOPLE'S REPUBLIC OF CHINA
Fax: +86 21 6377 0854 Phone: +86 21 6366 2032 E-mail:
[email protected]
Captain Ningbo Assistant Investigator of Navigation Department China Maritime Safety Administration Shenzheni 11 Jianguomennei Avenue Beijing 100736 PEOPLE'S REPUBLIC OF CHINA
Fax: +86 10 6 529 2882 Phone: +86 10 6 529 2896 E-mail:
[email protected]
CYPRUS
http://www.maiif.net/address.htm
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MAIIF - Contacts
Page 5 of 20
Captain N Economides (Nick) Marine Surveyor A Department of Merchant Shipping PO Box 6193 -CY 3305 Limassol CYPRUS
Fax: +357 5848 200 Phone: +357 5848 100 E-mail:
[email protected]
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
Fax: +1 212 447 1988 Phone: +1 212 686 6016 E-mail:
[email protected]
DENMARK
K S Eriksen (Knud Skaaereberg) Danish Maritime Safety Authority Investigation Division Vermundsgade 38 c 2300 Copenhagen Ø DENMARK
Fax: +0045 3917 4416 Phone: +0045 3917 4400 E-mail:
[email protected]
ESTONIA
T Linikoja (Taidus) Estonia Maritime Administration Vaige 4 11413 Tallinn ESTONIA
Fax: +372 620 5706 Phone: +372 620 5702 E-mail:
[email protected]
R Silm (Rein) Estonia Maritime Administration Vaige 4 11413 Tallinn ESTONIA
Fax: +372 620 5706 Phone: +372 620 5704 E-mail:
[email protected]
FIJI
Captain J Rounds (John) Senior Marine Officer Marine Department Regulatory Section GPO Box 326 Suva FIJI
http://www.maiif.net/address.htm
Fax: +679 303 251 Phone: +679 315 266
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Page 6 of 20
FINLAND
Website: http://www.onnettomuustutkinta.fi
Dr T Karppinen (Tuomo) Finnish Maritime Administration Porkkalankatu 5 00180 Helsinki FINLAND
Fax: +358 204 484 336 Phone: +358 204 484 1
Mr M Heikkilä (Martti) Chief Accident Investigator Accident Investigation Board Yrjönkatu 36 00100 Helsinki FINLAND
Fax: +358 9 1825 7811 Phone: +358 9 1825 7638 Mobile: +358 405 219 343 E-mail:
[email protected]
Captain R Repo (Risto) Accident Investigator Accident Investigation Board Yrjönkatu 36 00100 Helsinki FINLAND
Fax: +358 9 1825 7811 Phone: +358 9 1825 7817 Mobile: +358 405 028 714 E-mail:
[email protected]
FRANCE
Rear Admiral Rtd J L Guibert (Jean Louis) Bea-mer / METL Arche Sud 92055.La Défense Cedex 04 FRANCE
Fax: +33 1 4081 3842 Phone: +33 1 4081 3824 E-mail:
[email protected]
J M Schindler (Jean-Marc) MAE/DAEF 37 Quai d'orsay 75007 Paris SP FRANCE
Fax: +33 143 1789 51 Phone: +33 143 1781 64 E-mail:
[email protected]
GERMANY
Mr D Graf Federal Bureau of Maritime Casualty Investigation Bernhard-Nocht-Str 78 20359 Hamburg GERMANY
Fax: +49 40 31 90 50 00 Phone: +49 40 31 90 50 00 E-mail:
[email protected]
Dr K Grensemann (Klaus) Head Maritime Safety Division Federal Ministry of Transport Postfach 20 01 00 D-53175 Bonn GERMANY
Fax: +49 228 300 1454 Phone: +49 228 300 4630 E-mail:
[email protected]
http://www.maiif.net/address.htm
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Page 7 of 20
Captain J Erhardt (Jan) Executive Officer Federal Ministry of Transport Postfach 20 01 00 D-53175 Bonn GERMANY
Fax: +49 228 300 1454 Phone: +49 228 300 4636 E-mail:
[email protected]
GREECE
Captain (HCG) Constantinos Brilakis Director - Civil Emergency Planning Directorate Hellenic Ministry of Mercantile Marine 150 Gr Lambraki Street 18518 GR Piraeus GREECE
Fax: +30 1 412 -8150/7843 Phone: +30 1 422 0795 E-mail:
[email protected]
HONG KONG
Captain S Anand (Suresh) Chief, Marine Accident Investigation Marine Department 21st Floor Harbour Building 38 Pier Road Central HONG KONG
Fax: +852 2542 4841 Phone: +852 2852 4603 E-mail:
[email protected]
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
Fax: +852 2542 4841 Phone: +852 2852 4603 E-mail:
[email protected]
Captain Lee Kai Leung Chief, Marine Accident Investigation Marine Department 24th Floor Harbour Building 38 Pier Road Central HONG KONG
Fax: +852 2542 4841 Phone: +852 2852 4603 E-mail:
[email protected]
ICELAND
Captain J A Ingolfsson (Jon) Director Rannsoknarnefnd Sjoslysa Flugstodin 340 Stykkisholmur
http://www.maiif.net/address.htm
Fax: +354 551 5152 Phone: +354 552 5105 Mobile: +354 893 2629 E-mail:
[email protected]
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Page 8 of 20
ICELAND INDONESIA
Mr Yudustar Head of Guard and Rescue Division Port Administration of Tanjung Priok Jin. Palmas No.1 Tg Priok Jakarta INDONESIA
Fax: +62 21 492 214 Phone: +62 21 492 214
Rachmat Sasraatmadja Directorate General of Sea Communication JL. Merdeka Barat No.8 Jakarta 10110 INDONESIA
Fax: +62 21 350 5687 Phone: +62 21 345 8835 Mobile: +62 811 841 730
ISLE OF MAN
Website: http://www.gov.im/dti/shipping
Captain D Howell (Desmond) Principal Surveyor Marine Administration Isle of Man Government Peregrine House Peel Road, Douglas Isle of Man IM1 5EH UK
Fax: +44 1624 688 501 Phone: +44 1624 688 500 E-mail:
[email protected]
Captain B McGrath (Barry) Principal Surveyor Marine Administration Isle of Man Government Peregrine House Peel Road, Douglas Isle of Man IM1 5EH UK
Fax: +44 1624 688 501 Phone: +44 1624 688 500 E-mail:
[email protected]
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
Fax: +39 06 5908 4282 Phone: +39 06 5908 4273 Mobile: +39 349 159 1797 E-mail:
[email protected]
JAMAICA
http://www.maiif.net/address.htm
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MAIIF - Contacts
Page 9 of 20
Captain N Robin Lee Director Training & Safety Maritime Authority of Jamaica Dyoll Building, 40 Knutsford Blvd Kingston 5 JAMAICA
Fax: +1 876 754 7256 Phone: +1 876 929 2201 Phone: +1 876 754 7260/5 E-mail:
[email protected]
JAPAN
Mr T Yamamoto (Tetsuya) Judge Yokohama Marine Accidents Inquiry Agency Kasumigaseki 2-1-2 Chiyoda-ku Tokyo 100-8918 JAPAN
Fax: +81 3 5253 1680 Phone: +81 3 5253 8824 E-mail:
[email protected]
Captain T Fujie (Tetsuzo) Manager of International Affairs Team High Marine Accidents Inquiry Agency Kasumigaseki 2-1-2 Chiyoda-ku Tokyo 100-8918 JAPAN
Fax: +81 3 5253 1680 Phone: +81 3 5253 8821 E-mail:
[email protected] (Also Mr Nagata)
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
Fax: +1 212 697 5655 Phone: +1 212 697 3434 Phone: +1 703 251 2407 direct Email:
[email protected]
MALAYSIA
Mr J B Yusuf (Jamaludin) Marine Department Headquarters Peninsular Malaysia PO Box 12 42007 Port Klang Selangor MALAYSIA
Fax: +60 3 3368 5289 Phone: +60 3 3346 7777 E-mail:
[email protected]
Captain Mohamad H Bin Ahmed (Halim) Enforcement Unit Marine Department Headquarters
Fax: +60 3 3368 5289 Fax: +60 3 3368 4454 Phone: +60 3 3368 6616
http://www.maiif.net/address.htm
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Peninsular Malaysia PO Box 12 42007 Pelabuhan Klang Selangor Darul ehsan MALAYSIA
E-mail:
[email protected] E-mail:
[email protected]
Mr Abdul Samad Shaik Osman Maritime Control Division Marine Department of Peninsula Malaysia PO Box 12 42007 Pelabuhan Klang Selangor Darul ehsan MALAYSIA
Fax: +60 4 3168 5289 Phone: +60 4 3169 5100 E-mail:
[email protected] E-mail:
[email protected]
MALTA
Mr L C Vassallo (Lino) Executive Director Merchant Shipping Directorate Malta Maritime Authority Maritime House Lascaris Wharf Valletta VLT 01 MALTA
Fax: +356 21 241 460 Phone: +356 21 250 350 Mobile: +356 21 9494 316 E-mail:
[email protected]
Captain J Zerafa (Joe) Technical Manager Merchant Shipping Directorate Malta Maritime Authority Maritime House Lascaris Wharf Valletta VLT 01 MALTA
Fax: +356 21 241 460 Phone: +356 21 250 360 Phone: +356 21 250 352 direct Mobile: +356 21 9494 318 E-mail:
[email protected]
Mr S Mifsud (Sean) Merchant Marine Diretorate Malta Maritime Authority Maritime House Lascaris Wharf Valletta VLT 01 MALTA
Fax: +356 21 241 460 Phone: +356 21 250 352 E-mail:
[email protected]
Mr K Thomas Ghirxi (Kevin) Merchant Shipping Directorate Malta Maritime Authority Maritime House Lascaris Wharf
Fax: +356 21 241 460 Phone: +356 21 250 352 Mobile: +356 21 9494 318 E-mail:
[email protected]
http://www.maiif.net/address.htm
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Valletta VLT 01 MALTA Mr D Kerr (David) Malta Maritime Authority Maritime House Lascaris Wharf Valletta VLT 01 MALTA
Fax: +356 21 241 460 Phone: +356 21 250 360 E-mail:
[email protected]
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
Fax: +1 703 476 8522 Phone: +1 703 620 4880 ext 385 E-mail:
[email protected]
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
Fax: +31 70 333 7078 Phone: +31 70 333 7000 Phone: +31 70 333 7037 direct E-mail:
[email protected]
G Th Koning (Thom) Investigator Shipping Dutch Transportation Safety Board PO Box 95404 2509 CK The Hague NETHERLANDS
Fax: +31 70 333 7078 Phone: +31 70 333 7038 direct E-mail:
[email protected]
Mr H Zieverink (Henk) Secretary of the Chamber Shipping Dutch Transportation Safety Board PO Box 95404 2509 CK The Hague NETHERLANDS
Fax: +31 70 333 7078 Phone: +31 70 333 7035 direct E-mail: A.Groenin'
[email protected] E-mail: A.Groenin'
[email protected] E-mail:
[email protected]
NEW ZEALAND
Mr M Eno (Mike) Maritime Safety Authority PO Box 27006 Wellington 6036
http://www.maiif.net/address.htm
Fax: +64 4 473 8111 Phone: +64 4 494 1232 Mobile: +64 25 481 267 E-mail:
[email protected]
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NEW ZEALAND Trasnport Accident Investigation Commission
Website: http://www.taic.org.nz
Captain J Mockett (John) Transport Accident Investigation Commission PO Box 10-323 Wellington 6036 NEW ZEALAND
Fax: +64 4 499 1510 Phone: +64 4 473 3112 Pager: +64 26 100 101 Mobile: +64 25 425 548 E-mail:
[email protected]
NORWAY
Kristin Asgard Kleven Norwegian Maritime Directorate PO Box 8123 Dep N-0032 Oslo NORWAY
Fax: +47 22 45 47 90 Phone: +47 22 45 45 84 E-mail:
[email protected]
Dag Erik Danielsen Norwegian Maritime Directorate PO Box 8123 Dep N-0032 Oslo NORWAY
Fax: +47 22 56 87 80 Phone: +47 22 45 44 08 E-mail:
[email protected]
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
Fax: +1 212 575 2285 Phone: +1 212 869 6440 E-mail:
[email protected]
PANAMA CANAL
Captain D Porras (Diego) Senior Canal Operations Captain - Pacific Panama Canal Authority ACP-MRTC Miami Florida 33102-5543
http://www.maiif.net/address.htm
Fax: +507 272 4212 Phone: +507 272 4212 E-mail:
[email protected]
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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
Fax: +507 272 3548 Phone: +507 272 3403 E-mail:
[email protected]
PHILIPPINES
Commander R A Campos PN (Ruben) Coast Guard Intelligence & Investigation Force Headquarters Philippine Coast Guard 139 25th Street Port Area Manila PHILIPPINES
Fax: +63 2 527 3883 Phone: +63 2 527 3885
Administrator Maritime Industry Authority PPL Building UN Avenue Ermita Manila 1000 PHILIPPINES
Phone: +63 2 523 86 -51/60
Mr R C Areco (Roberto) Regional Director Northern Luzon Maritime Regional Office Maritime Industry Authority PPL Building UN Avenue Ermita Manila 1000 PHILIPPINES
Phone: +63 2 523 86 -51/60
PORTUGAL
Mr P Correia (Paulo) Instituto Maritimo Portuário Edifico Vasco Da Gama Rua General Gomes Araujo 1399-005 Liboa PORTUGAL
http://www.maiif.net/address.htm
Fax: +351 21 397 9794 Phone: +351 21 391 4643 E-mail:
[email protected]
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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
Fax: +82 2 3148 6239 Phone: +82 2 3148 6236 E-mail:
[email protected]
Mr Park Youngsun Senior Investigator Korean Maritime Safety Tribunal 139 Chungjong-No 3 Seodaemun-Gu Seoul 120-715 REPUBLIC OF KOREA
Fax: +82 2 3148 6230 Phone: +82 2 3148 6236 E-mail:
[email protected]
Mr In-Chul Kim 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:
[email protected]
Dr Choi Jeong-seop Commissioner Incheon Maritime Safety Tribunal 25 Jun-Dong Chung-Gu Incheon 400-190 REPUBLIC OF KOREA
Fax: +82 32 763 3522 Phone: +82 32 762 3826 E-mail:
[email protected]
Captain Suh Sung-ki Chief Investigator Mokpo Maritime Safety Tribunal 2-4 Hang-dong, Mokpo-shi Jeonnam REPUBLIC OF KOREA
Fax: +82 61 242 9812 Phone: +82 61 242 1765
Mr Jo Byeongyong Senior Investigator Busan Maritime Safety Tribunal 1116-1Chwacheon-Dong Dong-Gu Busan 601-053 REPUBLIC OF KOREA
Fax: +82 51 646 4094 Phone: +82 51 647 0092 E-mail:
[email protected]
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:
[email protected]
http://www.maiif.net/address.htm
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ROMANIA
Ion Mircea Inspectorate of Civil Navigation 8700 Constanta Port Nanlomar Building ROMANIA
Phone: +40 241 60 22 29 Email:
[email protected] Email:
[email protected]
Serban Berescu Inspectorate of Civil Navigation 8700 Constanta Port Berth 0 ROMANIA
Fax: +40 24 1618 299 Phone: +40 24 4312 299 Email:
[email protected]
SINGAPORE
Captain I G Sangameswar Assistant Director - Shipping Division Maritime & Port Authority of Singapore 460 Alexandra Road #21-00 PSA Building SINGAPORE 119963
Fax: +65 375 6231 Phone: +65 375 6205 E-mail:
[email protected]
SOUTH AFRICA
Captain R Zanders (Robert) Principal Officer South African Maritime Safety Authority Private Bag X54309 Durban 4000 SOUTH AFRICA
Fax: +27 31 306 4983 Phone: +27 31 307 1501
Captain T Wilson (Tom) Deputy Principal Officer South African Maritime Safety Authority Private Bag X7025 Roggeby Capetown 8012 SOUTH AFRICA
Fax: +27 21 419 0730 Phone: +27 21 421 6170 E-mail:
[email protected]
Captain T Clarke (Tony) South African Maritime Safety Authority Suite 1401 Kingsfield Place, 30 Field Street Durban 4001 SOUTH AFRICA
Fax: +27 31 306 4983 Phone: +27 31 307 1501
Mr P van Gysen (Peter) South African Maritime Safety Authority 19th Floor, No 2 Long Street
Fax: +27 21 419 0730 Phone: +27 21 421 6170 E-mail:
[email protected]
http://www.maiif.net/address.htm
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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
Fax: +43 915 979 120 Phone: +43 915 979 273
SWEDEN
Website: http://www.sjofartsverket.se E-mail:
[email protected]
Captain S Anderson (Sten) Maritime Safety Inspectorate Swedish Maritime Administration SE-601 78 Norrköping SWEDEN
Fax: +46 11 239 934 Phone: +46 11 191 269 E-mail:
[email protected]
Board of Accident Investigation
Website: http://www.havkom.se
Ms L Svenaeus (Lena) Director General Board of Accident Investigation PO Box 12538 SE-102 29 Stockholm SWEDEN
Fax: +46 8 441 3821 Phone: +46 8 441 3820 E-mail:
[email protected]
Mr S E Sigfridsson (Sven-Erik) Board of Accident Investigation PO Box 12538 SE-102 29 Stockholm SWEDEN
Fax: +46 8 441 3821 Phone: +46 8 441 3823 E-mail:
[email protected]
Captain H Rosengren (Hans) Board of Accident Investigation PO Box 12538 SE-102 29 Stockholm SWEDEN
Phone: +46 480 470 801 E-mail:
[email protected]
Mr P Lindemalm (Per) Lindemalm CoPAB Igelokottsvägen 23 16756 Bromma SWEDEN
Phone: +46 8 735 8535 E-mail:
[email protected]
UNITED KINGDOM
Rear Admiral S Meyer (Stephen)
http://www.maiif.net/address.htm
Fax: +44 2380 232 459
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Chief Inspector of Marine Accidents Marine Accident Investigation Branch Carlton House Carlton Place Southampton Hants SO15 2DZ UK
Phone: +44 2380 395 528 E-mail:
[email protected]
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
Fax: +1 202 267 1416 Phone: +1 202 267 1430 E-mail:
[email protected]
Mr T Farley (Timothy) Senior Marine Casualty Analyst United States Coast Guard Headquarters 2100 2nd Street South West Washington DC 20593 USA
Fax: +1 202 267 1416 Phone: +1 202 267 1430 E-mail:
[email protected]
Ms M Murtagh (Marjorie) Director - Office of Marine Safety National Transportation Safety Board 490 L'Enfant Plaza East SW Washington DC 20594 USA
Fax: +1 202 314 6454 Phone: +1 202 314 6450 E-mail:
[email protected]
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
Fax: +1 202 314 6454 Phone: +1 202 314 6455 E-mail:
[email protected]
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
Fax: +1 202 314 6454 Phone: +1 202 314 6459 E-mail:
[email protected]
Mr M E Jones (Michael)
Fax: +1 202 314 6454
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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
Phone: +1 202 314 6417 E-mail:
[email protected]
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
Fax: +1 202 314 6454 Phone: +1 202 314 6494 E-mail:
[email protected]
Mr R Henry (Robert) National Transportation Safety Board 490 L'Enfant Plaza East SW Washington DC 20594 USA
Fax: +1 202 314 6454 Phone: +1 202 314 6490 E-mail:
[email protected]
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
Fax: +1 212 425 9652 Phone: +1 212 425 9600 E-mail:
[email protected]
Captain C H Grainger Deputy Commissioner of Maritime Affairs Success TOTSUKA Building #303 4893 Totsuka-cho Totsuka-ku Yokohama 244-0003 JAPAN
Fax: +81 45 866 1167 Phone: +81 45 866 1164 E-mail:
[email protected]
HONORARY MEMBERS
Dr W H Lampe Birkenweg 9 22880 Wedel bei Hamburg GERMANY
http://www.maiif.net/address.htm
Phone: 04103 8 29 44
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Captain B D Thorne (Brian) 12 Dunvegan Road Ottawa Ontario K1K 3E9 CANADA
Fax: +1 613 745 0504 Phone: +1 613 745 4521 E-mail:
[email protected]
Captain W A Chadwick (Bill) 400 Chesapeake Drive PO Box 100 Great Falls Virginia 22066 USA
Fax: +1 703 759 4896 Phone: +1 703 759 9259
Captain J Palmgren (Johannes) Brunstrop SE 523-99 Hokerum SWEDEN
Fax: +46 321 80321 Phone: +46 321 80275 E-mail:
[email protected]
Captain P B Marriott (Peter) Hazlemere 6 Mill Meadow Milford on Sea Hants SO41 0UG UK
Phone: +44 1590 642 300
Mr R H Musker 29 Monk's Orchard Road Petersfield Hampshire GU32 2JD UK
Phone: +44 1730 267 807 E-mail:
[email protected]
Captain K M Varghese Assistant Director - Shipping Division Marine Department 22nd Floor Harbour Building 38 Pier Road Central HONG KONG
Fax: +852 2854 9416 Phone: +852 2852 4404 E-mail:
[email protected]
Captain T Legge (Tony) Unit 2/148 Evans Bay Parade Roseneath WELLINGTON
Phone: +64 4 385 2844 E-mail:
[email protected]
Dr D Steinicke (Dietrich) Assistant Secretary Head of the Maritime Safety Division Federal Ministry of Transport Postfach 20 01 00 D-53175 Bonn
Fax: +49 228 300 1454 Phone: +49 228 300 4630 E-mail:
[email protected]
http://www.maiif.net/address.htm
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GERMANY Rear Admiral J Lang (John) Wangfield House Martyr Worthy Winchester Hants SO21 1AR UK
E-mail:
[email protected] E-mail:
[email protected]
Mr A Paquet Conseiller Technique Ministere des Transports Commissariat aux Affaires Maritimes 19-21 Blvd Royal L-2938 LUXEMBOURG
Fax: +352 465 753 Phone: +352 478 4452
http://www.maiif.net/address.htm
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Appendix 8 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.
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 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 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 contributing factors and cause. I have provided summaries of two accident causation 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 information which will enable enable you to build a reconstruction reconstruction of the sequence of events which which occurred prior to the accident 2. To collect information which which will allow allow you to make suppositions about the factors factors which may may have contributed to the accident occurring 3. To collect information information which will support the recommendations recommendations you make and MSA’s further action 4. To collect other statistical information information for analytical analytical purposes at head office. Information can be collected in two ways: Hardware evidence and interviews.
Hardware Evidence Hardware evidence includes: charts • ship log books equipment, materials, wreckage wreckage etc. • pieces of equipment, • photos • video recordings • company records and logs • maintenance records certificates and licences • • personnel or training records 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. •
Interviews Who should be interviewed? 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 manufacturer/boat builder/designer, builder/designer, stevedore, Harbourmaster etc. Interviewing a selection of people will help to confirm, clarify or supplement information received from other sources.
Planning 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. 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 particularly applies to owners and their lawyers. 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.
Timing 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.
Rapport 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.
Listening 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 directly to the witness’s witness’s experience. Listening can be a very tiring experience. experience. Take frequent breaks so that you and the witness can refresh yourselves.
Non-verbal communications communications 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 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 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.
Questioning Once the interview is underway, it is often best to start with a ‘ free ‘ free recall’ question 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 ‘open ended’ question 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?” 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’ ‘closed’ questions questions which evoke a yes/no response as they produce limited information. 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’ ‘negative’ questions 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 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 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. investigation.
Appendix 6 of the MAIIF Manual gives examples of questions which should be used as a guide when interviewing witnesses involved in 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 person in the room. You should do another check, with all all people in the room talking (one at a time) to see how the tape picks up their voices.
2
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.
3
Ensure that all mobile phones, pagers etc., are turned off during the interview.
4
Post a "Quiet Please" notice on the door.
5
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] [Date] [Month] [Year]. I have here with me 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, interviewed, and also 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
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.
2
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.
3
If they begin to speak too quickly, mumble, or speak quietly, remind them to speak slowly, loudly and clearly.
4
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 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 when the tape will reach reach the end.
5
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: ......................... .........................
...
(TAPE STOPPED)
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 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 to you. If you would like the hard copy 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, 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 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 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, physiological, psychological and psychological and psychosocial .
Firstly, the physical the physical factors 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 The physiological aspect 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 The psychological element 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 would include - Was the training, training, knowledge and experience 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 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 which could have been factors in 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 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.
James Reason 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. 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 system for pilots into into place which is organised organised by line management. 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 operators is to create the the conditions under which which these latent failures 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 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. 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, chronologically, either from left to right if if developing a diagram, diagram, or from the earliest 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 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.
Key Events 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.
Key Conditions 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. Rotorua. These were MV Grand Honest at 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 d eck 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 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
Pilot boards
Vessel leaves berth
Large diameter ropes Wet and slippery ropes
Water on deck
Heavy rain
Pilot disembarks by way of pilot ladder
Vessel rolls heavily
Wind ENE 60 knots
Pilot falls onto deck
Suffers injuries
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.
Definitions An accident means an occurrence that involv-es a ship and in which (a) A person is seriously seriously harmed as a result 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
(iv)
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 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, laceration, crushing. 3. Amputation of body part. 4. Burns requiring referral to a specialist registered medical practitioner practitioner or specialist outpatient clinic. 5. Loss of consciousness from lack of oxygen. 6. Loss of consciousness, or acute illness requiring treatment treatment by a registered medical medical practitioner, from absorption, inhalation, or ingestion, of any substance. 7. Any harm that causes the person harmed to hospitalised hospitalised for a period of 48 hours or more commencing commencing within 7 days of the harm's occurrence. A Seafarer a) Means any person whoi) Is employed or engaged on any ship ship in any capacity capacity for hire 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 pilot or any person temporarily temporarily employed on a ship while it is 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
