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MARINE ACCIDENT & INCIDENT INVESTIGATION(Part-01) 30 Nov, 2014

MARINE ACCIDENT
AND
INCIDENT INVESTIGATION

Aim


It is the Aim of this 1-Day Course to familiarize Senior Officers with processes & procedures to carry out a structured MARINE ACCIDENT and INCIDENT INVESTIGATION as per their Company requirements.
OBJECTIVES


On the completion of the course participants will be able to :

• explain the impact that serious accidents have on the general public and how sections in the marine industry are perceived.

• state the objectives & the need for different types of investigation.
• describe the objectives of the Code for Investigation of Marine Casualties & Incidents.
• describe interviewing techniques & procedures to follow in interviewing individuals.
• explain the importance of human factors in marine casualties, in terms of human performance.
• state what evidence is & describe standards & type of evidence as well as how to collect evidence.
• describe systematic approaches to accident investigations, determining the sequence of events making use of the principles of accident analysis & investigating human factors.
• report the accidents or incidents in the recommended structured reporting as per DNV M-SCAT format.

Chapter 1- Introduction to Marine Accident Investigations

1.1 - Overview

"To err is human, to forgive divine" – Alexander Pope, an Essay on Criticism (1711)

For many years the shipping industry has concentrated on the physical condition of the ship. It has, however spent little time on the other aspects that are now seen as equally important – the people factor, the performance of the master, officers and crews, and the manner in which the ship is operated.





Good ship management requires all aspects to be controlled.

This human factor is the most prominent cause of most shipping incidents.
These incidents include but are not limited to the following:
Accidents, Injury, Death, Pollution, Collision and Grounding.


"It has been estimated that up to 90% of all workplace accidents have human error as a
cause"
The above is one estimate of the contribution of human error to accidents (and refers to
errors and violations). The term 'human failure' is used to refer to errors and
violations: newspaper headlines tend to use 'human error' as a blanket term for both.
Whether the true figure is 90 % or some other higher or lower figure, it is clear
from a wide range of sources of information that human failures make a significant
contribution to incidents and accidents. An example of a recent study [4] for the maritime
industry (which included UK data), found that:
'…approximately 50% of maritime accidents are initiated by human error, while another
30% of maritime accidents occur due to failures of humans to avoid an accident. In other
words, in 30% of maritime accidents, conditions that should have been adequately
countered by humans were not.'
It should be noted that the remaining accidents causes were attributed to mechanical
failures (up to 10 %) and it is almost certain that human error – for example in installing or
servicing equipment – contributed to those failures.


Human failure in incidents and accidents
It is unfortunate that the phrase, 'human error' has become virtually meaningless through
over-use and that it is usually interpreted to mean that the person 'at the sharp end' was at
fault by committing some form of error or 'violation'.
It is easy to be misled and to believe that human errors arise because of
carelessness, inattention, incompetence or reckless rule breaking by the workforce.
However, human errors occur because the systems for preventing them failed in some way. An incident, then, is not a person failure but a system failure and, to prevent further incidents, it is important to understand those systems: what they are, how they are intended to work and how, in specific cases, they have failed.
• The only way to prevent further regulations is to prevent further incidents especially major incidents.
• This is the only hope for the seafarer and the only one in which the seafarer is reasonably in control.
• Out of 5,315 seafarers studied, 64 percent were repatriated due to illnesses, and 36 percent due to injuries.
• Unfortunately 13 percent, were declared permanently disabled.
• Just like us, none of them probably gave it a thought & now its too late for them to think and too bad for their families.
• Be Safe; Don’t become a Statistic

• Safety is not a shirt that can be slipped on when you desire and discarded when you don’t, because sooner or later you will fail and possibly the results may be catastrophic in fact you may not even get another chance.
• You can’t really be safe on the job & unsafe off it (in normal life).
• Safety is a way & a part of life & cannot be separated from it.

Many petroleum and allied industry businesses investigate both incidents and accidents
whether these have process safety/major hazards potential or occupational safety potential
only. However, in these investigations, human factors issues are typically not well addressed.
As an example, one company’s accident report form includes a section for the
investigator to describe the root causes of the accident. The section includes items such as
'lack of competence', 'inadequate procedures', 'inadequate tools or equipment'. To a
human factors analyst, however, these are not root causes: the root cause in those cases
would be the system deficiencies that led to poor competence, procedures and equipment.
In another company’s report form, there is a blank space for entering root causes
and example entries from real investigations include weather conditions, fatigue and even
'human error' as root causes identified by the analyst. Again, these are not root causes.
These investigations should have probed further than this to explain the organization’s
failure to deal with, for example, 'weather conditions' or 'fatigue'. These are, to a human
factors analyst, performance-shaping factors, not root causes of error


1.2- Loss events & Causal factors


• Figure 2, “Relationship of Incident Investigation Terms,” is provided to show the interrelationship of the various terms defined here


1.2.1- LOSS EVENT

• Undesirable consequences resulting from events or conditions or a combination of these.
• The way the loss event is stated and understood will define the scope of the incident analysis. For example, selecting engine failure as the loss event will result in focusing on the engine failure.
• Selecting vessel grounding after engine failure as the loss event will result in focusing on the engine failure as well as the grounding incident. Selecting oil release after grounding following engine failure as the loss event will result in the investigation of all three aspects of the incident.
• Because of this, the loss event should be stated carefully and be precisely defined. A loss event definition that only includes the immediate consequences results in recommendations that are fairly narrow in scope. A loss event definition that also includes the subsequent consequences of the incident results in recommendations that are broader in scope.
• Multiple loss events may be identified as part of a single investigation.

1.2.2-CAUSAL FACTORS

• Structural/Machinery/Equipment/Outfitting problems, human errors and external factors that caused an incident, allowed an incident to occur or allowed the consequences of the incident to be worse than they might have been.
Notes:
• For a typical incident, there are multiple causal factors.
• Causal factors are identified during the first stage of the analysis.
• Each causal factor is an event or condition for which steps should be taken to reduce or mitigate
its occurrence.
• For each causal factor, underlying causes will be identified and recommendations will be developed.

Who did what wrong? What equipment failed?

If these problems had not occurred, it could have prevented the incident (circle) from occurring or significantly reduced the incident’s consequences.


1.3 - The need for Investigations

Why do we require Accident Investigation?

• ISM Code – Implicit
• OCIMF – TMSA
• Manage shipboard risks better
• Continuous Improvements


• Two sides of a coin
– Risk Assessment to prevent accidents.
– Accident Investigation to improve our risk assessment process by learning from our mistakes.

WHEN?


• Accident Investigation after a Near Miss/Incident/Accident

WHERE?
• These techniques are generic and can be applied in any situation as required.

WHO?

• Senior Officers to start but unless it becomes a part of every individual, it can never be very successful.

HOW?

• Look before you LEAP!
• Learn the Techniques & Lead by example
• Educate Others
• Assess Application of Techniques
• Proactively improve

• The objective of any marine casualty investigation is the prevention of further similar casualties by discovering the reasons behind the casualty and then promulgating actions, information & recommendations where appropriate with a view to preventing similar casualties. It is important that any recommendations arising from an investigation are based on sound analysis and are capable of practical implementation.
• It follows from this that any accident, from the trivial to the major can be the subject of a marine casualty investigation. A simple personnel accident with the potential for learning something which could prevent recurrences might be worth investigating thoroughly while a major collision resulting from a straightforward wrong application of the COLREGS might not show anything new. Another different collision might indicate a need to look at fatigue, management procedures, training, certification and bridge design. Each accident which is reported should be assessed on its merits.

However, in using incident investigation methods, investigators should be aware that:
— Incidents often arise because of a highly unusual combination of underlying
problems. The investigation may therefore deal with only that combination, and
other factors that could have been identified in the investigation are left unchanged.

— High probability but low consequence (HPLC) incidents – 'everyday' mishaps that
do not cause major harm – can become the main focus of an organization’s
attention. HPLCs are very visible, typically less complex and thus easier to deal with
than low probability high consequence (LPHC) events – disasters.


Basics of Incidents and Investigations


• Is there a Need for Incident Investigation
• Question: If an organization has never had a means for formally investigating incidents and yet still learns something from past mistakes, why is a structured approach needed? Why should time be invested in performing an incident investigation?
• Answer: While something may be learned from every incident by performing even a cursory investigation, much more can be learned by using a more structured approach. If the structured approach is efficient, the user can obtain an increased level of learning without much additional effort.

Experience has shown that accidents are rarely simple and almost never result from a
single cause.

Each incident or accident is a learning opportunity, but one that could be wasted unless the
effort put into analysing it focuses on discovering the true underlying causes of the incident
rather than focusing on the people directly involved and the immediate causes of their
failure.
Incident investigation is one of the tools for improving control over hazards in the
working environment. It is a retrospective tool – applied once the flaws in our systems
have drawn attention to themselves via an incident. Any modern organisation may also have
in place proactive methods of observation, inspection and audit as complementary methods
for improving hazard control.
• The marine industry experiences incidents that range from major accidents to near misses.
• These incidents should be investigated since many flag administration regulations require it; international agreements mandate it (such as the IMO “International Safety Management Code”) and industry initiatives encourage it.
• Incident investigation is a process that is designed to help people and organizations learn from past performance and develop strategies to improve safety.

1.4- Structured & unstructured approaches to Investigations

• The focus of this section is on the application of structured analysis techniques, to the incident investigation process.
• There are two levels of analyses that can be used as part of the incident investigation process: apparent cause analyses (ACAs) and root cause analyses (RCAs).
• Root cause analyses involve a deeper level of analysis than apparent cause analyses & more effort is usually required to gather data for a root cause analysis.


Rationale for Taking a Structured Approach to Incident Investigation

• Unstructured approaches can allow an organization to prevent the same incident from recurring, but often unstructured approaches simply delay the recurrence (or change the specifics of) the incident.
• Example: A bearing on a pump fails. During an unstructured analysis, when it is discovered that a pump failed because of a bad bearing, the bearing would be replaced and the pump started again.
• But with this approach was anything learned from this failure?
• No. How might something be learned?
• One means would be to ask questions in a structured fashion, such as:
– Why did the bearing fail?
– Was the correct bearing for the pump used?
– Was it installed correctly?
– Was the bearing made of the correct material?
– If it is made of the wrong material, how did our organization allow that to occur?
– Why did a bearing of the wrong material get installed?
– How is it determined which bearings to use when a repair is needed?

• The answers to all of these questions allow a more thorough analysis of the incident.

Chapter 2- Code for Investigation of Marine Casualties and Incidents


ASSEMBLY
20th session
Agenda item 11

RESOLUTION A.849(20)

Adopted on 27 November 1997

CODE FOR THE INVESTIGATION OF MARINE CASUALTIES AND INCIDENTS

THE ASSEMBLY
RECALLING article 15(j) of the convention on the International Marine Organization
Concerning the functions of the Assembly in relation to regulation and guidelines concerning
maritime safety and prevention and control of marine pollution from ship,

NOTING with concern that, despite the best endeavours of the Organization, casualties and incident
resulting in loss of life, loss of ship and pollution of the marine environment continue to occur,

NOTING ALSO that the safety of seafarers and passengers and the protection of the marine
environment can be enhanced by timely and accurate reports identifying the circumstances and
causes of marine casualties and incidents,

NOTHING FURTHER the rights and obligations of coastal and flag states under the provisions
of articles 2 and 94 of the United Nations Convention on the Law of the Sea (UNCLOS),

NOTHING IN ADDITION the responsibilities of flag States under the provisions of the
International Convention for the Safety of Life at Sea, 1974 ( regulation l/21), the International
Convention on Load Lines, 1966 (article 23) and the International Convention for the Prevention
of Pollution from Ships, 1973 (article 12), to conduct casualty investigations and the supply the
Organization with relevant findings,

CONSIDERING the need to ensure that flag States are required, under the aforementioned
conventions, to investigation 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 co – operation
between Government having a substantial interest in a marine casualty or incident for the
purpose of determining the circumstance 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. REQUEST 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 resolution A.173(ES.lV), A.440(Xl) and A.637(16).



4.6.1

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 its judges that such an investigation may assist in determining what change in the present regulation may be desirable
or if such an casualty has produced a major deleterious effect upon the environment. The code also takes in to 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 person into certain casualties or incidents of navigation on the high seas. However, the code
Also recognizes that where a casualty occur 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 environment, involve the coastal State’s search and rescue authorities, or otherwise affect the coastal State.

1.2 The aim of this code is to promote a common approach to the safety investigation of marine casualties and incident, and also to promote co-operation between Sates in identifying the contributing factors leading to marine casualties.The result of this common approach
And co-operation will be aid remedial action and to enhance the safety of seafarers and passengers
and the protection of the marine environment. In achieving these aims, this code recognizes the
need for mutual respect for national rules and practices and puts particular emphasis upon co- operation.

1.3 By introducing a common approach to marine casualty investigation and the reporting on
such casualties, the international maritime community may br better informed about the factors
which lead up to an cause, or contribute to, marine casualties. This may be facilitated by:

1. Clearly defining the purpose of marine casualty investigation and the guiding principles for its
conduct.
2. defining a framework for consultation and co-operation between substantially interested
States.
3. Recognizing that the free flow of the 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.
4. 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 from 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 to the casualty and to make appropriate safety recommendation. Ideally, marine casualty investigation should be separate from, and independent of, any other from of investigation.


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 analyzing information and drawing conclusions. Ideally, it is not the purpose of such investigation to determine liability, or apportion blame. However, the investigating authority should not refrain from fully reporting the causes because fault or liability mat be inferred from the findings.

3. Application
This code applies, as far as national laws allow, to the investigation of marine casualties or incident 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 operation
of a ship; or
3. the loss, presumed loss or abandonment of a ship; or
4. material damage to a ship; or
5. the standing 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 ship or ships.


4.2 Very serious casualty means a casualty to a sip which involves 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. a fire, explosion, grounding, contact, heavy weather damage, ice damage,hull
cracking or suspected hull defect, etc., resulting in:
2. structural damage rendering the ship unseaworthy, such as penetration of the hull
underwater, immobilization of main engines, extension accommodation damage etc.: or
3. pollution ( regardless of quantity); and / or
4. a breakdown necessitating towage or shore assistance.

4.4 Marine incident means an occurrence or event being caused by, or in connection with,
the operation of a ship by which the ship or any person is imperiled, or as a result of which
serious damage to the ship or structure or the environment might be caused.

4.5 Causes means actions, omissions, event, existing or pre- existing conditions or a
combination thereof, which led to the casualty or incident.

4.6 Marine casualty or incident safety investigation means a process held either in public or in
camera conducted for the purpose of casualty prevention which includes the gathering and
analysis of information, the drawing of conclusions, including the identification of the
circumstances and the determination of causes and contributing factors and, when
appropriate, the making of safety recommendations.


4.7 Marine casualty investigator means a person or persons qualified and appointed to investigate
a casualty, or incident, under procedures laid down in national legislation for the furtherance of
marine safety and protection of the marine environment.

4.8 Serious injury means an injury which is sustained by a person in a casualty resulting in
incapacitation for more than 72 hours commencing within seven days from the date of injury.

4.9 Ship means any kind of vessel which is used in navigation by water.

4.10 Lead investigation States 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. which is the flag State of a ship that is the subject of an investigation; or
2. in whose internal waters or territorial sea a marine casualty has occurred; or
3. where a marine casualty caused, or within those area over which the state is entitled to exercise jurisdiction as recognized under international law; or
4. 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
5. where, as a result of a casualty, nationals of that State lost their lives or received serous injuries; or
6. that has at its disposal important information that mat be of use to the investigation; or
7. that for some other reason establishes an interest that is considered significant by the lead investigation State.

5 Conduct of marine casualty investigations

5.1 Where an investigation is to conducted, the following should be taken into consideration:

1. Thorough and unbiased marine casualty investigations are the most effective way of establishing the circumstances and causes of a casualty.
2. Only through co-operation between States with a substantial interest can a full analysis be made of a marine casualty.
3. Marine casualty investigation should be given the same priority as criminal or other investigations held to determine responsibility or blame.
4. Marine casualty investigators should have ready access to relevant safety information including survey records held by the flag State, the owners, and classification societies. Access to information should not be barred by reason of competing investigations.
5. 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.
6. 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.
7. The investigation should take into account any recommendations or instrument published by IMO or ILO, in particular those relating to the human factor, and any other recommendations or instrument adopted by other relevant international organizations.
8. Reports of investigations are most effective when released to the shipping industry and public.


5.2 In accordance with 9, other substantially interested States should be invited to be represented during any such investigation and should be admitted as a party in the proceedings and have equal standing, rights and access to evidence as the States conducting the investigation.


5.3 Recognizing that any vessel involved in a casualty may continue in service and that a ship should not be delayed more than is absolutely necessary, the State conducting the investigation should start the investigation as soon as practicable, without delaying the ship unreasonably. Other substantially interested States may, by mutual agreement, join the investigation either immediately or at a later stage.


6 Responsibility for investigating casualties and incidents


6.1 Flag States are encouraged to ensure that investigations are carried out into all casualties occurring to its ships. All cases of serious and very serious casualties should be investigated.


6.2 Where a marine casualty or incident occurs within the territorial sea of a State, the flag and coastal States recognizing the obligations of that State to its citizens and the legal status of the territorial sea under the provisions of UNCLOS and also recognising the duties placed on 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 of lead investigating State.


6.3 Where a marine casualty or incident occurs on the high seas, a flag State should carry out an investigation into a casualty to, or on, any of its ships. If that casualty is a collision involving a ship of another flag State, than the state 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 Sate by virtue of the nationality of the ship’s crew, passengers or other person, 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.

6.5 An investigation should be started as soon as practicable after the casualty occurs. Substantially interested States should, by mutual agreement, be allowed to join an investigation conducted by another substantially interested State at any stage of the investigation.

7. Responsibilities of the lead investigating State

The lead investigating State should be responsible for:
1. developing a common strategy for investigating the casualty in liaison with substantially interested States;
2. providing the investigator in charge and co-ordinating the investigation;
3. establishing the investigation parameters based on the laws of the investigating State and ensuring that the investigation respects those laws;
4. being the custodian of records of interviews and other evidence gathered by the investigation;
5. preparing the report of the investigation, and obtaining and reflecting the view of the substantially interested States;
6. co-ordinating, when applicable, with other agencies conducting othet 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 States.


8.2 Following a casualty, the investigating State should inform the other substantially interested States, either through the consular Office in the State or by contacting the relevant authorities listed in MSC/Circ.781/ MEPC.6/Circ.2. That State and the other substantially interested States should consult, at the earliest opportunity, on the conduct of the investigation and to determine details of co-operation.

8.3 Nothing should prejudice the right of any State to conduct its own separate investigation into a marine casualty occurring within its jurisdiction according to its own legislation. Ideally, if more than one State desires to conduct an investigation of its own, the procedures recommended by this Code should be followed, and those State 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:

1. question witnesses;
2. view and examine evidence and take copies of documentation;
3. produce witnesses or other evidence;
4. make submissions in respect of the evidence, comment on and have their views
properly reflected in the final report; and
5. be provided with transcripts, statements and the final report relating to the
investigation.

9.2 States are encouraged to provide for maximum participation in the investigation by all States with a Substantial interest in the marine casualty.

9.3 The flag State of a ship involved in a marine casualty should help to facilitate the availability of the crew to the investigation and encourage the crew to co-operate with the State conducting the investigation.





10 Disclosure of records


10.1 The State conducting the investigation of a casualty or incident, wherever it has occurred, should not make the following records, obtained during the conduct of the investigation, available for purposes other than casualty investigation, unless the appropriate authority for the administration of justice in that State determines that their disclosure outweighs any possible adverse domestic and international impact on that or any future investigation, and the State providing the information authorizes its release:

1. all statements taken from persons by the investigating authorities in the course of the investigation;
2. all communication between persons having been involved in the operation of the ship;
3. medical or private information regarding persons involved in the casualty or incident;
4. opinions expressed during the conduct of the investigation.

10.2 These records should be included in the final report, or its appendices, only when pertinent to the analysis of the casualty or incident. Parts of the record not pertinent, and not included in the final report, should not be disclosed.

11 Personnel and material resources
Government 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 report and submission to IMO

12.1 The lead investigating State should send a copy of the draft if the final report to all substantially interested States, inviting their significant and substantiated comments within thirty days, or within some mutually agreed period, it should either amend the draft final report to include the substance of the comments, or append the comments to the final report. If the lead investigating State receives no comments after the mutually agreed period has expired, it should send the final report to the Organization in accordance with applicable requirements and cause the report to be published.

12.2 By fully participating in an investigation conducted by another substantially interested state that will be reporting to IMO, the flag State shall be considered as fulfilling its obligations under IMO conventions.

12.3 Reports, or relevant parts of reports, into the circumstances and causes of a marine casualty should be completed as quickly as practicable, and be made available to the public and the shipping industry in order to enhance safety of life at sea and protection of the marine environment through improved awareness of the factors which combine to cause marine casualties.
12.4 Where a substantially interested State disagrees with whole or part of the report referred to in 12.1 above, it may submit its own report to the organization.

12.5 The investigating State, upon determining that urgent safety action is needed, may initiate interim recommendation to the appropriate authority.

13 Re-opening of investigation

When new evidence relating to any casualty is presented, it should be fully assessed and referred to other substantially interested State 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, State should reconsider their findings.


14 Contents of reports


14.1 To facilitate the flow of information from casualty investigations, each report should conform to the basic format outlined in 14.2 below.
14.2 Report should include, wherever possible:


1. a summary outlining the basic facts of the casualty and stating whether any deaths, injuries or pollution occurred as a result;
2. the identity of the flag State, owners, managers, company and classification society;
3. 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;
4. a narrative detailing the circumstances of the casualty;
5. analysis and comment which should enable the report to reach logical conclusion, or findings, establishing all the factors that contributed to the casualty;
6. a section, or sections, analyzing and commenting on the causal elements, including both mechanical and human factors, meeting the requirements of the IMO casualty data base; and
7. where appropriate, recommendations with a view to preventing similar casualties.





15 Contact between Administrations

To facilitate implementation of this code, State should inform the Organization of the responsible authorities within their Governments that may be contacted regarding cooperation in casualty investigations.

4.6.2
Guidelines to assist investigators in the implementation of the code

Introduction
The contents of this section should be treated as guidelines to assist investigators co-operating in an investigation. Investigator 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 investigations is being conducted. In particular, co-operating 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, maker)
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: Any documents that may have relevance to the investigation should be produce. Where possible original documents should be retained, otherwise authenticated and dated photocopies should be taken in accordance with 9.1.2 of the code. A number of these documents will contain details sought under1.1 of these guidelines.)


Ship’s register
Current statutory certificates
ISM code certification
Classification society or survey authority certificates
Official log book
Crew list
Crew qualification (see also 1.4 of these guidelines)
Deck log book
Port log, log abstract and cargo log book
Engine movement book
Engine-room log book
Date logger print-out
Course recorder chart
Echo sounder chart
Oil record book
Sounding 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
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 type of vessel
Experience in current capacity
Experience in other ranks
Number of hours spent on duty on the day and the previous days
Number of 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 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 event 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 book, data log printout,
Computer printouts, course and engine speed recorder, radar log, etc.
Details of communications made between the vessel and radio station, SAR centers 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
If assistance was summoned, what form and by what means
If assistance was offered or given, by whom and of what nature, and whether it was effective and competent If assistance was offered and refused, the reason for refusal

1.8 Authentication of documents

The master should be asked to authenticate all documents and to sign all copies taken of documents as being true copies, also to authenticate relevant dates and times.

1.9 Engine-room orders

In all cases where a collision or a stranding is the subject of an investigation, and the movements of the engine are involved, the master or officer on watch and other persons in a position to speak with knowledge are to be asked whether the orders to the engine-room were promptly carried out. If there is any doubt on the matter, the investigator shall refer to it in his report.

1.10 External sources of information

Investigators should consider independent corroborating information from external sources such as radar or voice recordings from vessel traffic systems, shore radar and radio surveillance systems, marine rescue co-ordination centres, coroners and medical records.

2 Additional information required in specific cases

2.1 Fire/Explosion (Investigators should bear in mind the IMO Fire casualty Record.)


How was the ship alerted to the fire?
How was the individual alerted to the fire?
Where did it start?
How did it start (if known)?
What was the immediate action taken?
Condition of fire-fighting equipment, supported by dates of survey / examination
Extinguishers available:
Type available in the vicinity
Type available on the ship
Type used
Hoses available/ used
Pumps available/ used
Was water immediately available?
Were air vents closed off to the space?
What was the nature of the material on fire and surrounding the fire?
Fire retardant specification of bulkheads surrounding the fire
Restrictions caused by (a) smoke, (b) heat, (c) fumes
Freedom of access
Access availability for fire fighting equipment
Preparedness of crew – Frequency, duration, content and location of fire musters and drills
Response by land-based fire-fighting brigades



2.2 Collision (Investigators should bear in mind the IMO damage cards and
intact stability reporting format.)

General
Local or other special rules for navigation
Obstructions, if any, to manoeuvring, e.g. by a third vessel, shallow or narrow waters,
Beacon, buoy etc.
Circumstances affecting visibility and audibility, e.g. state of the sun, dazzle of shore light, 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 of other ship, if observed by radar, timing of observations and subsequent alterations of bearing
If other ship was plotted and by what method (auto-plot, reflection plotter, etc.), and copy of plot, if available
Check performance of equipment
Course recorder
Lights/day signals carried and operated in ship, and those seen in other ship sound signals, including fog signals, made by ship and when, and those heard from other ship and when
If a listening watch was keep on VHF radio channel 16, or other frequency, and any messages sent, received or overheard
Number of radars carried on ship, number operational at time of casualty, together with ranges used on each radar
Whether steering by hand or automatic
Check that steering was operating correctly
Details of look-out
The parts of each ship which first came into contact and the angel 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
Subsequent weather and tidal or other current 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 sounding taken, when and by what means
Draught of ship before grounding and how determined
Position of grounding and hoe determined
Cause and nature of any engine or steering failure before the grounding
Readiness of anchors, their use and effectiveness
Nature and extent of damage
Action Taken, and movements of ship, after grounding
(Note: information as in cases of foundering may also be required)



2.4 Foundering (Investigators should bear in mind the IMO damage cards and
intact stability reporting format.)

Draught and freeboard on leaving last port and changes consequent upon consumption of stores and fuel
Freeboard appropriate to zone and date
Loading procedures, hull stresses
Particulars of any alterations to hull or equipment, since survey, and by whom such alterations sanctioned
Condition of ship, possible effects on seaworthiness
Stability data and when determined
Factors affecting stability, e.g. structural alterations, nature, weight, distribution and shift of any cargo and ballast, free surface in tanks or of loose water in ship
Subdivision by watertight bulkheads
Position of, and watertight integrity of, hatches, scuttles, ports and other openings
Number and capacity of pumps and their effectiveness; the position of suctions
Cause and nature of water first entering ship
Other circumstances leading up to foundering
Measures taken to prevent foundering
Position where ship foundered and how established
Life- saving appliances provided and used, and any difficulties experienced in their use


2.5 Pollution resulting from an incident
(Investigators should bear in mind IMO reporting of incidental
spillages of liquids, 50 tonnes or more, and reporting of
information from investigation of incidents involving dangerous
goods or marine pollutants in packaged form.)

Type of pollutant
UN number/IMO hazard class( if applicable)
Type of packaging (if applicable)
Quantity on board
Quantity lost
Methods of stowage and securing
Where stowed and quantities in each compartment/container
Tanks/spaces breached
Tanks/spaces liable to be breached
Action taken to prevent further loss
Action taken to mitigate pollution
Dispersant/neutralizer used, if any
Restricting boom used, if an.

3 Securing of physical evidence

3.1 Occasions may arise where physical evidence may be available and which will require scientific examination. Some examples are oil, paint/scale. Pieces of equipment and machinery, pieces of structure.


3.2 Before removal, such evidence should first be photographed in situ. The sample should then be photographed on a clear background before being placed in an appropriate clean container(s), glass bottle, plastic bag, tin container, etc. The container should be sealed and clearly labeled, 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.


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