Unit 5 -Accident Investigation Flashcards
memorise concepts
What is an accident?
An accident is unplanned sequence of events or conditions resulting in injury, damage, pollution, loss of process i.e. some kind of loss.
What is an incident?
An incident is any undesirable or
unexpected situation including accidents and also near misses
Why do we investigate accidents?
- An informal approach to dealing with the aftermath of accidents
might reveal the causes behind accidents, without too much effort
or application of resources, however, the likely effect on any
corrections or changes because of this approach is not likely to be
effective or long lasting. - Effective managers recognise that a systematic and organised
approach is likely to create a much deeper understanding of the
causes and any implemented recommendations are likely to be
long lasting and effective.
What are the Pros of accident investigation?
By performing even a cursory investigation something may be learned from every incident.
However, much more may be learned if a more structured approach is taken. If the structured approach is efficient, the user can obtain an increased level of learning without much additional effort.
What are the Cons of accident investigation?
Investigating accidents means applying resources (money, manpower, time).
After investigation we might not get anything significant back (it might might be inconclusive).
What are the depth levels of an investigation?
The deeper
investigation, the greater
the understanding of how
an organisation
functions: Human error -> Task control issues -> Process control issues -> Management system issues -> organisational culture issues
Dilemma of applying resources to accident investigation, how far do you investigate?
The dilemma for management is this:
spend more time and resources now to understand the underlying causes of accidents and failures and to address them and solve the problem, reducing the chance of future failures and accidents occurring.
Or
deal with each incident as it arises, spending less time, effort and money by not investigating too deeply, but understand that you will always need
to ‘fight the latest fire’.
What are the problems of NOT investigating incidents too
deeply?
On one hand, it requires fewer resources (on the face of it) and is quicker, on the other hand, there is a risk of not address the root of the accident and risking similar incidents may need to be investigated repeatedly.
What are the levels of investigation?
§ Serious accidents or casualties require major mobilization of resources to investigate fully, flag
State and other regulatory bodies and insurers are involved in investigation.
§ Less serious accidents require a lower level of response involving one or two investigators to attend the ship and conduct interviews, collect
evidence and prepare a report for flag State.
§ Minor events require one investigator on scene to collect evidence, conduct interviews and prepare a brief report. Accident may only require investigation onboard without requiring ‘office resources’.
Which accidents to choose to investigate?
Instead of investigating every accident, investigate those where:
§ the consequences are large enough that such an incident, would not be tolerated to the organisation if repeated.
§ a near miss where consequences are small but having the potential to have resulted in consequences large enough to be considered not tolerable.
§ a number of smaller incidents, that collectively add up to something significant.
Explain the structured root
cause analysis approach for incident investigation (8 features)
- All relevant events and conditions are identified
- All causal factors identified
- Deep underlying causes of all causal factors identified
- Recommendations are more focused
- Management system approach
- Focus on effective and long term solutions
- Human factors considered as causal factors
- Seafarers are not seen in terms of blame
Explain how to start an incident investigation process:
(draw the diagram for help)
- Identify the type of incident and the loss incurred (or the potential loss) and determine the level or depth of investigation.
- Initiate accident investigation and initial actions (Notification//Emergency response//Immediate response//Decide of the level of response/classify incident type/severity//Assign resources//Assemble team//Consider status of equipment or systems associated with the incident//Gather resources)
- Emergency response and notification
Regulatory obligations:
ISM emergency response procedures//SOPEP/SMPEP (tankers)//Port State and coastal State national or port reporting
procedures//Emergency or distress co-ordinating organisations (IAMSAR
and International Convention on Maritime Search and Rescue
SOLAS requirements)
Others required to be notified: Hull and machinery and P&I Insurers//Charterers
- Initial communication with the ship:
Instruct the master of the vessel to arrange for an initial report of facts
(sometimes referred to as statement of facts) and arrange for scanned
copies of the following documents :
§ relevant documents and forms
§ logbook entries (key events, times and personnel involved)
§ photographs, notes, sketches
§ written statements by witnesses
§ any documents from other parties (letters of protest, for example)
§ notes of communications with third parties (telephone, radio or face to
face conversations with surveyors, port officials, government officials,
for example)
§ Secure relevant data from recording devices (Voyage Data Recorder (VDR),
course recorder, for example) and samples (cargo, fuel, mooring/towing
rope) - Assign the investigation team:
Investigation team may be:
§ master and officers (ship based)
§ office-based individual
§ office-based team (internal to the organisation)
§ team consisting of office-based staff and others (fireinvestigators, engineers, divers, equipment manufacturers
technicians, and other specialists)
** other organisations may assist (chemists, testing organisations,
naval architects, translators etc.) - Prepare to gather evidence:
Request the master to prepare contemporaneous reports to be sent to the office
§ Plan the scope of the investigation
§ Instruct those onboard to take measures to preserve evidence as far
as possible
§ Make arrangements for a command centre ashore with suitable
communications (internet connection IT support) and suitable for
press briefings
§ Seek co-operation with port State and establish whether national
jurisdiction compels cooperation and access to evidence
§ Set up meetings with various interested parties
§ Ensure access to legal, specialist technical and media advice and
maintain records of costs
Request the master to prepare contemporaneous reports to be sent to the office
§ Plan the scope of the investigation
§ Instruct those onboard to take measures to preserve evidence as far
as possible
§ Make arrangements for a command centre ashore with suitable
communications (internet connection IT support) and suitable for
press briefings
§ Seek co-operation with port State and establish whether national
jurisdiction compels cooperation and access to evidence
§ Set up meetings with various interested parties
§ Ensure access to legal, specialist technical and media advice and
maintain records of costs
How should you choose investigation team members?
The investigators should:
Have undergone training in accident
investigation techniques such as interviewing witnesses, evidence collection, accident site
inspection.
Have an understanding of the ship operation and have the technical skill, perseverance, and ability to take a logical, systematic approach.
Be able to conduct the investigation
dispassionately but also sensitively, recognizing that some personnel may be suffering emotional trauma.
