Marine Accident Investigation Course
ORGANISED BY
THE DEPARTMENT OF SHIPPING
DHAKA BANGLADESH
Session 1
COURSE ORGANIZATION
AND
OVERVIEW
ORGANIZATION
Course duration
Timings
Facilities
Entertainment
Mobile phone policy
Attendance
Participation
Facilitators
Course media assistant WhatsApp
WhatsApp number
01713110140
MARINE CASUALTY INVESTIGATION
Overview
After a major incident or accident an investigation ought to be
carried out. The quality of these investigations is fully dependent on the
quality of investigators. The quality of investigators depends fully on the
quality of their training. This course will give you the technical knowledge
about investigations and the understanding of how to perform the investigation
in such a way that others will learn from it as much as possible. After this
course, participants will be able to perform Safety Investigations as part of a
team. By means of discussions, case studies, video examples and group
exercises, participants will become familiar with: The objectives of a Safety
Investigation; The Roles and Responsibilities within a Safety Investigation
Team; Human elements from four different angles; The development of dealing
with Human Error; The required Terms of Reference for Investigators; The value
of Safety Investigation Interviews; The different approaches to Data Analysis;
and the Collaboration with other Authorities.
Investigator’s training
IMO Member States should develop their own systems of investigator
training taking into account Part III of the CI Code,
States should ensure that marine safety investigating Authorities
have available to them sufficient material and financial resources and suitably
qualified personnel to enable them to facilitate the State’s obligations to
undertake marine safety investigations into marine casualties and marine
incidents.
Any investigator forming part of a marine safety investigation
should be appointed on the basis of the skills outlined in III Code.
However, it does not preclude the appropriate appointment of
investigators with necessary specialist skills to form part of a marine safety
investigation on a temporary basis, neither does it preclude the use of
consultants to provide expert advice on any aspect of a marine safety
investigation.
Any person who is an investigator, in a marine safety
investigation, or assisting a marine safety investigation, should be bound to
operate in accordance with the Casualty Investigation Code.
Investigator training and competence
Marine safety investigation is a specialised task, which should,
ideally, only be undertaken by suitably qualified investigators consistent with
the CI Code, Ch.15 and III Code. However, some States will not have personnel
dedicated solely to marine safety investigation. In these States, it may be
appropriate that suitabl
personnel should be identified and trained in marine safety
investigation techniques prior to being assigned to marine safety investigation
duties. When assigned to a marine safety investigation, such personnel should
be relieved of their regular duties and, in the context of the investigation,
be free from external direction (CI Code, Ch.11). However, they must not
conduct an investigation where they themselves may have a conflict of interest.
It is desirable that a marine accident
investigator has, as a foundation on which to develop further specialist
skills, an experienced professional maritime background with a good, sound
working knowledge of ship operations (III Code Para 38). Investigators do not
need to be experts in all the areas likely to be encountered in their work. The
expertise of specialists in areas such as human elements, metallurgy and
forensic fire analysis can always be sought.
Principles of investigation
As a general rule, the investigation should be
Unbiased: (i.e. find out what has happened as opposed to proving one's
assumptions)
based on a Just Culture approach (i.e. focus on the lessons to be
learned rather than on the person to be punished)
Safety focused:
It is not the objective of a marine safety investigation to determine
liability, or apportion blame. However, the investigator(s) carrying out a
marine safety investigation should not refrain from fully reporting on the
causal factors because fault or liability may be inferred from the findings.
Co-operation:
The investigating State(s) should seek to facilitate maximum cooperation
between substantially interested States and other persons or organizations
conducting an investigation into a marine casualty.
Priority: A marine safety
investigation should, as far as possible, be afforded the same
priority as any other investigation, including investigations by a
State for criminal
purposes being conducted into the marine casualty or marine
incident
Principles of investigation
Scope of investigation: Proper identification of causal factors requires timely and
methodical investigation, going far beyond the immediate evidence and looking
for underlying conditions, which may be remote from the site of the marine
casualty or marine incident, and which may cause other future marine casualties
and marine incidents. Marine safety investigations should therefore be seen as
a means of identifying not only immediate causal factors but also failures that
may be present in the whole chain of responsibility. (16.5 CI code)
Investigator’s Training Course
Course structure
The course features lectures, tutorials and practical training,
including simulation of an accident investigation. The theory is brought to
life through case study investigations and hands-on exercises. All participants
will complete a series of assessment tasks throughout the course and receive
feedback.
What you will learn
On successful completion of the course, you will be able to:
Describe the accident investigation process, including factors of
preparation, evidence collection and analysis, report writing and safety
recommendations.
Conduct witness interviews and collect material evidence from a
variety of relevant sources.
Perform an analysis of evidence to develop a no-blame report of
what occurred and recommendations for future preventions
Investigator’s Training Course
After the course the participants will be able to:
·
Use the techniques in accident investigation with focus on human
elements.
·
Identify underlying causes and explanatory factors.
·
Make practical recommendations for corrective
·
actions, which will prevent similar events in the future.
·
Use practical tips to write revealing reports.
·
Use practical and effective interviewing techniques.
Course Contents
• Legislation and Regulation
• Accident model
• The purpose of an investigation
• Systemic Approach to Investigation
• Appraisal of the Accident Site
• Collection of Evidence
• The sources of information to include when gathering facts
• Accident Photography
• Management On Site
• Interviewing Techniques
• Conducting a meaningful witness interview
• Analysing information obtained in aninvestigation
• Report Writing
• Making effective recommendations for corrective actions
• Case study
• Accident causation
• Effective documentation in an investigation
• Reporting to IMO
What is Marine Casualty
• A marine casualty means an event, or a sequence
of events, that has resulted in any of the following which has occurred
directly in connection with the operations of a ship:
• .1 the death of, or serious injury to, a person;
• .2 the loss of a person from a ship;
• .3 the loss, presumed loss or abandonment of a ship;
• .4 material damage to a ship;
• .5 the stranding or disabling of a ship, or the involvement of a
ship in a collision;
• .6 material damage to marine infrastructure external to a ship,
that could seriously endanger the safety of the ship, another ship or an
individual; or
• .7 severe damage to the environment, or the potential for severe
damage to the environment, brought about by the damage of a ship or ships.
However, a marine casualty does not include a deliberate act or
omission, with the
intention to cause harm to the safety of a ship, an individual or
the environment.
Why do we conduct casualty investigation
• SOLAS (regulation I/21) ,Load Lines, (article 23) and MARPOL
(article 12), put obligation to parties to conduct casualty investigations and
to supply the Organization with relevant findings.
• UNCLOS), Article 94(7) puts obligation to flag states to conduct
casualty investigation.
• To stop recurrence
• To find the lessons to be learned
• For consolation of the affected
Why do we conduct casualty investigation
• SOLAS (regulation I/21) ,Load Lines, (article 23) and MARPOL
(article 12), put obligation to parties to conduct casualty investigations and
to supply the Organization with relevant findings.
• UNCLOS), Article 94(7) puts obligation to flag states to conduct
casualty investigation.
• To stop recurrence
• To find the lessons to be learned
• For consolation of the affected
Who is the investigating state
• Flag state(s)
• Port state
• Coastal state
• Affected state(s)
• Substantially interested state(s)
Investigating State
Investigating State
Obligatory investigations
The marine safety investigation body, in the Coastal, Flag or
Substantially Interested State, must determine from the notification
information if the casualty meets the criteria of a very serious casualty, as
defined by the CI Code, Ch.6 and the definition of a ‘very serious casualty’ in
Ch.2 (loss of a life, loss of ship or severe pollution). If so, a safety investigation
must be conducted into that occurrence.
Session 2
ACCIDENT MODEL
Accident model
Hazards
Storm
• Fog
• Snow
• Rain
• Cargo shifting
• Current
• Fire
• Shoal
• Wreck
• Other Ships
• Debris
Accident Model
Hazards
Barrier
Ship
Barriers
Barriers are made of
• Rules and regulations
• Crew training
• Safety Management System
• Weather forecast
• Construction Code
• Survey and certification
• Repair maintenance
• Regular Inspection
Accident model
Hazards
Rules Barriers
Training Barriers
SMS Barrier
Ship
Holes in the barrier
Holes vary in size and position that depends on the surrounding
conditions
Cargo not secured properly
Improper lookout
No updated training
Lack of Supervision
Latent corrosion
Not listening weather report
Taking avoiding action too late
Holes in a Barrier
• Definition of a hole in a barrier
• Holes are caused by latent conditions and active failures. No
one can foresee all possible accident scenarios. Therefore, some holes in
defensive layers caused by latent conditions will be present from the time of
system establishment or will develop unnoticed or uncorrected during system
operation. Holes caused by active failures are triggered by operators’ unsafe
acts and appear immediately. An unsafe act is an error or a violation committed
in a hazardous or potentially hazardous situation
Holes in the Barrier not coinciding
Hazards
Ship
Holes in two barriers coinciding
Hazards
Ship
Holes in three barriers coinciding
Hazards
Holes in three barriers coinciding
Hazards
Accident Model
Control Layer
Control Layer
Control Layer
Accident trajectory
Hazards
Accident trajectory
Session 3
INVESTIGATION
Documents to be referred for conducting investigation
• Resolution MSC.255(84), Code of the International Standards
and Recommended Practices for a Safety Investigation into a Marine Casualty or
Marine Incident (CIC)
• Resolution A.1075(28), Guidelines to assist Investigators
in the Implementation of the Casualty Investigation Code (IG)”
• “The Marine Accident Investigator’s International Forum’s
(MAIIF’s) Investigation Manual.
Casualty Investigation Code
• Part II – Mandatory standards
• Chapter 4 – Marine safety investigation Authority
• Chapter 5 – Notification
• Chapter 6 – Requirement to investigate very serious marine
casualties
• Chapter 7 – Flag State’s agreement with another substantially
interested
• State to conduct a marine safety investigation
• Chapter 8 – Powers of an investigation
• Chapter 9 – Parallel investigations
• Chapter 10 – Co-operation
• Chapter 11 – Investigation not to be subject to external
direction
• Chapter 12 – Obtaining evidence from seafarers
• Chapter 13 – Draft marine safety investigation reports
• Chapter 14 – Marine safety investigation reports
Casualty Investigation Code
• Part III – Recommended practices
• Chapter 15 – Administrative responsibilities
• Chapter 16 – Principles of investigation
• Chapter 17 – Investigation of marine casualties (other than very
serious marine
• casualties) and marine incidents
• Chapter 18 – Factors that should be taken into account when
seeking
• agreement under chapter 7 of Part II
• Chapter 19 – Acts of unlawful interference
• Chapter 20 – Notification to parties involved and commencement
of an investigation
• Chapter 21 – Co-coordinating an investigation
• Chapter 22 – Collection of evidence
• Chapter 23 – Confidentiality of information
• Chapter 24 – Protection for witnesses and involved parties
• Chapter 25 – Draft and final report
• Chapter 26 – Re-opening an investigation
Sequence of investigation process
• Following stages in chronological order to be followed for
conducting an investigation
· Notification
· Preparation
to go on Site
· Arrival
on Site/Site Management
· Evidence
and Information Collection
· Interview
· Analysis
· Reporting
· Recommendations
Referred Documents should be consulted for detailed guidance on
the investigatory stages of analysis, reporting and the formation
recommendations
Investigation flow chart
The relationship between Analysis and other investigation tasks
Investigation time and effort
• The figure below indicates the level of investigation effort
that might be applied over time on analysis tasks relative to other
investigation tasks. The figure is an indicative example rather that an
accurate picture for all
Data Collection
Analysis
Report preparation
Investigation flow chart
The relationship between Analysis and other investigation tasks
Investigation time and effort
• The figure below indicates the level of investigation effort
that might be applied over time on analysis tasks relative to other
investigation tasks. The figure is an indicative example rather that an
accurate picture for all investigations.
Investigation architecture
• Through the investigation process we tray to make a reverse
video of an accident scenario
• We collect data
• We collect information
• We collect evidence such as photograph, objects, articles, bits
and pieces
• Put them together to reveal the story
• There is no scope to put or add investigator’s idea or thinking
into the story
• The structure must be based on what is found
• It is like completing a sentence with some scattered words,
based on the available clew Initial accident scene capture
• An initial walkthrough of the marine casualty or incident site
may be the only or best opportunity the investigators have before it is
disturbed by others. The opportunity should therefore be taken to:
• Photograph the scene as thoroughly as possible;
• Make written and voice notes, photographs, sketches and
diagrams, particularly of the positions of controls and switches, the location
of used emergency equipment, the extent of damage, and the location and nature
of other items of interest;
• Record exactly what any emergency response personnel are doing
in order to work back to the state of the scene before they started their
activities.
Physical evidence
• The investigation team should proceed with gathering,
cataloguing, and storing physical evidence from all sources as soon as it
becomes available. The most obvious physical evidence related to an accident or
accident scene often includes: Equipment; Tools; Materials; Pre- and
post-accident positions of accident-related elements; Scattered debris;
Patterns, parts, and properties of physical items associated with the accident.
• Evidence should be carefully documented at the time it is
obtained or identified.
• Sketching and mapping the position of debris, equipment, tools
and injured persons may be initiated by the team as soon as it arrives on
scene.
• A good quality digital camera is an essential tool for all
investigators and a thorough knowledge of the features of the particular model
used is important.
• Video can help an investigator recall the location and layout of
an accident scene.
Collecting documentary evidence
• Documentary evidence can provide important data and should be
preserved and secured as methodically as physical evidence.
• The ISM Code documentation should be inspected as a matter of
routine.
• Investigators should be sensitive to the possibility that
photocopies of documents may not truly depict the original document.
• With digital cameras it is often just as easy to take a photograph
of the relevant pages of the document, which may show up the original better.
Electronic evidence
• Now in the electronic age in which we live, we have far more
‘hard evidence’ that can be used to support/disapprove witness accounts. The
key electronic tool now available to marine accident investigators is the
Voyage Data Recorder (VDR), the marine equivalent of an aircraft black box
flight recorder.
• The VDR or S-VDR records and stores ship’s data in a protective
capsule and usually also on a computer hard disc, namely Date & time; Main
alarms; Position; Rudder order and response; Speed; Engine order and response;
Heading; Hull openings;
• GPS units will be found on many ships and potentially can
provide vital clues to an accident.
• Other electronic evidence include, laptop, USB flash memory,
ECDIS, AIS transponder, Bridge and ER recording equipment, mobile phone etc.
VDR
VDR & S-VDR
Simplified Voyage Data Recorder (S-VDR), as defined by
the requirements of IMO Performance Standard MSC.163(78),is a lower cost
simplified version VDR for small ships with only basic ship’s data
recorded. It is not required to store the same level of detailed data as a
standard VDR, but nonetheless should maintain a store, in a secure
and retrievable form, of information concerning the
position, movement, physical status, command and control of a vessel
over the period leading up to and following an incident.
• Hence, the principle difference between VDR and S-VDR lays
in the requirements for recording of additional data
Comparison between VDR & S-VDR recording data
|
INPUT |
VDR |
SVDR |
|
Date and time |
|
|
|
Ship’s position |
|
|
|
Speed |
|
|
|
Heading |
|
|
|
Bridge audio |
|
|
|
Communication audio |
|
|
|
Radar data |
|
|
|
AIS (Radar Alternative) |
|
|
|
Acceleration/Hull stress |
|
|
|
Echo Sounder |
|
|
|
Engine Order and response |
|
|
|
Hull opening status |
|
|
|
Rudder order and response |
|
|
|
Wind speed and direction |
|
|
Information sources
• Access to information is always important especially at the
beginning of an investigation. Sources of information useful to investigators
include:
• Contact details of worldwide Flag States (available through the
IMO);
• 24-hour contact details for the investigating body in each
Member State (GISIS – CI Code, Ch.4);
• National authority contact details, e.g. maritime
Information sources
• AIS information sources, e.g. AISLive, SafeSeaNet;
• Environmental/hydrology conditions – National Meteorological
Offices;
• Marine casualty information database(s), e.g. GISIS;
• Access to IMO Codes/Conventions/Regulations;
• Nautical publications, e.g. almanacs, charts, tidal data, pilot
books;
• Airport/train/ferry timetables, hire car and/or travel agency
contact details;
• Some of these sources of information are freely available whilst
others need to be purchased or require subscription fees. It may be useful to
have prearrangements in place to ensure availability of these sources.
Collection of documents
Coll Related Documents
• Ship certificates
• Crew Certificates
• Inspection Logs
• Policy & Procedures Manual
• Equipment Operations Manuals
Investigation analysis process
For the purpose of investigation, a simple approach to analysis,
consist of the following steps:
• Develop a sequence of events diagram.
• Identify which events in the sequence should be considered
as Casualty and Accident Events.
• Analyse each Accident Event to determine why the event occurred
(discovering the Human Error and Technical Failure
Mechanisms).
• For each Individual action and technical failure analyse
the Operational factors which may have had an influence
including any Risk Controls that failed or were not in place.
• Analyse further to discover why the relevant Operational
factors existed to discover the Shore Management and
Organisational factors that underlay the events.
• At each stage in the analysis process identify gaps in his
evidence and understanding of the case and seek clarification through
additional evidence and analysis. The analysis process should start at the very
beginning of the investigation and continue throughout.
Develop a sequence of events diagram
• Using the evidence collected in witness interviews, from
recordings, VDR records and other sources, develop a complete timeline of the
events that were associated with the accident.
• Identify the sequence of events that led to the casualty
event(s):
• Determine all happenings or action steps:
• Portray events in a logical flow indicating ‘what’ happened:
• Identify all events against a single time base
Constructing the event chart
• Constructing the Event and Contributing factors Chart should
begin immediately at the start of the investigation. However, the initial chart
will be only a skeleton of the final product. Many facts and conditions will be
discovered in a short amount of time, and therefore, the chart should be
updated frequently throughout the investigative data collection phase. Keeping
the chart up to date helps ensure that the investigation proceeds smoothly,
that gaps in information are identified, and that the investigators have a
clear representation of accident chronology for use in evidence collection and
witness interviewing.
Identify casualty and accident events
• Firstly identify and clearly depict the Casualty Events,
bearing in mind that there may be more than one. For instance Mechanical
Failure, leads to Grounding, leads to Pollution.
• Then identify all the Accident Events in the
sequence. To determine which events can be deemed Accident Events an
investigator should consider every event in turn asking the questions:
• 1. Is this event significant in the sequence of events that led
to the casualty?
• 2. Does this event concur with what would have been expected on
a well-run ship given the particular circumstances at the time?
• If the answer to question 1 is ‘Yes’ and the answer to question
2 is ‘No’ then the event should be designated as an Accident
Event. If the answer to either question is not as indicated above the
event should be passed over and the next event in the sequence considered.
• When this process has been completed the investigator will have
almost certainly identified several human errors, and possibly mechanical
failures and environmental events, which can be considered as Accident
Events and which should form the basis for the ongoing analysis
Analyse the accident events
• The next stage in the analysis process is to analyse each Accident
Event in turn considering in detail the questions ‘How?’ and especially
‘Why?’ the event occurred.
• This process will firstly uncover the mechanisms and error types
which best describe the Human Errors and Technical
Failures and then, by continuing to ask ‘Why?’ these features existed
on board the ship conditions which are Contributory factors concerning
the Operation of the vessel will be uncovered .
• More than one contributory factor might be uncovered for
each Accident Event or Accident Event Mechanism at
this level and some Contributing.
• The SHEL Model in the back of the mind when considering these
questions might help to ensure that all the main areas of human elements are
considered (Software, Hardware, Environment and
Liveware)
The SHEL Model
• The SHEL Model, provides a simple means of breaking down the
various factors related to human elements.
• The SHEL Model consists of four components:
• ·Software - S
• ·Hardware - H
• ·Environment - E
• ·Liveware - L
• The model is commonly depicted as seen in the diagram.1 It
highlights not only the elements themselves but also the relationship between
the key human component (Central Liveware) and the other components. The
diagram attempts to highlight that the matches or mismatches of the interfaces
are just as important as the components themselves, and are therefore just as
important to investigate as the factors themselves
Analyse the accident events (contd)
• The process should be continued further by asking again ‘Why?’
each of the Operational Contributory factors existed at that
time. The results of this questioning might uncover more Operational
factors and Shore Management and Organizational Contributory
factors
• Once again, the process may highlight gaps in the evidence or
understanding of the case and/or the factors uncovered might be presumptive. In
either case more investigation is likely to be needed.
• This process can be likened to the questioning of a young child
who is apparently never satisfied by the answer that it is given. Likewise the
investigator must continue asking ‘Why?’ until he is satisfied that
investigating that particular Accident Event further would
serve no practical purpose.
• Taking this process to five levels (5 ‘Whys’) will
certainly fulfil the objective of the operation.
Where to stop
• How far back into the system does an investigation need to go -
that is, what is ‘where to stop’? This depends on many factors, such as the
severity of the occurrence and the resources available.
• If the investigation is:
• ·Still identifying safety issues that are significant and could
practicably be addressed, then the investigation should continue.
• ·Focusing on factors that no organisation could reasonably be
expected to address then the investigation should be finalised.
• However, even when the investigation has reached this ‘stop’
point, it can be useful to try to explain why the highest level safety issue(s)
occurred - not for the purpose of identifying additional safety issues, but to
provide information on the context in which the issues occurred.
Root Cause
• A root cause is an initiating cause
of either a condition or a causal chain that leads to an outcome.
• There are several useful methods for identifying root
causes. One method for identifying root causes is to
construct a root cause tree. Start with the
problem and brainstorm causal factors for that problem by asking why. Connect
them in a logical cause and effect order until arriving at
the root of the problem.
• 5 Whys is an iterative interrogative technique
used to explore the cause-and-effect relationships underlying a
particular problem. The primary goal of the technique is to determine the root
cause of a defect or problem by repeating the question
"Why?". ... Not all problems have a single root cause.
• The 5 Whys is a technique used in the Analyze
phase by repeatedly asking the question “Why” (five is a good rule
of thumb), you can peel away the layers of symptoms which can lead to the root
cause of a problem.
Finding the root cause
Finding the root case is like peeling an onion, every layer has
another layer below it till you reach the core.
Cause(s) of accident
• An immediate cause is the direct, obvious cause of
the incident, usually as an unsafe act or condition, such as not wearing PPE.
The root or underlying cause is the events or
condition that allowed the immediate cause to develop, such as
poor company culture and management controls.
• Cause elements can be grouped into the following
categories:
• human elements/personnel error.
• malfunction or failure of structures, engines, or other systems.
• deficient maintenance.
• hazardous environment involving weather, fog, etc.
• any combination of the above.
Session 4
Putting together scattered information
Exercise
…………………………..
………………………….
Concurrently with the tank cleaning, the Chief Engineer performed
a welding operation on the ventilation duct of one of the cargo tanks. The
welding caused ignition of the cargo vapours in the ventilation duct, which
caused an explosion in the cargo tank. Three crew members working in the
vicinity suffered injuries, including the Chief Engineer. The Chief Engineer
succumbed to his injuries as a result of the explosion.
Exercise solution
• A 700 GT chemical tanker had discharged a cargo of base oil at
the Bandar Abbas port oil terminal. En route to the next port, the vessel was
performing tank cleaning operations. Prior to tank cleaning, there was no
flushing of cargo tanks and pumps carried out by the crew.
• Concurrently with the tank cleaning, the Chief Engineer
performed a welding operation on the ventilation duct of one of the cargo
tanks. The welding caused ignition of the cargo vapours in the ventilation
duct, which caused an explosion in the cargo tank. Three crew members working
in the vicinity suffered injuries, including the Chief Engineer. The Chief
Engineer succumbed to his injuries as a result of the explosion.
Session 5
HUMAN ELEMENT INVESTIGATION
Human element
• Human elements form an integral part of virtually every
investigation, and it is essential to develop an understanding of systemic
technical, contextual and social parameters that influence human information
processing and decision making within virtually every aspect of ship design,
operation, management and regulation.
• The IMO defines human (people) elements as information related
to ability, skill, knowledge, personality, physical condition, behaviour and
attitude and its interaction with the assigned duties, organization on board,
working and living conditions, ship elements, shore-side management, and
external influences and environment.
• Human elements, which contribute to marine casualties and
Objective of the HE investigation
• ·Discovering how mismatches between system requirements and
human capacity could have caused or contributed to the occurrence.
• ·Identifying safety hazard (engineering, administration and
personal protection) mitigation strategies that result in conditions that are
likely to exceed human operational capacity,
• ·Making recommendations to eliminate or reduce the severity or
likelihood of consequences resulting from mismatches between system operating
requirements and human physiological, perceptual or cognitive abilities.
Scope of HE
• HE investigation should extend beyond the examination of the
actions of front-line operators such as masters, pilots, ships’ officers,
ratings, and maintainers, etc. to include an analysis of any individual or
group involved in the occurrence, be it management, the regulator, or the
manufacturer.
• The success of the human factors investigation depends largely
on the type and quality of the information collected. As no two occurrences are
the same, the investigator will need to determine the type and quality of data
to be collected and reviewed. As a rule, the investigator should be over
inclusive in gathering information initially and set aside superfluous data as
the investigation unfolds.
HE to be covered
Factors influencing human performance
Classification of human error
• Action, such as too early or too late, too little or too much,
too fast or too slow
• Observation, such as overlook, false recognition
• Planning/Intention, such as inadequate plan, incomplete plan,
priority
• Interpretation, such as wrong diagnosis, deduction error,
incorrect prediction
Investigating for fatigue
• Sleep and fatigue: human performance can be degraded by sleep
loss and sleepiness, including physical, psychomotor, and mental performance;
mood can be affected, and attitudes can change.
• Fatigue has its basis in the combined interaction of the
circadian rhythm in alertness/sleepiness and the effects of inadequate sleep.
• Alertness enables us to make conscious decisions and our level
of alertness determines how well we perform our job.
• Whenever alertness is affected by fatigue, human performance can
be significantly impaired.
• Alertness dramatically changes with time.
• Alertness cycles closely follow the body temperature cycle with
peak alertness occurring when the body temperature is the highest (near midday)
and low alertness occurring when the body temperature is lowest (between 3:00
and 5:00 am).
• Cool, dry air can increase alertness while heat can bring on the
desire for sleep.
• Alertness is also influenced by music and aroma
Biological clock
• Our biological clock regulates the daily cycle of activity and
inactivity
• In normal conditions, the sleep/wake cycle follows a
24-hour rhythm with approximately ⅓ of this time spent sleeping.
• The cycle isn’t the same for everybody as the main peak of
alertness can occur earlier or later in the day. Although individual rhythms
vary, everybody’s cycle has two distinct peaks and dips.
• Big dips between 3.00 and 5.00 am/pm and peaks immediately
before that
• Sleeping is difficult during peaks
Sleep architecture
• Night sleep architecture consist of light, deep and REM sleep episode
• Every 90 minutes sleep cycle has stage 1,2,3,4,and REM
• Quantity of sleep about 7.5 to 8 hours. Sleep
requirement do not change with age, sleep patterns do change with age.
• Younger people can easily adjust to irregular schedule
• Quality of sleep, recuperative sleep requires 4 to 5
uninterrupted sleep cycles.
• Sleep disorders/disturbances may be because of
breathing, obstruction in the airway or damage to part of the
brain that controls respiration. It is often associated with obesity.
• There are wide differences between individuals in their ability
to tolerate sleep disturbances.
• Irregular schedule: The circadian clock is perfectly
synchronized to the traditional pattern of daytime wakefulness and night-time
sleep.
• Irregular schedules, which include rotation of shifts within a
time zone and those which require time zone crossings, play havoc with that
synchronization.
• The main problem with shift work is that it desynchronizes the
body rhythms.
Effects of fatigue on performance
• When a person is suffering from fatigue, his or her performance
on the job will be affected.
• The most extreme form of fatigue is uncontrollable sleep, i.e.
falling asleep against the will of the individual.
• Fatigue affects the ability to judge distance, speed, and time.
• Fatigue can lead to forgetting or ignoring normal checks or
procedure
• Fatigue can result in reduced motivation to perform well.
Fatigue investigation checklists
• Fatigue should be considered an underlying factor in virtually
all occurrences. The following four questions provide guidance as to the
initial assessment of fatigue as a contributing factor to an occurrence:
• 1. At what time of day did the occurrence take place?
• 2. Was the operator’s normal circadian rhythm disrupted?
• 3. How many hours had it been since awakening?
• 4. Does the 72-hour sleep history suggest a sleep debt?
• If the answer to any of the above questions indicates a problem,
then fatigue should be investigated in depth.
• To establish fatigue as a contributing factor, it must be
demonstrated both that:
• 1. The person or crew was in a fatigued state; and
• 2. The unsafe act or decision is consistent with the type of
behavior expected of a fatigued person or crew .
Session 6
INTERVIEW
Interview as a tool
• Investigative interviewing is one of the key means of gathering
evidence in support of a successful accident investigation. The ability to
conduct effective interviews with a variety of different witness types is one
of the core skills of an accident investigator.
• To conduct an effective interview preparation and planning is
the key.
• Interview outcome may be misleading if not conducted properly
• Sequencing the interview with other events is important
Interviews
• Experienced personnel should conduct interviews
• If possible the team assigned to this task should include an
individual with a legal background
• After interviewing all witnesses, the team should analyze each
witness' statement
Witness Interviews
• DO
• Separate Witnesses
• Written Statements
• Open ended questions
• Provide Diagrams
• Encourage Details
• Show Concern
• Record w/permission DON’T
Don’t
• Suggest Answers
• Interrogate
• Focus on Blame
• Dismiss Details
• Bar Emotions
• Make Judgments
Conduct of Interview
• In Conducting Investigation Interviews
• Keep an Open Mind. ...
• Ask Open-Ended Questions. ...
• Start With the Easy Questions. ...
• Keep Your Opinions to Yourself. ...
• Focus on the Facts. ...
• Find Out About Other Witnesses or Evidence. ...
• Ask About Contradictions. ...
• Keep It Confidential.
Before the Interview
• Put the person at ease
• People may be reluctant to discuss the incident,
particularly if they think someone will get in trouble
• Reassure them that this is a fact-finding process only
• Remind them that these facts will be used to prevent a
recurrence of the incident
During Interviews
• Take Notes!
• Ask open-ended questions
• “What did you see?”
• “What happened?”
• Do not make suggestions
• If the person is stumbling over a word or concept, do not help
them out
Ask All Witnesses
• Name, address, phone number
• What did you see?
• What did you hear?
• Where were you standing/sitting?
• What do you think caused the accident?
• Was there anything different today?
Interview proven techniques
• Interview witnesses individually. ...
• Always try to interview where the incident took
place. ...
• Do not play the blame game. ...
• Be a good listener. ...
• Attain pertinent details. ...
• Take notes Be thorough. ...
• Be compassionate. ...
• Use the interview as an opportunity to improve.
The interview
The opening of the interview should reassure the interviewee
about:
• 1. The purpose of the interview (safety investigation);
• 2. Interviewee’s rights;
• 3. Your role as the interviewer;
• 4. The procedures to be followed. Establish a rapport with the
interviewee at the outset, and:
• 1. Be polite;
• 2. Behave in a natural manner; do not make the interview seem
artificial;
• 3. Keep interruptions to a minimum;
• 4. Strive for an atmosphere of friendly conversation;
• 5. Intervene only enough to steer the conversation in the
desired direction;
• 6. Display a sincere interest;
• 7. Frequently summarise the information being given (this
indicates an interest and avoids later misunderstandings).
Interviews
• Analyze this information along with data from the accident
site
• Not all people react in the same manner to a particular
stimulus
• A witness who has had a traumatic experience may not be
able to recall the details of the accident
• A witness who has a vested interest in the results of the
investigation may offer biased testimony
Interview Victims & Witnesses
• Interview as soon as possible after the incident
• Do not interrupt medical care to interview
• Interview each person separately
• Do not allow witnesses to confer prior to interview
Interview questions
• Don’t ask leading questions
• Bad: “Why was the forklift operator driving recklessly?”
• Good: “How was the forklift operator driving?”
• If the witness begins to offer reasons, excuses, or explanations,
politely decline that knowledge and remind them to stick with the facts
Interview questions
• Use closed-ended questions later to gain more detail
• After the person has provided their explanation, these type
of questions can be used to clarify
• “Where were you standing?”
• “What time did it happen?”
Interview summary
• Summarize what you have been told
• Correct misunderstandings of the events between you and the
witness
• Ask the witness/victim for recommendations to prevent
recurrence
• These people will often have the best solutions to the
problem
Interview ending
• Get a written, signed statement from the witness if
possible;
• It is best if the witness writes their own statement;
• interview notes signed by the witness may be used if the
witness refuses to write a statement;
• A recorded verbal statement is preferable to written
statement
• Most people can not write in details as they can say
verbally
Cognitive interviewing
• Cognitive interviewing is a particular interviewing technique.
Its general aim is to help the recall of an interviewee. The key to cognitive
interviewing is letting the interviewee do the talking.
• The first technique very simply focuses on asking the
interviewee to tell the interviewer everything they can remember about the
incident, not leaving anything out and not editing anything. This is often
referred to as the free recall. The key to this approach is emphasising at the
start the importance of just recalling everything and to tell the interviewee
to take their time.
• The next technique, which builds on the first, is context
reinstatement. This gets the interviewee to think back in their mind’s eye to
the environment in which they witnessed the casualty event, by encouraging the
interviewee to close their eyes The interviewer should then, with short
statements and questions, encourage the interviewee to picture the scene.
Cognitive interviewing
• Another technique is the reverse order recall method. This
method requires pursuing with the
interviewee the course of events by taking the last thing
remembered or the most memorable aspect and working backwards and forwards in
time. When an interviewee wants to lie he will tend to rehearse the lie in
chronological order and, therefore, recalling the false events in reverse is
difficult and hopefully easy to spot.
• Applying cognitive interviewing techniques will not be appropriate
in many of the interview scenarios encountered in a marine safety investigation
when, for example, interviewing shipping managers and owners who were not at
the scene of an accident.
• Applying the cognitive interviewing technique fully requires the
recollection of the chain of events three times or more in order to gain
greater detail. This amount of time will not always be available to the
investigator but it is important to use the full technique when specific events
are critical to the investigation.
Audio recording
• The investigator should consider the use of audio recording when
interviewing. The use of the audio recorder can save the investigator time and
effort, and in the ideal situation he should record his questions and the
answers, and any other information the interviewee gives him. Audio recordings
can be used as the investigator’s notes from which the key points can be drawn.
Where required, the bullet points of the interview can then be written on to a
suitable form and signed by the witness.
• Before the interview starts the investigator should introduce
the recording in the following way:
• ·Name of ship to or on which the accident occurred; ·Date of the
accident; ·File reference number (if known); ·Date and time of the interview;
·Place of the interview; ·Names of the investigator(s); · Name of the
interviewee, together with rank, rating or job title; · Name of anyone else
present.
• The investigator should also verbally record the time when the
interview concludes.
Verification of contradicting or confusing information
• Try to find minute details of the information
• Cross check with other source
• Assess the possibilities of the sequence of facts
• Where possible verify physically
topics of interview
• Any definition of enclosed/confined spaces held on board ship?
• What procedures are in place, e.g. space entry, ventilation of
space, atmosphere monitoring?
• What equipment is held on board (atmosphere meters, BA,
extraction equipment) and was it maintained properly?
• Records and crew experience of drills on enclosed space rescue.
• If possible obtain independent measurement of atmosphere before
ventilation after the accident.
• Do not enter enclosed space until certified safe.
• Check boundaries and penetrations of compartment for source of
contamination.
• Check validity of the procedures in place.
• Establish familiarity of crew with the procedures.
• Establish the maintenance history of relevant equipment on
board.
• Consider whether cargo handling or other work on board had an
influence.
• Consider whether weather and sea conditions were influential.
Session 7
Exercise on verification of conflicting
information
Banga Biraj collision confusing facts
• On 21 September 2003 a collision between the Bangladesh flag
carrier Banga Biraj (outbound) and the Panamanian flagship Eagle Strength
(inbound) in the channel near cement clinker jetty caused extensive damage to
18 navy ships and navy installations.
• During the investigation the master of Banga Biraj gave a
statement that before the collision he gave helm order hard starboard and then
again to hard port.
• To verify his statement the historical GPS position and the
course recorder data were obtained. The course recorder data supported the
master’s statement but the GPS data showed the opposite that is the vessel went
to port.
• In depth analysis was carried out to resolve the confusion.
Exercise
• Participants are required to analyze the Master’s statement and
the Course recorder and GPS data to resolve the confusion. informational
regarding the accident will be provided as required.
Description:
BANGA BIRAJ
YOB:1982,Hamburg,
GT:8350, DWT:11804, LOA:133.3 m , Breadth:20,20 m, Draught:8.648
m, Speed:16 kn
Session 8
Exercise
Interview topic
Exercise
• An inland tanker capacity 1200 DWT built in Japan carrying a
cargo of condensate from Bahirab to Chittagong completed discharging at Jamuna
oil terminal in Chittagong port.
• The vessel completed discharging at 1700 hrs on 12th August 2004
• At 1830 hrs three persons went down to the pump room for
shutting down the main switch of the cargo pump.
• At 1845 there was a big explosion and the entire pump caught
which lasted for 2 minutes and extinguished by itself.
• All three men suffered third degree burn and died in the
hospital after 7 days.
• Vessel details LOA 72m, Breadth 11.5 m maximum draft 4.1m Built
in 1971
• Both Master and Ch.Engineer holding Inland class 1 certificate
As a member of the investigating team make a list of topics for interview
Fire and explosion topics of interview
• Outfit of firefighting systems and appliances, fire plan.
• Firefighting appliances and systems properly serviced and
maintained (PMS records, safety record book, certification etc.).
• Structural fire protection, e.g. insulation, fire doors,
dampers, cable glands.
• Containment used, use of fire doors and hatches, boundary
cooling.
• Sprinklers and gas drenching systems used.
• Instructions posted for fixed firefighting systems.
• Portable fire appliances used, e.g. fire hoses and
extinguishers.
• Emergency fire pump use.
• Fire detection system, units activated, alarms
given/noticed.
• Organization and procedures for fire emergency control.
Ø Fire drills practised and logged.
Ø Seat of fire, source of ignition, material initially ignited.
Ø Spread of fire and smoke; was flashover involved?
Ø Means of escape.
Ø General alarm sounded, crew mustering, broadcast on P/A system.
Ø Deployment of fire parties.
Ø Fire dampers and fuel quick closing valves, shut down
arrangements for fans and fuel pumps.
Ø Shore side fire brigade involvement.
Ø Hot work involved, permit to work procedure followed.
Ø Dangerous goods involved.
Ø Stability considerations with respect to firefighting water's
free surface
Ø PMS/maintenance records of tests (QCVs, fixed systems, other
equipment, etc.).
Session 9
Case study of a launch accident
A scenario of an accident
• A small passenger launch was on the way from Dhaka to Zazira on
2nd January 2002. Another large passenger launch was on the way
from Barisal to Dhaka on the same date. At about 0210 hours on 3rd January
both ship collided causing the smaller ship to capsize with heavy loss of life.
• An accident investigation committee is to investigate the
accident in order to find:-
• The cause(s) of the accident
• The contributing factors
Session 10
Exercise
Contributing factor to an accident
Scenario of an accident
• A seafarer went on shore leave to visit one of his friend who
had called him from another ship that berthed about 2 kilometers away. He
planned to take a taxicab from outside the gate. He walked from the ship to
gate. While waiting for a taxicab he found his wallet is missing, not sure if
it has been pick pocketed or lost otherwise, he thought for a while whether to
go back to the ship or not but then decided to walk for two kilometer and visit
his friend.
• He was walking on the foot walk beside a highway which had
incomplete railing on the side. The walk way railing construction had been
suspended a week earlier due to non payment of contractor's running bill by the
city corporation.
• As he was walking along the foot walk thinking about his wallet, he stepped on a banana peel, thrown by another pedestrian, he slipped, tipped over and fell on the highway. A speeding truck ran over him leaving him dead on the spot
Session 11
Investigation Report
Report writing
• Writing of the report is the most important part of the
investigation, often requiring several revisions. Report quality is crucial,
because the final report is the official record of the investigation and the
whole effort is lost if the final report does not reveal a clear set of facts,
supporting evidence and firm conclusions supported by the facts and evidence.
To produce a good quality report:-
• Develop a report outline as soon as possible
• Begin drafting the accident chronology, background information
and facts as soon as possible.
• Continuously review the progress to identify where sections
should be added or amalgamated.
• Follow the CI Code section 2.12 for contents of the report
• The main sections to be included in any report should be Title page, Preamble page, Factual information, Analysis, Conclusion, Recommended safety actions, Appendices
Factual information and analysis
• The factual information section should the chronological
description of what happened include all significant facts relevant to aspects
of voyage planning, crew competence and experience, findings from autopsies and
engineering reports, observations by witnesses and information from data
loggers, voyage data recorders, radio recordings and transcripts. Safety
related activities which took place before the accident, Safety deficiencies
discovered during the investigation Human factors information is an integral
part of the investigation.
• The analysis section is the bridge between the factual information and the conclusions. Analysis should include a logical identification of the key events in the chain of events that led to the accident and a description of the arguments considered in analysing why and how those events occurred. Clarify what is not known and could not be determined and describe both controversial and contradictory evidence. Analysis should also include that the underlying reasons for the accident cannot be determined with certainty, if that is the case.
Conclusion and recommendation & appendix
• Conclusions are to be based on interpretation and assessment of
scientific evidence. Therefore, to ensure these are not taken out of context,
or misinterpreted, the source for the conclusions should be clearly identified,
and the conclusions should be quoted verbatim, if at all possible.
• Recommendations need not be confined to the contributing factors
to the accident, but they should be related to matters covered in the
investigation; they must be practicable, and they must be reasonable. They must
be clearly derived from the analysis section of the report.
• Recommended safety actions in whatever form should clearly
identify what needs to be done, who or what organisation is to implement the
change, and where possible, the urgency for completion.
• An appendix may contain information relevant to the investigation, such as, regulations or extracts from codes, copies of ship certificates, expert reports etc. Any non-confidential documentation, including photographs, charts, drawings etc. should be incorporated in to the actual report or as appendices.
Submission of investigation reports to IMO
• A marine safety investigation Authority is required to conduct
marine safety investigations in accordance with SOLAS regulation XI-1/6, as
supplemented by the provisions of the Casualty Investigation Code.
• Chapter 14 of the Casualty Investigation Code requires the
marine safety investigating State to submit the final version of a marine
safety investigation report to the Organization for every marine safety investigation
conducted into a very serious marine casualty, or for any other marine casualty
or marine incident where a resulting marine safety investigation report
contains information which may prevent or lessen the seriousness of marine
casualties or marine incidents in the future.
• Additionally, the marine safety investigating State should populate the GISIS marine casualties and incidents module in accordance with the revised harmonised reporting procedures set out in MSCMEPC. 3/Circ.4/Rev.1.
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