Marine Accident Investigation Course

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 2^nd January 2002. Another large passenger launch was on the way from Barisal to Dhaka on the same date. At about 0210 hours on 3^rd 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.