Marine Incident Investigation

Course
Module 01
 Module 01
Learning objectives
1. Why conduct a marine incident investigation?
2. What can we learn from a marine incident investigation?
Why incident investigation ?

Group discussion
 Objectives of a marine incident investigation
• Incident investigation is a ‘reactive’
approach, aimed at learning from
incidents.
• Incident investigation is about
identifying controls/barriers/defenses
which:
− have either failed and require
improvement
− are missing and require
implementation
MV Wakashio hit a coral reef off the Indian Ocean island of Mauritius
on July 25, 2020

It is essentially the identification of

system failures!
Video: Contrasting views of the
South Korea ferry accident
 How and why to investigate?

How Why
• Describe (understand) what happened • Learn from experience
• Evaluate loss potential • Comply to rules and regulation
• Understand sequence of events • Continual improvement of safety
• Identify contributing conditions • Demonstrate management commitment on safety
• Identify causes • Propose effective corrective and preventive actions
and to avoid recurrence

? ?
Obligations to carry out maritime casualty
investigations
Rules and regulations

Covered in
Module 02
 Legal developments –
driven by accidents
Examples include:

AMOCO HERALD OF FREE COSTA

TITANIC PRESTIGE
CADIZ ENTERPRISE CONCORDIA

SOLAS 1914 MARPOL, ISM - Code MARPOL Oil SOLAS

SOLAS Tanker 74/III
Protocol 78 Double Hull
 Trends in accident causes (a)

Source: Lloyds List Intelligence – Maritime Safety 2020 - 2021

 Trends in accident causes (b)

Source: Lloyds List Intelligence – Maritime Safety 2020 - 2021

 Trends in accident causes (c)

The main causality of events between 2014 and 2019 is “Loss of control – Loss of propulsion power”.
It is the only accident/incident type that has seen a continuous increase from 2014, until 2020 where it saw a
12.6% decrease.

Source: EMSA – Annual Overview of Marine Causalities and Incidents 2021

 Learning from Incidents
GISIS database
Global Integrated Shipping Information System:
[Link]
 What are Events & Conditions ?
Example:
Event:
Something that takes place, especially a
significant occurrence.
C3 Event x
synonym: occurrence.
Event 3 Source: The American Heritage® Dictionary of the English Language, 5th
Edition.
Event 2

Event 1 C2
Condition:
C1
something essential to the appearance or
Event 1: brick 1 falls Conditions C: occurrence of something else: PREREQUISITE
Event 2: brick 2 falls C1: Surface conditions
Event 3: brick 3 falls C2: Distance between bricks Source: Merriam Webster
Event X: last brick falls C2: Angle between bricks
 Further definitions
Causal factors
CI Code 2.2
A causal factor means actions, omissions, events or conditions, without which:
1. the marine casualty or marine incident would not have occurred; or
2. adverse consequences associated with the marine casualty or marine incident
would probably not have occurred or have been as serious; or
3. another action, omission, event or condition, associated with an outcome in 1
or 2, would probably not have occurred.
 Definitions – for our course
• There are no unique definitions / taxonomies
• Different Codes / Standards are using different definitions / taxonomies
• The following applies for our course:

Resulting in LOSS to An incident is

• People (injury/illness/fatality)
• Property (ship/cargo/facilities) an undesired No LOSS
• Environment (spillage/pollution)
event

ACCIDENT NEAR MISS

(casualty)
 Incident – definition by:
ISO 45001:2018 - 3.35:
Occurrence arising out of, or in the course of, work that could or does result in injury or ill health

CI Code - 2.10:
A marine incident means an event, or sequence of events, other than a marine casualty, which has
occurred directly in connection with the operations of a ship that endangered, or, if not corrected,
would endanger the safety of the ship, its occupants or any other person or the environment.

An event which could or does result in unintended harm or damage

 Accident - definition by:
ISO 45001:2018 - 3.35 / Note 1:
An incident, where injury or ill health occurs is sometimes referred an an „accident“.

CI Code - 2.9:
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.

An event which results in unintended harm or damage

 Near Miss - definition by:
MSC-MEPC.7/Circ.7 (Guidance on near Miss Reporting) – 2.1:
- A sequence of events and/or conditions that could have resulted in loss.
- This loss was prevented only by a fortuitous break in the chain of events and/or
conditions.
- The potential loss could be human injury, environmental damage, or negative business
impact (e.g., repair or replacement costs, scheduling delays, contract violations, loss of
reputation).

ISO 45001:2018 - 3.35 / Note 2:

- An incident where no injury or ill health occurs, but has the potential to do so, may be
referred as a ‘near miss’…
 Therefore we are using for our course:

Resulting in LOSS to
An incident is
• People (injury/illness/fatality)
• Property (ship/cargo/facilities) an undesired No LOSS
• Environment (spillage/pollution)
event

ACCIDENT NEAR MISS

(casualty)
 Accident ratio study

1 Fatality or Major Injuries

‘Expensive
Accidents 10 Minor Injuries learning’

30 Property Damage

Near
misses 600 No Injury or Damage
‘Free
learning’

Accident/incident causes remain the same!

 Incident Model

Degradation /
Routine Service Build up Period Critical Period Recovery

Event Event Event Event Event Event Event Event Incident Event Event
1 2 3 4 5 6 7 8 9 10

Latent Factors Preconditions for Active Failures

Unsafe Acts
 The ‘Swiss Cheese Model’

Some holes are due

to active failures

Other holes are due

to latent conditions
ISM-Code [Link]:
Assessment of all identified risks to its ship, personnel and the environment and to establish
appropriate safeguards
Video: James Reason
Swiss Cheese Model
 The Investigation Process

Initial Planning and Collecting Reporting/

Root-cause
reporting/ preparing Collecting and recommendations Follow-up
and cause
securing the for an evidence structuring to avoid and review
analysis
scene investigation data recurrence
 Group activity 01

Task:
Develop a Barrier Analysis (Swiss Cheese Model)

Case: Scandinavian Star

[Link]
End of Module 01
Any questions?