Accident Investigation

Accident Investigation
Incident Accident Investigation Vos obligations Pourquoi faire une investigation Ships in Service Training Material

Pourquoi faire une investigation
Le coût élevé des conséquences d’un incident L’ incident est un évènement imprévu, il peut être la cause de: - perte de vie et handicape, - souffrances, - arrêts de travail, - perte de revenus, - dommages à la propriété, - dommages à l’environnement, etc. Il est donc dans l’intérêt de l’entreprise de prendre les dispositions nécessaires pour que ces évènements indésirables ne se reproduisent plus. Ships in Service Training Material S. ISIK

Le coût élevé des conséquences d’un incident Ceci peut être fait efficacement en réalisant l’investigation de l’incident. Le coût des pertes humaines, matérielles et financières sera toujours plus élevé que le coût d’une investigation. Ships in Service Training Material S. ISIK

Pour rester compétitives le respect de ces règlements
Pourquoi faire une investigation C’est une exigence Les entreprises doivent se conformer aux exigences des conventions et règlements internationaux et nationaux. Les entreprises évoluent dans un environnement ou la compétitivité est internationale. Pour rester compétitives le respect de ces règlements est incontournable. Ships in Service Training Material S. ISIK

Prévenir que des incidents similaires puissent se reproduire dans
Pourquoi faire une investigation Le but de l’investigation 2000 98 78 84 82 80 90 88 86 96 94 92 4 3 5 2 1 Pertes par 1000 navires Prévenir que des incidents similaires puissent se reproduire dans le futur. Quoi? Pourquoi? Ships in Service Training Material A-M CHAUVEL

L’investigation devrait s’appuyer sur des faits : - Pas seulement pour être en conformité avec une exigence ou trouver un coupable. Il est important que toute personne concernées par un accident soit rassurée pour pouvoir décrire ce qu’il est arrivé sans penser à un blâme éventuel. Cela exige que les procédures de l’entreprise soient claires sur ce sujet: - Pourquoi une investigation est nécessaire - Comportement des enquêteurs pour réussir Une investigation devrait être considérée comme une opportunité pour apporter des améliorations. Ships in Service Training Material S. ISIK

Les causes d’un incident peuvent être divisées en trois niveaux: Causes directes – Elles arrivent juste avant l’incident. Indirect causes – Elle préparent l’incident et sont de ce fait les causes réelles de l’incident. Causes Racines – Elles sont les causes réelles de l’incident qui généralement sont liées à une défaillance du système de gestion de la sécurité. Ships in Service Training Material S. ISIK

Causes Racines Doivent être identifiées. Elles nécessitent une analyse séquentielle de l’incident. Causes directes et indirectes Sont plus faciles à identifier mais elles ne peuvent pas résoudre le mystère de l’incident. L’action corrective, basée ces causes, n’est pas une solution à long terme. Ships in Service Training Material S. ISIK

Les facteurs contribuant peuvent comprendre: Matériel Travail et taches Personne System de gestion Environnement Ships in Service Training Material A-M CHAUVEL

Accident La séquence des évènements concernés par l’incident peut présenter des interactions complexes. Incident Incident Personne Processus/ taches Matériels Environ- nement L’erreur humaine a besoin d’être clairement définie. Système de gestion de la Sécurité Ships in Service Training Material S. ISIK

Exemples de causes concernant l’erreur humaine - Stress Formation insuffisante Heures de travail Procédures non actualisées Design du système inadéquat (Trop ou pas assez de données) Charge de travail Changements d’équipage Equipage réduit , etc. Beaucoup d’incidents ont plutôt pour origine des comportements dangereux que des conditions de travail dangereuses Ships in Service Training Material S. ISIK

Une investigation est généralement conduite dans les situations suivantes: Avaries navires Blessés ou décédés L’investigation des situations dangereuses est une opportunité pour en identifier les causes avant qu’un incident plus sérieux puisse se produire. Ships in Service Training Material S. ISIK

10 blessés mineurs 30 dommages matériels
Théorie de l’iceberg 1 mort 10 blessés mineurs 30 dommages matériels 600 incidents. Ships in Service Training Material A-M CHAUVEL

L’entreprise à la responsabilité ultime de conduire l’investigation. L’investigation est généralement réalisée par l’officier de sécurité. Les participants à l’investigation devraient être préparés à cette activité, et recevoir la formation nécessaire. Ships in Service Training Material S. ISIK

Lorsque possible des membres de l’équipage devraient participer à l’investigation. Implication de l‘équipage - Apporter une expertise additionnelle. - Crédibiliser les résultats. - Former l’équipage aux dangers potentiels. - Sensibiliser l’équipage à l’engagement de l’entreprise pour la santé et la sécurité au travail. Ships in Service Training Material S. ISIK

Quand conduire l’investigation
- Le planning de l’investigation est très important. - Elle devrait débuter le plus tôt possible. - Il existe une relation entre sa date de réalisation et l’exactitude des informations recueillies. - L’interview juste après l’évènement donne une plus grande fiabilité aux témoignages. Ships in Service Training Material S. ISIK

Incident Accident Investigation Réglementation et Normes Ships in Service Training Material

Règlements et Standards
Deux (2) types d’investigations sont obligatoires : Investigation des accidents par l’autorité maritime. Investigation des accidents par l’entreprise. Cela inclus l’obligation de l’entreprise de déclarer les accidents, à bord de ses navires, à l’autorité maritime. Ships in Service Training Material A-M CHAUVEL

Regulations & Standards
International requirements The International Maritime Organization (IMO) addresses maritime casualties for safety at sea and pollution prevention under the following : - UN Convention on the Law of the Sea (UNCLOS) - IMO Conventions - IMO Assembly Resolutions - IMO MSC Circulars and Codes - International Labour Organization (ILO) Conventions Ships in Service Training Material S. ISIK

Flag state obligations
United Nations Convention on the Law of the Sea (UNCLOS) Article 94 – “Duties of the flag State” Para. 7 “Each State shall cause and enquiry to be held by or before a suitably qualified person or persons into every marine casualty or incident of navigation on the high seas involving a ship flying its flag and causing loss of life or serious injury to nationals of another State or serious damage to ships or installations of another State or to the marine environment. The flag State and the other State shall co-operate in the conduct of any inquiry held by that other State into any such marine casualty or incident of navigation.” Ships in Service Training Material S. ISIK

Safety of Life at Sea (SOLAS) – Ch1 Part C Casualties “(a) Each Administration undertakes to conduct an investigation of any casualty occurring to any of its ships subject to the provisions of the present Convention when it judges that such an investigation may assist in determining what changes in the present regulations might be desirable.” Ships in Service Training Material S. ISIK

Safety of Life at Sea (SOLAS) – Ch1 Part C Casualties “(b) Each Contracting Government undertakes to supply the Organization with pertinent information concerning the findings of such investigations. No reports or recommendations of the Organization based upon such information shall disclose the identity or nationality of the ships concerned or in any manner fix or imply responsibility upon any ship or person.” Ships in Service Training Material S. ISIK

International Load Line Convention ILLC (1966) – Article 23 Casualties “(a) Each Administration undertakes to conduct an investigation of any casualty occurring to ships for which it is responsible and which are subject to the provisions of the present Convention when it judges that such an investigation may assist in determining what changes in the Convention might be desirable.” Ships in Service Training Material S. ISIK

International Load Line Convention ILLC (1966) – Article 23 Casualties “(b) Each Contracting Government undertakes to supply the Organization with the pertinent information concerning the findings of such investigations. No reports or recommendations of the Organization based on such information shall disclose the identity or nationality of the ships concerned or in any manner fix or imply responsibility upon any ship or person.” Ships in Service Training Material S. ISIK

International Convention for the Prevention of Pollution from Ships - MARPOL 73/78 - Article 12 Casualties “ (1) Each Administration undertakes to conduct an investigation of any casualty occurring to any of its ships subject to the provisions of the regulations if such casualty has produced a major deleterious effect upon the marine environment” Ships in Service Training Material S. ISIK

International Convention for the Prevention of Pollution from Ships - MARPOL 73/78 - Article 12 Casualties “ (2) Each Party to the Convention undertakes to supply the Organization with information concerning the findings of such investigation, when it judges that such information may assist in determining what changes in the present Convention might be desirable.” Ships in Service Training Material S. ISIK

ILO Merchant Shipping (Minimum Standards) Convention, 1976 (No. 147) Article 2 (g) “to hold an official inquiry into any serious marine casualty involving ships registered in its territory, particularly those involving injury and / or loss of life, the final report of such inquiry normally to be made public” Ships in Service Training Material S. ISIK

ILO Prevention of Accidents (Seafarers) Convention, 1970 (No. 134) Article 2: 1 “The competent authority in each maritime country shall take the necessary measures to ensure that occupational accidents are adequately reported and investigated, and comprehensive statistics of such accidents kept and analyzed” Ships in Service Training Material S. ISIK

ILO Prevention of Accidents (Seafarers) Convention, 1970 (No. 134) Article 2: 2 “All occupational accidents shall be reported and statistics shall not be limited to fatalities or to accidents involving the ship” Ships in Service Training Material S. ISIK

ILO Prevention of Accidents (Seafarers) Convention, 1970 (No. 134) 3 “The statistics shall record the numbers, nature, causes and effects of occupational accidents, with a clear indication of the department on board ship - for instance : deck, engine or catering and of the area - for instance : at sea or in port where the accident occurred” Ships in Service Training Material S. ISIK

ILO Prevention of Accidents (Seafarers) Convention, 1970 (No. 134) 4 “The competent authority shall undertake an investigation into the causes and circumstances of occupational accidents resulting in loss of life or serious personal injury, and such other accidents as may be specified in national laws or regulations” Ships in Service Training Material S. ISIK

IMO “Code for the Investigation of Marine Casualties and Incidents” - Resolution A.849 (20) and amendment Resolution A.884(21) This is the most important Code for the flag state investigators. However it is a Resolution and therefore has no mandatory force in international law The amendment Resolution A.884(21) introduced Annex II to the Code as “Guidelines for the investigation of human factors in marine casualties and incidents” Ships in Service Training Material S. ISIK

IMO sub-committee on Flag State Implementation (FSI) This sub-committee has a Correspondence Group and a Working Group to analyse casualty reports from investigations Lessons learned extracted from the reports are sent to seafarers as experience feedback Ships in Service Training Material S. ISIK

incidents Obligations de l’entreprise
Ships in Service Training Material

Company obligations for reporting incidents
Republic of Panama requirements - Merchant Marine Circular No. 33 “By means of Resolution ALCN Panama has approved a set of rules which govern the investigation of marine casualties involving Panamanian flag vessels. - In accordance with said Resolution, owner/operators and Masters of Panamanian flag vessels shall notify ……, as soon as possible, the occurrence concerning any serious accident or casualty to or on board such vessels. Ships in Service Training Material S. ISIK

Republic of Panama requirements - Merchant Marine Circular No. 33 - Owners / Operators or person in charge of the vessel shall : - Retain any records of material pertaining to a voyage upon which a casualty requiring a report occurred. - Cooperate in the investigation of the marine casualty. - Provide, when called upon, witnesses in their employ, any relevant books, papers, documents and other records in their possession…. Ships in Service Training Material S. ISIK

United Kingdom requirements – The Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 “6. – (1) “When an accident occurs the following persons associated with the ship shall send a report to the Chief Inspector as soon as is practicable following the accident and by the quickest means available : The master or, if he has not survived, the senior surviving officer, and The ship’s owner, unless he has ascertained to his satisfaction that the master or senior surviving officer has reported the accident…” Ships in Service Training Material S. ISIK

ILO Code of Practice on Accident Prevention on Board Ship at Sea and in Port “Shipowners should report occupational accidents, diseases and dangerous occurrences to the competent authority in accordance with national laws and regulations. All accidents to seafarers resulting in loss of life or serious injury should be reported forthwith to the competent authority and an investigation of these accidents should be carried out. Ships in Service Training Material S. ISIK

ILO Code of Practice on Accident Prevention on Board Ship at Sea and in Port “Shipowners should report occupational accidents, diseases and dangerous occurrences to the competent authority in accordance with national laws and regulations. Other injuries resulting in incapacity from work for periods of time as may be specified in national laws or regulations, as well as prescribed occupational diseases, should be reported to the competent authority within such time and in such form as may be specified”. Ships in Service Training Material S. ISIK

ISM Code The recognition that most accidents at sea are caused directly or indirectly by human factors has led to the introduction of SOLAS Ch IX and the “International Safety Management (ISM) Code” for the “Safe Operation of Ships and for Pollution Prevention”. Ships in Service Training Material S. ISIK

ISM Code The Code originates from late 1980s “…when there was mounting concern about poor management standards in shipping. Investigations into accidents revealed major errors on the part of management…” Ships in Service Training Material S. ISIK

ISM Code - This was a significant move as it is addressing “management by objectives”, where companies cannot rely on prescriptive rules and regulations alone, they also need to have their own Safety Management Systems (SMS) in place - The objectives under the ISM Code must “provide for safe practices in ship operation and a safe working environment”, “establish safeguards against all identified risks” and “continuously improve safety management skills”. Ships in Service Training Material S. ISIK

ISM Code - The ISM Code forces companies to address some crucial areas such as risk management and apply these for continuous improvement Ships in Service Training Material S. ISIK

ISM Code : Section 9 states : Reports and analysis of non-conformities, accidents and hazardous occurrences 9.1 “The safety management system should include procedures ensuring that non-conformities, accidents and hazardous situations are reported to the Company, investigated and analyzed with the objective of improving safety and pollution prevention”. 9.2 “The Company should establish procedures for implementation of corrective action”. Ships in Service Training Material S. ISIK

ILO : Codes of Practice The International Labour Organisation has issued guidelines intended for safety and health of all seafarers serving on board all seagoing ships : “Code of Practice on Accident Prevention on Board Ship at Sea and in Port – 1997” Ships in Service Training Material S. ISIK

Flag Administrations Codes of Practice Some flag administrations have written Codes of Safe Working Practices. These documents give valuable guidance to companies in establishing safe working practices on board. The following are particularly interesting : Ships in Service Training Material S. ISIK

Flag Administrations Codes of Practice UK MCA “Code of Safe Working Practices for Merchant Seamen – 2005 ” Australian AMSA “Code of Safe Working Practice for Australian Seafarers -1999” Ships in Service Training Material S. ISIK

Australian AMSA Code of Safe Working Practice for Australian Seafarers 3.1.1 The principal purpose of accident investigation, reporting and analysis is to minimise the potential for a recurrence of such accidents. 3.1.2 The cause or causes of any accident or dangerous occurrence should be investigated. Ships in Service Training Material S. ISIK

Australian AMSA Code of Safe Working Practice for Australian Seafarers 3.1.3 A full report of the investigation should be made to the health and safety committee and the shipowner. Accidents and dangerous occurrences must also be reported to AMSA… with the relevant provisions of the Occupational Health and Safety (Maritime Industry) Act and the Navigation Act 1912. Ships in Service Training Material S. ISIK

Australian AMSA Code of Safe Working Practice for Australian Seafarers 3.1.4 Reports of accidents and dangerous occurrences should be discussed at health and safety committee meetings on board ship and steps should be taken to minimise the possibility of recurrences. The shipowner’s shore management should consider the reports and, if necessary, amend the company’s health and safety policy to take account of the conclusions of the investigation”. Ships in Service Training Material S. ISIK

Tanker Management and Self Assessment (TMSA)
- These guidelines have been prepared by The Oil Companies International Marine Forum (OCIMF). - It was prepared from the recognition that the ISM Code requirements may only be fulfilled to the minimum by some companies. - Therefore a need arises to give best practice guidance to those companies that genuinely wish to achieve high ship management standards and continuously improve. Ships in Service Training Material S. ISIK

- TMSA defines 12 key elements of management practice. - Element 8 of the guidelines is “Incident investigation and analysis” - The objective of Element 8 is to use effective investigation, reporting and follow-up methods to learn from significant near-misses and prevent recurrence. Ships in Service Training Material S. ISIK

- It is based on the principal that incidents and accidents are preventable. - If they do occur, they should be thoroughly investigated and measures taken to prevent recurrence - Required systems and procedures for this are given in the guidelines Ships in Service Training Material S. ISIK

Voluntary reporting schemes for incidents
There are a number of schemes whereby anyone can report an incident, including near-misses, on a confidential basis. These schemes are either initiated by voluntary organisations or by governments. Below are some examples: - The Nautical Institute’s Marine Accidents Reporting Scheme (MARS). - Australian Confidential Marine Reporting Scheme (CMRS). - CHIRP – funded by the UK Department for Transport. Ships in Service Training Material S. ISIK

MARS International Marine Accident Reporting Scheme by the Nautical Institute This is a confidential reporting system for reporting of Accidents (and Near-Misses) without fear of litigation. Aim is to learn lessons by free flow of information and avoid similar accidents. Ships in Service Training Material S. ISIK

CHIRP Is a charity to carry out research on causes of incidents on aviation and maritime transportation Uses confidential reporting system for collection of Human Factors safety related issues, analyses data and identify trends, and advises interested bodies with the aim of preservation of human life Ships in Service Training Material S. ISIK

Incident Accident Investigation Procédures de l’entreprise Ships in Service Training Material

Procédures de l’entreprise
Les procédures d’analyse et d’investigation des accidents devraient faire partie du système de gestion de la sécurité ( SMS ) pour être en conformité avec la section 9.1 du code ISM Système de gestion de la sécurité Ships in Service Training Material S. ISIK

Procédures de l’entreprise
Code ISM Section 9.1 « Le système de gestion de la sécurité devrait prévoir des procédures garantissant que les irrégularités, les accidents et les incidents potentiellement dangereux sont signalés à la compagnie et qu’ils font l’objet d’une enquête et d’une analyse, l’objectif étant de renforcer la sécurité et la prévention de la pollution.” Ships in Service Training Material S. ISIK

Company Procedures - Each company’s SMS is different depending
on the company structure and operations. - Specific safety issues apply to different ship types and national / international regulations have to be taken into consideration. - Incident investigation and analysis procedures in the SMS therefore needs to be specific for the company, respecting applicable regulations and standards. - The procedures should cover both safety and environmental incidents. Ships in Service Training Material S. ISIK

Company Procedures The incidents can be divided into:
- Occupational incidents - Injuries and deaths - Ship incidents - Ship damages - Environmental damages There should be more detailed classification of incidents in the procedures. TMSA guidelines require this to be in line with the OCIMF marine injury reporting guidelines. Ships in Service Training Material S. ISIK

Company Procedures The procedures should also define which severity of near-misses are to be included in the investigations. Company procedures need to describe how incidents and near-misses are : - reported - investigated - analysed and - documented Ships in Service Training Material S. ISIK

Company Procedures The terminology used in accident investigation
and analysis can be defined by the company as seen fit. However it is better to have consistency with terminology used by the organisations such as the IMO, ILO, flag states and non-governmental organisations such as the OCIMF (for oil tankers) and International Association of Classification Societies (IACS). Ships in Service Training Material S. ISIK

Company Procedures Assignment of a Safety Officer
Normally for occupational incidents a Safety Officer is assigned on board to carry out the overall management duties on health and safety. Also a Safety Committee is formed. Some flag states have specific requirements for : - assignment of safety officers and - safety committees. Ships in Service Training Material S. ISIK

Company Procedures Duty of a Safety Officer ( UK )
The following slides are extracts from the UK “Statutory Instrument 1997 No. 2962 The Merchant Shipping and Fishing Vessels (Health and Safety at Work) Regulations 1997” describing the duties of safety officers and safety committees. Such duties should be clearly defined in the procedures however. Ships in Service Training Material S. ISIK

“(a) improve the standard of safety consciousness among the crew and ensure that … rules and guidance for the ship relating to health and safety are complied with ; Ships in Service Training Material S. ISIK

(b) investigate, so far as is reasonably practicable, (i) every accident involving death, major or serious injury and every dangerous occurrence as defined in…Regulations, (ii) all potential hazards to health and safety, and (iii) all reasonable complaints by workers about health and safety, and making recommendations to the master to prevent the recurrence of such an accident or to remove any hazard, provided that the duty to investigate shall not extend to accidents arising from a casualty to the ship. Ships in Service Training Material S. ISIK

(c) ensure that health and safety inspections of each accessible part of the ship are carried out at least once every three months… (d) make representations and, where appropriate, recommendations to the master, about any deficiency in the ship… and also suggest whether those representations and recommendations should be passed by the master on to the employer… Ships in Service Training Material S. ISIK

(e) maintain a record of every accident involving death, major or serious injury and every dangerous occurrence, and make it available on request to : - any elected representative, - the master and - any person duly authorized by the Secretary of State. Ships in Service Training Material S. ISIK

(f) stop any work which…may cause a serious accident, and immediately inform the master or the master's deputy who shall decide when work can safety be resumed. (2) Nothing in this regulation shall require a safety officer to take any action at a time when emergency action to safeguard life or the ship is being taken.” Ships in Service Training Material S. ISIK

Company Procedures 18. Safety representatives and safety committees may : (a) participate…in any of the investigations or inspections carried out by the safety officer… or …undertake similar investigations or inspections themselves, whether or not such investigations or inspections have already been carried out by the safety officer. (b) make representations to the employer on potential hazards and dangerous occurrences at the workplace which affect, or could affect, workers on the ship. Ships in Service Training Material S. ISIK

Company Procedures 18. Safety representatives and safety committees may : (c) make representations to the master and the employer on general matters affecting the health and safety of workers on the ship… (d) request the safety officer to carry out any occupational health and safety inspection they consider necessary and to report the findings to them.” Ships in Service Training Material S. ISIK

Company Procedures Reporting of incidents
- All the crew and shore personnel should be aware that incidents on board the ships must be consistently reported. - Persons responsible for reporting the incident to the company should be clearly indicated. - There should also be clear definition of roles as to persons responsible for reporting incidents to flag states and local authorities as required and according to the severity of the incident. Ships in Service Training Material S. ISIK

Company Procedures Reporting of incidents
- Some flag states, under statutory regulations, give this role to the master of the vessel or company personnel ashore. - Accident reporting should be made on : Standard Company reporting form Flag State reporting form Ships in Service Training Material S. ISIK

Company Procedures Investigations of incidents
- Procedures should identify people on board and ashore that are authorised to carry out the investigations. - Normally Safety Officers are given the duty for conducting investigations on occupational accidents. In TMSA guidelines, at least two persons on board and two persons ashore are required to be available for investigations. Ships in Service Training Material S. ISIK

Company Procedures Investigations of incidents
- Procedures should outline : - the training requirements of the investigators, - their authority and knowledge needed for different categories of accidents. - Procedures should describe : - the investigation process and - the timing of investigations. Normally investigation should start immediately. Ships in Service Training Material S. ISIK

Company Procedures Analyzing the incidents
- Procedures should indicate that : - The aim of the investigation is to find the root causes, not only symptoms. It is not to blame persons for the incident. - The analysis must lead to corrective action to deal with the immediate situation and preventive action with the objective of preventing recurrence. - The reporting from must gives references to the SMS and regulations which have been breached - Alerts are sent on urgent safety issues to the company’s fleet. Ships in Service Training Material S. ISIK

Company Procedures Documentation of incidents
This should be in line with company procedures in the SMS in line with ISM Code Section 11 on documentation. - The duration for keeping records should be indicated. - This is sometimes defined in the regulations. Ships in Service Training Material S. ISIK

Company Procedures Documentation of incidents
- Documentation such as reports and statistics on incidents should be distributed within the companies fleet. - The procedures also should list the external bodies for sending reports from accidents and sharing lessons learnt. These can be flag states, classification societies, shipowner organisations etc. Ships in Service Training Material S. ISIK

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Accident Investigation

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