An Introduction to Marine Incident Investigation

Introduction and International Legislation

Introduction and International Legislation

About safety issues, risk management, and the history of ferry and ship losses. The how and why of different forms of investigations. And a closer look at relevant conventions and articles.

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Preparing and Interviewing

Preparing and Interviewing

What to prepare and have in mind during an investigation. About neutral justice and involved organizations. How to approach media. Practical information regarding conducting interviews, including different kinds of witnesses and situations.

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Elements of Casualties

Elements of Casualties

This chapter looks into what can be the cause of an accident – often a complex chain of events.

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Evidence, Analysis and Report

Evidence, Analysis and Report

How to handle evidence, both when collecting them and when it is time to analyze them. The course wraps up with what to have in mind while writing reports, and procedures for the finished product.

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An Introduction to Marine Incident Investigation

An Introduction to Marine Incident Investigation.mp3

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Shipping is one of the safest and most environmentally friendly ways to transport goods. In any analysis, it is the only practical way for the vast bulk of the world’s trade. Shipping accidents, particularly those that involve pollution, bring into question the safety of shipping and the quality of the ships and their crews. Whether or not such questions are justified, it is shipping accidents that provide an image of the industry, which attracts considerable attention.

Marine accidents.


Short History of Incident Investigation

The following video explains the history of incident investigation and provides insight into the types of incidents that may occur.

Seeking Disabled

The Need for Incident Investigation

It is easy to assume that int he modern world of electronic navigation and health and safety culture that there is no need for incident investigations onboard. Unfortunately, this is not the case. 

Bulk carriers are notorious for incidents due to the extremely hazardous nature of some cargoes. Liquifaction can lead to immense capsize forces and cargo shift of heavy minerals can lead to frame damage or even breaking of the vessel in heavy seas.

Ferries account for about 5,8 per cent of the total number of the world fleet of ships over 1000 tons deadweight. Ferry accidents, particularly those involving loss of life, are significant incidents requiring the most rigorous investigation. Before 1989, several ferry casualties created considerable concern.

On the 3rd of February 2006, the passenger ferry Al Salam Boccaccio 98 sank in the Red Sea on its way to Safaga in southern Egypt. Nine hundred ninety-three persons lost their lives.

Tanker vessels can be even more publicised than other types of vessel losses due to the environmental impact of spilling oil, often lasting for years after the incident has occurred.

In the photo below you can see the Prestiege, a tanker that foundered in heavy seas and eventually broke apart off the coast of Spain, leading to one of the worst spill disasters in European history.


Types of Investigation

Flag State Investigations

The International Convention for the Safety of Life at Sea (SOLAS) requires any flag state administration to conduct investigations into any casualty suffered by a ship of its flag if an investigation may assist in identifying regulatory issues as a contributing factor.

Shipboard Investigations

A shipowner's Safety Management System (SMS) requires, at a certain level, an investigation of all shipboard accidents. In these investigations, the ship’s crew makes an important part, wherefore the onboard investigators must have the correct competence.


Why Should We Investigate Incidents?

It may seem simple to investigate the serious incidents onboard to determine the safety failings so that such mistakes will not be made again. However, it is less obvious as to the need to investigate minor and low-level incidents or even near-misses where no one was even harmed. 

However, studies have shown that investigation of all incidents and near-misses is crucial for ensuring the safety of all onboard and preventing the larger incidents from occurring in the first place.

Accidents can be seen as part of an iceberg above the sea surface. Beneath the surface, there is a myriad of minor accidents and near misses, which are mostly unreported. Whether an investigation takes place or not may rely on the company's safety culture and ethics. A study of industrial accidents undertaken by Frank E Bird Jr., and George L Germain (1969) analyzed 1 753 498 accidents reported by 297 companies from 21 industrial groups over covering a period of 3 billion working hours.
When comparing the severity of accidents, they discovered that for every significant injury reported (death, disability, lost time, or medical treatment), 9,8 minor injuries were requiring first aid. For each significant injury, there were 30,2 property damage accidents and 600 incidents. Bird and Germain pointed out that the best way to prevent significant accidents from occurring would be to address the lesser incidents first.

The North of England P&I Club has developed a similar model illustrated below, which appeared in Lloyd’s List in February 1998. The message seems to be that for every major accident, those usually investigated by government safety, there are many other minor or potential accidents. Also, the severity of accidents can depend on the degree of hazard. The ladder illustrates the point that in the same situational factors, i.e., an unlashed ladder, the outcomes may vary. If we can learn lessons from all accidents and incidents, we can reduce the base of the triangle, thereby reducing the risks of major accidents.