The Casualty Investigation Code

A group of international investigators recognized the need for a uniform approach to the investigation and analysis of marine casualties. The aviation industry already had such a code. The name of the Code is “Casualty Investigation Code,” which is the basis for this course.

The Code, annexed to IMO Resolution A.849 (20), includes responsibilities for flag states about marine casualty investigations. The Code was also amended by IMO Resolution A.884 (21) to include guidelines on the investigation of human factors.

Any safety information system, for a marine casualty investigation under the Code, depends on receiving accurate information. It requires that anyone involved can give accurate, honest evidence of what occurred. The Code aims to achieve:

The purpose of the Code for Investigation of Marine Casualties and Incidents is described in the following resolutions:

The coastal and flag states have rights and obligations described in the UN Convention on the Law of the Sea, UNCLOS. The flag states also have responsibilities under SOLAS, MARPOL, and Load Line conventions to conduct casualty investigations and supply IMO with relevant findings. The ILO Maritime Labour Convention 2006 (MLC 2006) requires that occupational accidents are reported and investigated.

The aim of the Code for the investigation of Marine Casualties and Incidents is to promote a common approach to safety investigations into marine casualties and promote cooperation between the states. The purpose of the Code is to create a process for the systematic investigation of marine casualties, to establish and publish causes and make recommendations. The objective of any marine casualty investigation is to prevent similar losses in the future. The Code applies, subject to national laws, to investigations of casualties where one or more states have a substantial interest in a casualty involving a ship under their jurisdiction.

Conduction of Marine Casualty Investigation

When conducting marine casualty investigations, unbiased investigations are most effective in establishing circumstances and causes. In analyzing casualties, cooperation between states with substantial interest is helpful. Marine casualty investigations should have the same priority as criminal or other investigations. Investigators should have access to government surveyors, pilots, other marine personnel, and relevant safety information and should make use of all recorded data. When conducting investigations, IMO, ILO, and other recommendations, particularly those relating to human factors, should be taken into account. Investigation reports are most effective when released to the shipping industry and the public.

Definitions

The Code defines the following expressions, which commonly appear within its text:

Marine Casualty

An event that is caused by, or in connection with, the operations of a ship. That and has resulted in the death of or serious injury to a person. Marie casualty also includes the loss of a person from a ship or the loss, presumed loss, or abandonment of a ship. It can also mean the vessel has suffered material damage, stranding or disabling, or that the ship has been involved in a collision. If a damaged ship causes damage to the environment, it classifies as a marine casualty.

Very Serious Casualty

A casualty to a ship which involves the total loss of the ship, loss of life or severe pollution.

Serious Casualty

A casualty does not qualify as a very serious casualty. A serious casualty involves a fire, explosion, grounding, contact, substantial weather damage, ice damage, hull cracking or suspected hull defect, etc. The accident/emergency has consequences and results in structural damage rendering the ship unseaworthy. Examples are penetration of the hull underwater, immobilisation of main engines, extensive accommodation damage, etc. It can also result in pollution (regardless of quantity), or a breakdown of the ship and necessitating towage or shore assistance

Causes

Actions, omissions, events, existing or pre-existing conditions or a combination thereof, which led to the casualty or incident.

Marine Incident, Marine Casualty, or Incident Investigation

A process held either in public or camera conducted for casualty prevention. It includes the gathering and analysis of information, the drawing of conclusions, the identification of the circumstances and the determination of causes and contributing factors. When it is appropriate, it also includes the making of safety recommendations.

Marine Casualty Investigator

A person or persons qualified and appointed to investigate a casualty or incident under procedures laid down in national legislation for the progress of marine safety and protection of the marine environment.

Serious Injury

An injury that is sustained by a person in a casualty resulting in incapacitation for more than 72 hours commencing within seven days from the date of injury.

Ship

Any kind of vessel which is used in navigation by water.

Lead Investigating State

The state that takes responsibility for the conduct of the investigation as mutually agreed between the substantially interested states is called the lead Investigating state.

Substantially Interested State

This means a State which is the flag State of a ship that is the subject of an investigation, or the State in whose internal waters or territorial sea a marine casualty has occurred. A Substantially Interested State can also be the State where a marine casualty caused, or threatened, serious harm to the environment, to the State itself or to artificial islands, installations, or structures – and where the casualty resulted in nationals of that State lost their lives or received serious injuries. A Substantially Interested State is a State that has essential information that may be of use to the investigation of the casualty, or that for some other reason establishes an interest that is considered significant by the lead investigating State.

Responsibility for Investigating Casualties and Incidents

Flag states are encouraged to ensure that investigations are carried out into all casualties occurring to their ships. Where a marine casualty or incident occurs within the territorial sea of a state, the flag and coastal states should cooperate to the maximum extent possible and mutually agree on which state should take the role of lead investigating state.

If a marine casualty or incident occurs on the high seas, involving at least two flag states, these should consult with each other and agree, on which will be the lead investigating state. An investigation should be started as soon as practicable after the casualty occurs.

The lead investigating state should be responsible for developing shared strategies for casualty investigation with substantially interested states. It is also responsible for providing the investigator and generous logistical support, coordinating the investigation, keeping records, and preparing reports. It should also liaise with agencies and other organisations in connection with the investigation

The master, or owners, of a ship, must inform its flag state authority of any casualty occurring to the ship where the casualty or incident occurs in the internal waters or territorial sea of another state. However, the coastal state should, as soon as possible, notify the flag state or states, of the circumstances and if the coastal state proposes any action.

Cooperation Between States

Cooperation between states within an investigation is crucial to allow witnesses to be questioned and to view and examine the evidence. Interaction is vital to make submissions and comments and to have their views reflected in the final reports. States need to work together to provide each other with transcripts, statements, and the final report.

The following records should not be included in the final report, or its appendices, if not pertinent to the analysis of the casualty or incident. Parts of the document not relevant, and not included in the final report, should not be disclosed. All statements by the investigating authorities taken from persons during the investigation should not be disclosed. Neither should any of the communication between persons having been involved in the operation of the ship. Medical or private information regarding persons involved in the casualty or incident is also included in the records that should not be disclosed. Opinions that are expressed during the conduct of the investigation are not to be disclosed either.

Governments should take all necessary steps to ensure that they have sufficient available means and suitably qualified personnel and material resources to enable them to undertake casualty investigations.

Issue of Marine Casualty Reports and Submission to IMO

The lead investigating state should send a copy of the draft of the final report to all substantially interested states, inviting their significant and substantiated comments on the report. The comments, if received within the agreed period, should either amend the draft final report to include the substance of the comments or append the comments to the final report. Where a substantially interested state disagrees with the whole or part of the report, it may submit its report to the organisation.

Re-opening of Investigations

When new evidence relating to any casualty is presented, it should be thoroughly assessed and referred to other substantially interested states for appropriate input. In the case of new evidence which may materially alter the determination of the circumstances under which the marine casualty occurred, and may materially change the findings concerning its cause or any consequential recommendations, states should consider their findings.

Content of Reports

To make the flow of information from casualty investigations better, the report should follow the basic format outlined by the Code. Reports should include, wherever possible:

To facilitate the implementation of this Code, states should inform the organisation of the responsible authorities within their governments that they may be contacted regarding cooperation in casualty investigations.