Advanced Maritime Incident Investigation

Advanced Maritime Accident
Investigations and Analysis
GL Academy
- where experts learn more
The Trainer
Name: Capt Frederick James Francis
Experience:
Sailed for more than 15 years with 5 years in command
Senior lecturer for 15 years at Singapore Maritime Academy
Served as IMO/ASEAN Legal Advisor/Consultant
Expert witness/investigator for numerous collision cases
Arbitrator and Mediator for numerous maritime cases
Author of 7 books including Halsburys Laws of Singapore
(including Sources of Singapore Law and Collision Law)
Phone:
Email:
+49 (40) 361 49 - 2110

gl-academy hamburg@gl-group.com
Advanced
| | No. 2Maritime Accident Investigations and Analysis | Rev 4.0 | No. 2
The Participants
Please introduce yourself
Name
Company
Position / Duty
Experience with the topic
Expectations
Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 3
Objectives
To introduce accident analysis tools suitable for use in the maritime
industry
To improve individual skills regarding casualty investigation and analysis
To discuss possible ways of introducing formal accident investigation
and analysis tools in shipping companies
Organisation
Course Documentation
GL Academy
Advanced MCI
Handout
Case Studies
Tools
Documentation
CD-Rom
Other Material
General information
Smoking Policy
Mobile Phones
Emergency Exits
Time Keeping
Certificates
Seminar Assessment
Timetable
09:00
09:15
Introduction
09:15
10:30
Module 2 Gathering Evidence
10:30
10:45
10:45
12:30
Module 3-4 Interviews & Analysis of Accident
12:30
13:30
Lunch
13:30
15:00
Module 4-5 Analysis cont. & Improving Safety
15:00
15:15
15:15
16:45
Module 5-6 Improving Safety & Implementation
16:45
17:00
Closing
Coffee Break
Coffee Break
Navigator
. Module 1 Introduction
Module 2 Gathering evidence
Module 3 Interviewing
Module 4 Analysing the accident
Module 5 Improving safety
Module 6 Implementation
Module 1:
Introduction
Why do we investigate accidents?

Nobody wants them
They are expensive
They cause lots of problems
Module 1:
Introduction
Can they be avoided?

Most likely not
So, what can be done in order to limit
their reoccurrence?
Careful accident investigation is one step
Module 1:
Introduction
What should be observed?

Human error vs. Technical failure
EXPRESS SAMIA 26. September 2000

Structural damage
Module 1:
Introduction
What should be observed?
Organizational
contributions
Module 1:
Introduction
What should be the focus of this seminar?

Practical aspects of casualty investigation
Enabling participants to carry out not only investigations,
but also the related analysis
Navigator
Module 1 Introduction
. Module 2 Gathering evidence
Module 2:
Gathering evidence
To introduce the tool evidence matrix to facilitate systematic

gathering of evidence
To highlight specific issues in gathering certain types of evidence
Evidence Matrix
A basic foundation of comprehensive accident investigation reports is
the validation of all findings of the elements of cause and the major
conclusions reached by the investigators.
Courtesy of NTSB
Evidence Matrix
To Accomplish This Validation the Investigator Must:
Correlate the investigative analysis to the facts given in the report

Correlate findings and conclusions back to the analysis
Ensure the logic used is sound
Provide ALL the facts related to the analysis, even contrary evidence
Courtesy of NTSB
Evidence Matrix
Evidence Matrix
Lists the major findings,

Shows the evidence related to the findings,
Sources of evidence
Location of where evidence may be found.
Courtesy of NTSB
Evidence Matrix
Constructing the Evidence Matrix
Is relatively easy
A simple straight-forward tabular format as shown below should be
sufficient for most instances
Courtesy of NTSB
Evidence Matrix
MAJOR FINDING
OR CAUSAL
ELEMENT
EVIDENCE
(Both Pro and Con)
SOURCE
OF EVIDENCE
Courtesy of NTSB
COMMENTS
Evidence Matrix
Example
Scenario
Seaman Jones who was working aloft fell to his death. The D hook, meant
to be used to attach the lifeline to the seamans safety belt, was so
encrusted with salt and corroded that opening it by the usual hand pressure
was not possible.
Courtesy of NTSB
MAJOR FINDING
OR CAUSAL
ELEMENT
D hooks were not
being used by
seamen
EVIDENCE
(Both Pro
and Con)
SOURCE
OF EVIDENCE
Salt encrustation & D hooks

corrosion made the
hooks very difficult
to open
Another seaman
unable to open D
hook taken from
victims lifeline
COMMENTS
Photos taken by
________, NTSB
Investigator
D hooks are in locked

safe located in
Evidence Storage
Room.
Photos (and negatives)
are in official file of
accident. File No.
xxx12345
Mr. Smith, a shipmate,

was unable to open the
D hook during post
accident interview.
Witnessed by NTSB
investigators, R.L.S.
and J.P.S. Statements
in official file.
Courtesy of NTSB
MAJOR FINDING
OR CAUSAL
ELEMENT
D hooks were not
being used by
seamen
EVIDENCE
(Both Pro
and Con)
SOURCE
OF EVIDENCE
COMMENTS
Oral testimony that

the D hooks were
being used.
Testimony of Seaman
Smith, taken by
_______, NTSB
Investigator
May 10, 2000.
Testimony tape
recorded and
transcribed. Original
tape and transcript (see
page 10) maintained in
official file.
Seaman Jones (the

victim) D hook took
486 lbs. of torque to
open
NTSB Materials
Laboratory
Tests
NTSB Materials
Laboratory Factual
Report (See Page 5)
Courtesy of NTSB
Rules for collecting evidence:

Keep all relevant documents and electronic information
Write down sequence of events
Times
Events
Persons involved
Evidence related to events
Take photos
Write down what is to be seen on the photo
Area photographed
Specific item displayed
Rules for collecting evidence:

Note persons involved and witnesses able to testify
(names and address details and make sure that they are willing to testify)
Keep damaged equipment (if possible or at least parts of it)
Keep cargo samples
Arrange for surveys in accordance with company instructions
(insurance, class if needed)
Keep record about all activities of the investigation
Advice on taking photos
What to take pictures of...
View from
4 points
What to take pictures of...

Long Range shots
All inclusive area of incident
Medium Range shots
Records orientation of item
Short RangeDetailed shots
Close up of failed or damaged items
Place a ruler/scale in picture

Place item on an appropriate background
Place people in the photo
Photo log
Event
Camera / Film
Date / Time
Notes
Case Study - Task 1

Coffee Break
Navigator
. Module 3 Interviewing
Module 3:
Interviewing
To explain typical problems related to interviewing

To introduce the Cognitive Interviewing method
To provide guidance how to use this method
Human Evidence
Most volatile form of evidence;

Interviews are the source of human evidence.
The fairly recent interviewing style cognitive interviewing;
Developed by Dr Fisher and Dr Geiselman.
Interviewing witnesses
Cognitive interviewing (CI) described as a systematic approach to

interviewing cooperative witnesses
Scientific experimental data reveals 30% to 70% more information

elicited than with conventional interviews
Most effective with cooperative witnesses
Types of witnesses
IMPARTIAL WITNESS
Nothing to gain, nothing to lose. Often the best sort of witness.
BIASED WITNESS
One who has a definite interest in the outcome, which can result in the
colouring or embellishment of a story, can be a biased witness. It can also lead
to a selective memory. Check story with known facts and against other
testimonies. Consider
The two sides in a collision incident
An oil tanker incident and the local inhabitants
Ship owner or operator
Types of witnesses
HOSTILE WITNESS
Hostile towards you or "authority in general". Often feels under threat.
Maintain complete impartiality, ensure that the witnesss rights and your
obligations are explained and the procedures and possible outcomes are
explained. Ensure that the witness understands his/her obligations.
Encourage the presence of a legal adviser.
RELUCTANT WITNESS
May be attributable to loyalty, or a defence mechanism against the
outsider. May be intimidated by the process or frightened of
consequences, threats, etc.
Types of witnesses
FOREIGN LANGUAGES
Always best to use an interpreter. Sometimes, however, the interpreter
can become involved. In the technical field an exact translation is often
difficult to obtain. Using an interpreter complicates an interview and can
often more than double the time. Such interviews can be successful if
they are well planned and controlled.
You should also be aware of cultural differences that may be expected
and the sub-cultures that may be onboard a ship, particularly those with
multi-national crews.
The principles of Cognitive Interviewing

Witness as the central element of the interview
Interview revolves around witness knowledge
Information gained vs. questions asked.
Slides used with permission of Kevin T. Ghirxi

The most effective interviewers

Those who ask fewer questions!!
burden on the interviewer;
disturbing the witness;
interviewer does not know the events.
but asking fewer questions requires you to explain your intentions to the witness

The interviewers challenges
Motivational uncooperative/hostile witness

Emotional an unpleasant experience
Cognitive witness unaware of his role

The motivational barrier

A very common reaction
You will never trick the witness
Establishing a bond.

The emotional barrier

Why should the witness go through it again?
Show your concern
Develop a rapportagain

The cognitive barrier

Is the investigator an intimidating figure?
The influence of TV on the witness will work against you
Develop a rapportyet again.

Once the social rules have been established
Motivate the witness to deliver the information

Open-ended questions vs. closed questions
Present yourself as the one who needs the witness knowledge
and that is exactly who you are!

The use of closed questions

Only used to fill the gaps;
Suggested sequence:
Free narrative
Open-ended
questions
Closed questions
During the course of the interview

Interviewer is interested in his cognitive needs;
Why does a witness pause?
Organising their thoughts
Feeling emotional
Validation process

Past experience from memory

Retrieval enhancing techniques
Helping the witness to use all his/her mental resources:
minimise the number of questions
avoid multiple questions
avoid taking breaks
avoiding direct eye contact
focused concentration
extending the interview functional time.

Asking the right questions

To follow after the free narration;
Your investigative needs are secondary to the witnesss access to
the image
Do not try to accommodate your cognitive needs to the detriment of
the witnesss efforts.

Multiple interviewers
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Different probing methods

Using different techniques
Visual vs. auditory processing
Different sensory modalities
Dead Poets Societythe movie
Free narrativein backward order
Zooming in on images.
Influencing the memory process

Speaking to other witnesses
The media
General knowledge
Negative or suggestive questions by the investigator

Problem of witness guessing

Guessing of witness
Commission and omission errors
FOLLOW UP QUESTIONS CAN STILL BE OPEN-ENDED
EVEN IF SLIGHTLY NARROWER.

The communication loop
Conveys investigative needs
Interviewer
Witness
Conveys knowledge

The Columbo effect

The onus of conveying the
investigation needs lies with the
investigator.
The communication loop continued

Witness presenting information in a chronological order but
...the investigator has to allow for events coming in an unpredictable
fashion.


Enough detail to see and know what has happened
Avoid restricting the witness to verbal communication.


When English is not the native language of the witness
The use of a translator during interviews for safety investigations.


Limiting the witness to verbal expression
Other methods help:
reinstate the experience context
interviewer understands better
witness expresses himself better

The use of tape recorders
Verbatim record;
Allows you to concentrate on the witness
but
Has its disadvantages as well
OBTAIN WITNESS PERMISSION.

Step-by-step a recollection
1.
Pre-interview exercise
2.
Introducing the interview session
3.
The open-ended narrative
4.
Probing each mental model
5.
Clarify ambiguities
6.
Get background info
7.
Extend functional life of an interview session
8.
Be flexible

Determining witness accuracy

Some practical hints
Corroboration with other sources of evidence
Confidence expressed during the interview
Output order of information
Attention paid to the event
Form of question asked
The sequence of eventsin the reverse order.

Other practical considerations

Where?
How?
Memory
When?
General
Specifics
Time
Who?
Prioritising witnesses
At your office during logistic preparations identify your key witness

and other possible witnesses
Determine who is available
During the interview pay attention for other liveware.

The developed CI technique:

1.
Introduce yourself
2.
Show that you care
3.
Clearly request witness to

generate info
10. Encourage witness to think about
Ask open-ended questions first

and after free narration
11. Do not ask leading questions
4.
5.
Avoid interrupting the witness
6.
Allow time for long pauses
7.
Recreate the context
8.
Encourage witness to close eyes

9.
Ask questions related to the

witnesss activated knowledge
event from different angles
12. Discourage guessing

13. Be flexible
14. Extend effective session time.
Interviewing
Question to the audience:
Do you have any experience with interviewing?
Would you like to share your experience with the other
participants?
Navigator
. Module 4 Analysing the accident
Analysis of the accident

Now that you have established the facts the next challenge is to link
the events and to analyze the accident

What do you do when you investigate an accident?
You establish a sequence of events leading to an accident
Truck driver
loads stone
on the truck
Truck driver
fastens
stone
Truck driver
starts truck
Truck
drives from
A to B
Accident investigation with a STEP map

(STEP Sequential timed events plotting)
Lashing fails
Stone falls
off the truck
Car driver
starts car
Car driver
notices the
falling stone
Car
drives
from A to B
Car driver
turns the
steering wheel
Car driver
pushes brakes
Car
hits the
stone

Is a sequence of events enough to explain how an accident
happened? No!
Identifying causes
Sequence of events is not enough
Starting point
Further investigation into the preconditions
for significant events leading to the accident

Identifying causes
What went wrong here?
It is important to understand the context of
events that occurred during an accident
What were influences on these events?
Who else was involved?
Truck driver
loads stone
on the truck
Truck driver
fastens
stone
Truck driver
starts truck

Accidents Involve
A sequence of EVENTS
Events are affected by CONDITIONS that exist at the time
Fog, rain, night time, tired, angry
The EVENTS and CONDITIONS result in unintentional harm

Events and Causal Factors Analysis
Organizes the accident data
Develops the investigation
Validates the accident sequence
Validates logic of findings, causes, & contributing factors
Helps organize the accident report
Source: NTSB
Event No.1
Start-up
Switch
Activates
Event No.2
Compressor
Runs
Event No.3
Tank
Pressure
Increases
Source: NTSB
Condition
Tank
at
300 psi

Understanding Conditions
Conditions express a state of being (e.g. it is dark)

Conditions result from events (e.g. sun set)
Conditions are a shortcut in E&CF charting
Note: Events leading to them may not be depicted.
Start-up
Switch
Activates
Compressor
Runs
Tank
Pressure
Increases
Source: NTSB
Tank
at
300 psi

Causal Factors Relationship
Management
Always ask
why an
unwanted
condition was
allowed to exist
Event
Supervision
Specific
condition
Event
Source: NTSB
Event
Accident

Events & Causal Factors Chart
How to do it
1.
All events are enclosed in rectangles
2.
All conditions are enclosed in ovals
3.
Presumptive events or conditions are shown by

dashed rectangles or ovals
4.
All events are connected to the preceding and

succeeding event by arrows

Guidelines
Are active (e.g. crane strikes building)
Should be stated using one noun and one active verb
Events
Should be quantified as much as possible and where applicable

(e. g.,the worker fell 8 meters rather than the worker fell off the
platform)
Should indicate the date and time of the event, when they are
known
Should be derived from the event or events and conditions
immediately preceding it.
Source: DOE Accident Investigation Workbook


Guidelines
Are passive (e.g. fog in the area)
Describe states or circumstances rather than occurrences or
events
Conditions
As practical, should be quantified

Should indicate date and time if practical/applicable
Are associated with the corresponding event.
Source: DOE Accident Investigation Workbook


Symbols used in Events & Causal Factors Charts
Presumed Condition
Condition
Presumed Event
Event
Accident

Condition
Events & Causal Factors Charts
Condition
Secondary event sequence
Secondary
event
Secondary
event
Primary
event
Primary
event
Primary event sequence
Primary
event
Primary
event
Accident

Events & Causal Factors Charts
Look at the conditions

and conclude
causal factors
Ask questions to
determine causal factors
(why, how, what and who)
Starting Point:
Ask why did this event happen?
Source: DoE
Lunch Break

EXAMPLE
The Epic Saga of the Boy and the Truck
Source: NTSB

Scenario
Ajax Construction Company was awarded a contract to build a condominium on
a hill overlooking the city. Prior to initiation of the project, a comprehensive safety
program was developed covering all aspects of the project. Construction activities
began on Monday, October 4, 1995, and proceeded without incident through
Friday, October 8, 1995, at which time the project was shut down for the weekend.
At that time, several company vehicles, including a 2-1/2-ton dump truck, were
parked at the construction site. On Saturday, October 9, 1995, a nine-year-old
boy, who lives four blocks from the construction site, climbed the hill and began
Source: NTSB
exploring the project site.


Upon finding the large dump truck unlocked, he climbed into the cab and began
playing with the vehicle controls. He apparently released the emergency brake
and the truck began to roll down the hill. The truck rapidly picked up speed. The
boy was afraid to jump out and did not know how to apply the brakes. The truck
crashed into a parked auto at the bottom of the hill. The truck remained upright,
but the boy suffered serious cuts and lacerations and a broken leg. The resultant
investigation revealed that, although the safety program specified that unattended
vehicles would be locked and the wheels chocked, there was no verification that
these rules had been communicated to the drivers.
Source: NTSB

Events
Ajax
Initiates
Hilltop
Project
Ajax shuts
down for
weekend
Source: NTSB
Driver parks
truck on hill
9-yr old
boy climbs
hill
Truck rolls
down hill
Boy enters
truck cab
Boy
manipulates
vehicle brake
Boy
releases
brake
Boy stays
in truck
Source: NTSB
Truck
crashes into
parked auto
Source: NTSB
Boy
suffers
serious injury

Conditions
Ajax
Initiates
Hilltop
Project
Ajax shuts
down for
weekend
Driver parks
truck on hill
NOTE: LTA = Less Than Adequate

Source: NTSB
9-yr old
boy climbs
hill
Supervision
of boy LTA

Wheels not
chocked
Truck not
locked
Truck rolls
down hill
Boy enters
truck cab
Boy
manipulates
vehicle brake
Boy
releases
brake
Boy stays
in truck
Afraid to
jump
Source: NTSB
Rules not
communicated
to drivers
Company rules
reqd trucks be locked
& chocked
Truck not
locked
Boy enters
truck cab
Wheels not
chocked
Boy
manipulates
vehicle brake
Truck rolls
down hill
Boy
releases
brake
Afraid to
jump
Source: NTSB
Boy stays
in truck
Case Study - Task 2

Navigator
. Module 5 Improving safety
Improving Safety
Objective
Individuals can fail
This is impossible to prevent
However, organizations can very often provoke failures of individuals
due to inappropriate working and living conditions offered on board ships
This can be avoided!!!
Improving Safety
Organizational influence can be important
The last final act usually has a history
Example: Herald of Free Enterprise
Improving Safety
Organizational influence
Source: Reason, 1990

Improving Safety
ISM Code Element 9 - Reports and Analysis of Non-Conformities, Accidents
and Hazardous Occurrences
Procedures to ensure that non-conformities, accidents and hazardous
situations are
reported
investigated and
analyzed
Procedures for the implementation
of corrective actions to prevent recurrence
Improving Safety
Tier diagramming
Technique used to identify
Root causes of an accident
Levels of line management that have the responsibility
and authority to correct the accidents causal factors
11 Step approach
Starting point is the Event and Causal Factor Chart
Improving Safety
Tier diagramming (DoE, 1999)
Step 1 Identify the significant events and conditions
in the Event and Causal Factor Chart
Step 2 Mark the causal factors in the chart
(letters, numbers )
Improving Safety
Direct Cause
Immediate events or conditions that caused the accident
Should be stated in one sentence
Contributing Causes and Factors

Events or causes that collectively with other factors or causes increased the
likelihood of an accident but that individually did not cause the accident
May be longstanding conditions, a series of prior events
Set the stage of accidents
If allowed to persist or reoccur, increase the probability of future accidents
Improving Safety
Accident Causation
Contributing
Causes and Factors
Root Cause
Lack of planning,
standards,
procedures,
enforcement,
compliance
Personal Factors
(e.g. Lack of skills,
knowledge, stress)
Organizational Factors
(e.g. Inadequate
supervision,
maintenance)
Other Unsafe
Conditions
(e.g. Workspace
restrictions )
Consequences
Accident
Personal injury
Occupational
accident
Damage to the ship

and property
Fire, explosion
Environmental
damage
Direct Causes
Unsafe Acts
(e.g. Working without
authority, using
defective equipment,
improper use of
equipment)
Grounding
Financial damage
Collision
Commercial
damage
Rules not
communicated
to drivers
Company rules
reqd trucks be locked
& chocked
Truck not
locked
C
Wheels not
chocked
Boy enters
truck cab
Truck rolls
down hill
Boy
manipulates
vehicle brake
Boy
releases
brake
Boy stays
in truck
Source: NTSB
Afraid to
jump
Improving Safety
Step 3 Develop a tier diagram framework
Tier
Causal Factors
Tier 5: Senior
Management
Tier 4: Middle
Management
Tier 3: Lower
Management
Tier 2: Supervision
Tier 1: Worker Actions
Tier 0: Direct Cause
Root Causes (Optional column)
Improving Safety
Tier diagram framework
Make sure your organization is reflected in an adequate way in your tier diagram
If this happened when a subcontractor was working one needs two diagrams
Structure of the subcontractor

Your own organizational structure
Improving Safety
Step 4 Begin with Tier 0. Insert the direct cause into Tier 0. Insert all causal
factors in Tier 1 worker actions
Tier
Causal Factors
Tier 1: Worker
Actions
B Truck was not locked

wheels not chocked
Tier 0: Direct
Cause
C Company policies
were ignored
A Boy released brake and caused

the truck to roll down the hill
D Company policies
were not communicated
Improving Safety
Step 5 Evaluate Tier 1. Look at the worker actions in Tier 1 and ask
yourself if this is the responsible level for the actions?
Tier
Causal Factors
Tier 1: Worker
Actions

wheels not chocked
Tier 0: Direct
Cause
C Company policies
were ignored

D Company policies
Improving Safety
Step 6 Evaluate Tier 2. If a factor is a worker action in Tier 1 is the factor
solely attributable to this tier or were the supervisors involved as well?
Tier
Causal Factors
Tier 2: Supervision

wheels not chocked
Tier 1: Worker
Actions
Tier 0: Direct
Cause
C Company policies
were ignored

D Company policies
Improving Safety
Step 6 Evaluate Tier 2
In order to evaluate the responsibility you may use the following questions as
guidelines here is the example for Tier 1
Typical Integrated Safety
Management Responsibilities
Sample Questions for Consideration in Assigning Causal Factors to

Management Levels
Maintain technical
competence
Perform work within controls
Identify hazards and report
incidents
Stop work, if necessary
Were the worker's knowledge, skills and abilities adequate to perform the job
safely?
Did the worker understand the work to be performed?
Were communications adequate to inform the worker of any hazards?
Was the worker knowledgeable of the type and magnitude of hazards
associated with the work?
Was the work covered by procedures?
Was the worker trained on the procedures?
Did the worker have the right tools and equipment to perform the job safely?
Did the worker have stop-work authority?
Did the worker understand she/he had stop-work authority?
Improving Safety
Step 7 Evaluate the other tiers. Evaluate the other management levels
until you are satisfied that you have found the right level of responsibility (use
the guideline questions)
Step 8 Repeat for each causal factor. Repeat the Steps 5 7 for each
causal factor.
Tier
Causal Factors
D Company policies
Tier 5: Senior
Management
Tier 4: Middle
Management
C Company policies
were ignored
D Company policies
Tier 3: Lower
Management
Tier 2: Supervision

wheels not chocked
Tier 1: Worker
Actions

wheels not chocked
C Company policies
were ignored
Tier 0: Direct
Cause
Improving Safety
Step 9 Identify links
Finally ask yourself do links exist between the causal factors (e.g. several causal
factors pointing towards lack of training)
Group these factors together
Find a short description for this group (this can be one of the causal factors that
describes it best or a new, more precise statement)
This group description becomes a potential root cause
Tier
Tier 5: Senior
Management
Tier 4: Middle
Management
Causal Factors
f
o
k
c
a
L
nt
e
m
e
c
r
o
f
en
D Company policies
C Company policies
were ignored
D Company policies
Tier 3: Lower
Management
Tier 2: Supervision

wheels not chocked
Tier 1: Worker
Actions

wheels not chocked
C Company policies
were ignored
Tier 0: Direct
Cause
Improving Safety
Step 10 Identify root causes
Evaluate the causal factors and causal factor group descriptions
There may be more causal factors in your diagram than in your Event and
Causal Factor Chart
Highlight those causal factors that are root causes
Remember:
Not all causal factors are root causes
If a causal factor does not meet the criteria of a root cause do nothing
it remains a causal factor
Improving Safety
Improving Safety
Step 11 Simplify root cause statements
If there are more than three root causes reexamine the list of root causes in order
to find out if they cannot be combined further
Improving Safety
Guidelines and reminders
Root causes can be found in any tier of the diagram (however, one
finds them usually in higher tiers of the diagram)
Root causes can only be found at the worker level if
Management systems were in place and functioning, i.e.
providing management with feedback about the status of the
system
Management took appropriate actions based on feedback
Management, including supervision, could not be expected to
take action based on their responsibilities and authorities
Improving Safety
Guidelines and reminders
Root causes can be found at more than one level of an organization

(e.g. one root cause can relate to Tier 4, while other may point at Tier 5)
Root causes are generally attributable to an action or lack of action by a
particular group or individual in the line organization
Case Study - Task 3

Coffee Break
Improving Safety Safety recommendations
The purpose of Accident investigation is not only to find somebody who

can be blamed for it
It is much more concerned with learning how to avoid similar accidents in
the future
This is why, at the end of an investigation, safety recommendations
should be given

What are the principle considerations after an accident investigation?
To learn how existing safety measures failed or where they need to be put in place
Danger /
Hazard
B
A
R
R
I
E
R
Safety
Critical
Operation /
System

We need to know how our safety measures/barriers are functioning
BARRIERS
Accident
V
T
S
P
I
L
O
T
B
U
O
Y
S
D
R
E
D
G
E
D
F
A
I
R
W
A
Y
S
K
I
L
L
E
D
C
R
E
W
Ship

At the end of an investigation a basic safety barrier analysis and
evaluation should be carried out
No
Root
Cause
Existing Safety
Measures
Are Additional
Safety
Measures
Needed?
Suggested New
or Additional
Safety
Measures
Relationship to
ISM and TMSA
Case Study - Task 4

Navigator
. Module 6 Implementation
Accident investigation
Introduction of procedures and forms
Step by step approach
Evidence matrix
Event and Causal Factor Charts
Tier Diagramming
Safety Recommendations
Seminar closing
Do you have any further questions?
Have we met your expectations?
Seminar closing
How did you like the seminar?
Please tell us your opinion on the seminar
assessment forms
Distribution of course certificates
Hope to welcome you again !
Contact Details:
GL Academy Singapore
83 Clemenceau Avenue #13-05/06
UE Square Singapore 239920
Phone: +65 6835 9714
Fax: +65 6887 4526
gl-academy-singapore@gl-group.com
http://www.gl-academy.com

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Advanced Maritime Accident

Investigations and Analysis

+49 (40) 361 49 - 2110

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 3

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 4

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 5

Module 2 Gathering Evidence

Module 3-4 Interviews & Analysis of Accident

Module 4-5 Analysis cont. & Improving Safety

Module 5-6 Improving Safety & Implementation

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 6

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 7

Why do we investigate accidents?

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 8

Can they be avoided?

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 9

What should be observed?

EXPRESS SAMIA 26. September 2000

What should be observed?

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 11

What should be the focus of this seminar?

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 12

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 13

To introduce the tool evidence matrix to facilitate systematic

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 14

To Accomplish This Validation the Investigator Must:

Correlate the investigative analysis to the facts given in the report

Lists the major findings,

Salt encrustation & D hooks

D hooks are in locked

Mr. Smith, a shipmate,

Oral testimony that

Seaman Jones (the

Rules for collecting evidence:

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 23

Rules for collecting evidence:

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 24

Advice on taking photos

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 25

What to take pictures of...

What to take pictures of...

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 27

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Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 32

Place a ruler/scale in picture

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 33

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Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 35

Case Study - Task 1

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 37

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 38

To explain typical problems related to interviewing

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 39

Most volatile form of evidence;

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 40

Cognitive interviewing (CI) described as a systematic approach to

Scientific experimental data reveals 30% to 70% more information

Most effective with cooperative witnesses

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 41

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 42

Advanced Maritime Accident Investigations and Analysis | Rev 4.0 | No. 43