Risk Assessment

and Incident
Investigation
Veritas Training Dept. Introduction

The Veritas Training Department

Vision

To become the leading maritime institutes Offering Quality Training Services and
Constantly innovating using The latest technology in training for a globally
competitive marine crew responsive to the maritime industry needs

Mission

Provide quality training program facilities,instructor and other needs resources

that will ensures skill enhancement of maritime professionals.

Provide modern state-of-the-art training equipment and constantly updating

content to be always up to date with the regulations.

2
VMTC House Rules

 No wearing of slippers, short pants, T-shirts without collars and other attire not within
the bounds of proper grooming.

 Cellular phones and other electronic gadgets must be switched off while inside the
training room.

 Do not bring your coffee, chocolate drinks, tea or any other beverages, other than
bottled water, inside the training room.

 BE PUNCTUAL. No trainee will be permitted to join the class after the scheduled
starting time of the course had elapsed. Doors will be locked.

 Breaks normally are from 1000H – 1015H and 1500H – 1515H or as per discretion of
the Instructor. After 15 minutes, doors will be locked.

 Under any circumstances, no trainee shall be permitted to leave the room and
perform any other activity e.g. reporting to Crewing Department, going to the
Accounting Department and claiming training allowance, etc. The only exception is
during emergency and call of nature.

3
Course Objective

At the end of the Course, the trainees must be able to:

1. To state the basic principles of Risk Assessment.
2. To demonstrate how to carry-out Risk assessment and
Management.
3.To demonstrate understanding and identify ways to assist
in the realization and review of SMS.
4.To demonstrate how to accomplish the following:
• Data Gathering
• Data Analysis
• Root Cause Determination
• Generating Recommendations

5.To state successful implementation of the Company’s

System in the smoothest possible way .

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Course Topic

• Basics and Need for Risk

Assessment
• Risk Management Rules and
Techniques
• Risk Assessment Process
• Carrying Out a risk Assessment
• Case studies and Hands-on
Sessions
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Introduction

 ACCIDENT
An unplanned event or sequence of events giving rise to a
fatality, injury or ill health and/or damage to the environment, the
ship or third party property.
 Incident
An unplanned event or sequence of events that had the
potential to lead to an accident but for the intervention actions
taken.
 Safety Culture
An assembly of characteristics and attitudes in organisations
and in individuals which establishes, as an overriding priority that
safety issues receive the attention warranted by their
significance.

6
 Hazard
A condition with the potential for causing injury,
damage,or mission degradation.
 Risk
An expression of possible loss in terms of severity and
probability

Risk is a combination of two elements:

The severity of the hazardous event.

The likelihood that the hazard will occur.

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What is Risk assessment
Careful examination of what
could cause harm so that
decisions can be made as to
whether sufficient precautions
have been taken to minimise
the risk of injury to personnel,
damage to the environment
and/or damage to the ship.

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 Purpose and Objectives

Purpose : to ensure that a careful examination of shipboard

operations are carried out to determine what can cause harm,
that existing controls are adequate and determine if risk levels
are tolerable

Objective of Risk Assessment :

To minimize accidents and incidents onboard.

Where risk levels are unacceptable, to identify and implement

existing controls to reduce risk levels to as low as reasonably
practicable (ALARP)

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Expected outputs of risk assessment

• Minimization of risk to people & the

environment

• Improvement in operational performance

• Assist in establishing a responsible image

within the market place

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 Why ???
Are shipboard risks well managed?

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 Accidents will and do Happen?
 In complex systems such as ship
operations accidents are inevitable.
Unexpected interactions will sooner or
later occur.
 In today’s litigious society it is unlikely
that God or Mother Nature will be blamed
for an accident if an Organisation or
Individual can be found responsible.
 Introduction of Corporate Killing and
Corporate Manslaughter.
 Through risk assessment we can, and
do, have a significant effect on accident
prevention.

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13
 Causes of Marine Accidents

*Poorly defined / non-existent Procedures / Instructions

*Varying criteria for selecting ship’s personnel

*Depletion of Training Standards, especially on board

training

*Lack of emergency preparedness

*Preventive maintenance not carried out / non-existent

14
 Tanker trade
16.3
Number of spills >700 m/t

12.5
'10000 Bn TM and

13.

9.8 9.3 8.8

7.8
6.6
6.5
3.5
3.3

0.
80's 90's PR00's
1517
 Leading Indicators
Tanker accidents
1000
Number of accidents

750

500

250

0
'90 '94 '98 '02
16
Perception

• The risks are well managed.

• Further improvements - only

incremental.

Risk Assessments – Why?

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18
Reality
• IMO / Flag regulated • Reactive not Proactive

• Why fix it, if it ain’t broken? • Compliance driven

Risk Assessment Status

Industry would rather learn from the mistakes and accidents
that have already happened than the ones that are waiting to
happen or may happen in future.

Great fire-fighters, maybe not so good at looking ahead long

term.

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 History of Risk Assessment

U.S. nuclear industry carried out some of the first & most
extensive analysis of risks from potential catastrophes

Bhopal, Piper Alpha & Other Accidents

Set forth requirements for risk studies, process safety
management and risk assessments

Widely used today by many industries

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Risk Assessment

All employers have a “Duty of Care” to ensure the health and

safety of employees and other persons as far as possible, by
evaluating risks and taking actions to reduce these risks.
Specifically, employers are required to make suitable and
sufficient assessment of the risks to health and safety arising
from normal duties, for the purpose of identifying:
Groups of workers at particular risk in the performance with
their duties.
Measures and procedures to be implemented to comply with
the company requirements in meeting their duty of care.
Employers and employees must ensure that improvement
measures are implemented in respect of the risks identified by
the assessment.

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When must Risk Assessment be performed?

If the agreed shutdown period for shipboard critical

equipment or systems is to be exceeded, any extension
or alternative actions will require review by the vessel’s
Superintendent. Such an extension or alternative actions
will also require a further risk assessment to consider
changed circumstances such as environmental
conditions, crew fatigue or operational parameters
change.
Shipboard Management shall re-evaluate the risk
involved every time the activity is carried out. In this
case it may not be a documented process.

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23
TORREY CANYON

MARPOL

24
HERALD OF FREE ENTERPRISE

ISM

25
EXXON VALDEZ

OPA 90

26
Causes of Marine Accidents

*Poorly defined / non-existent Procedures / Instructions

*Varying criteria for selecting ship’s personnel

*Depletion of Training Standards, especially on board

training

*Lack of emergency preparedness

*Preventive maintenance not carried out / non-existent

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Simple example of risk
assessment Risk

Climbing Stairs

Driving a car

Entering enclosed space

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Identify the Risk

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CONCLUSION

SHE IS NOT WEARING A SAFETY HELMET!

In fact she’s not wearing much protection at all!

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10 Steps to Effective Risk Assessment
1.Make sure the risk assessment process is practical and
realistic.

2. Involve as many people as possible in the process,

especially those at risk.

3. Use a systematic approach to ensure all relevant risks and

hazards are addressed.

4. Look at the big picture; don’t waste time on the obviously

minor risks; and don’t obscure the process in too much
detail.

5. Start by identifying the hazards.

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6. Assess the risks from those hazards, taking into account the
effectiveness of the existing controls;

7. Be realistic, not idealistic. Look at what actually occurs and

exists in the workplace and, in particular, include non-routine
operations.

8. Identify who is at risk. Include all workers, including visitors,

contractors and the public.

9. Start with the simple methods, use more systematic

methods as necessary.

10. Always record the assessment in writing, including all

assumptions you make, with the reasons why. 32
Ask Fundamental risk Question

Why am I doing it at all?

What Are the consequences
What could go wrong?

How could it affect me?

- Others?
- Company?
- Customers? Etc.

How likely is it to happen?

What can I do about it?

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Company’s Objectives: Build the risk
culture and provide the tools to...
Identify and correct sources of
risk

Improve decision making, and

Implement controls to preserve the gains.

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Risk Assessment

HAZARD EVENT

Slippery surface Slipping, causing a minor injury

Rung collapsing causing cut

Corroded ladder foot

Toxicity Inhalation causing fatality

Darkness Banging head or tripping

causing injury

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Review of Assessment

When reviewing the risk assessment, use the

following guidelines:
Risk level should be tolerable

Risk should be as low as reasonable practicable

Any new hazards created should be acceptable

Feedback from personnel on planned controls

Suggestions for improvement

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How to reduce the risk
Restrict access

Use of work permits – Hot , Cold, Enclosed space etc

Warning Signs

Use of other guidance/publications (e.g. ISGOTT)

Personal protective equipment

Integrate Risk Assessment with Procedures for Key

Shipboard Operations.

Plan, advise, follow the plan

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JUST REMEMBER….

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RISK MANAGEMENT

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 Video Film/showing

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Risk Management
Rules and
Techniques

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RISK MANAGEMENT

The Navy calls it Operational Risk Management (ORM)

Levels of Application

1.Hasty- On the Run Consideration

2.Deliberate- Application of the Complete 5-Step Process with
Detailed Analysis

The IMO call it Formal Safety Assessment (FSA)

It is a life skill that leads to sound decision making, greater

capability and fewer losses of our valuable assets.

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 The Benefits of Risk Management

Reduction in Serious Injuries & Fatalities.

Reduction in Material & Property Damage.

Effective Task Accomplishment and Cost Management.

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WHAT……
The term Risk Management is defined as:

A structured (logical and systematic) process for:

identifying, analyzing, assessing, treating, monitoring

and communicating risks for any activity, and;

achieving an acceptable balance between the costs of

an incident, and the costs of implementing measures to
reduce the risk of the incident happening.

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 RISK MANAGEMENT

Business Management is about maximising the chance of

success.
Risk Management is about minimizing the chance of failure –
pure risk
Effective Risk Management requires structured Risk
Assessment as an input

4544
RISK MANAGEMENT RULES
Integrate Into Planning

Accept No Unnecessary Risks

Make Risk Decisions at the Proper Level

Accept Risk If Benefits Outweigh the Cost

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RISK MANAGEMENT

Risk management is practiced on ships.

Is it properly structured and directed?

SMS based on risk management principles.

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WHO……..
Risk Assessment should be carried out by every person
irrespective of rank, whether on or off-duty, in all activities.

Formal Risk Assessment is generally carried out by Senior

Officers and inspected by the Master.

Technical Manager and Safety & Quality Manager ashore

shall review and evaluate the result of Risk Assessments
submitted to the office.

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RISK ANALYSIS TECHNIQUES

Cause-Consequence Hazard & Operability Analysis

Analysis Checklist (HAZOP)

Event Tree Analysis Human Reliability Preliminary

Failure Modes & Effects Hazard Analysis (PHA)
Analysis (FMEA)
Relative Ranking
Failure Modes, Effects
and Criticality Analysis Safety Review
(FMECA)
What-If / Checklist Analysis
Fault Tree Analysis
(FTA) What-If Analysis
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 Is the Risk Acceptable?
Risk Management Decision Options
AVOIDANCE
Discontinue the practice that
creates the risk
MITIGATION
Implement strategies to
reduce the impact
TRANSFER
Use Shore Assistance
Purchase financial relief
(Insurance)
ACCEPTANCE
Live with the risk

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RISK MANAGEMENT PROCESS
IDENTIFY HAZARDS

ASSESS HAZARDS & RISKS

MAKE RISK DECISIONS

IMPLEMENT CONTROLS

REVIEW, SUPERVISE, EMERGENCY

PROCEDURES

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RISK ASSESSMENT FORM

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RISK MATRIX

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 Classification
High: Work shall not start. Appropriate additional controls
must be taken to reduce residual risk level to Moderate or
Low.
Additionally, vessel’s Superintendent shall be contacted by
Master for Company concurrence before commencement of the
work activity.

Moderate: Efforts should be made to reduce the risk, with

heightened monitoring of the additional controls that are
implemented

Low: No additional controls required, monitoring required

to ensure identified controls are maintained

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 SUMMARY
Risk management is a systematic way of thinking

It increases awareness of hazards and risks involved in an

operation

Process should be dynamic

If you want to know the cost of safety, try having an accident

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56
REMEMBER……

It should be simple, practical and

meaningful.

“What has not been identified

cannot be assessed,
eliminated, safeguarded or
controlled.”

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 Maxims of Risk Management
* Everything has hazards, and all hazards have risk.
* Risks are not equally consequential.
* Risk has two components –severity and probability of loss.
To assess risk, both must be evaluated.
* Man lacks omniscience –some risks won’t be known.
* Man lacks precognition –some risks won’t be foreseen.
* Man’s resources are finite –resources available to control
risks are limited.
* A thing operates beneficially only if its risks are more than
offset by its benefits.
* A thing is “safe” only to the degree that its risks are
acceptable. There is no absolute safety.
* Recognized risks exceeding the acceptability limit must
be made known to those who may suffer their
consequences.
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 Risks

*We accept risk when:

•We don’t know it’s there.
•When it’s insignificantly low.
•When it’s worth it.

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Risk Assessment Process

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Let someone else do it!

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62
 Identify Work Activity and Evaluate
Alternatives

The Work Activity must be clearly defined (e.g. in tank repair of

cargo pump).

Each task which is a part of the work activity shall be considered

(e.g. enclosed space entry, lifting/shifting weights, mechanical
repair work at the cargo pump, etc.).

Alternative methods of work that permit safe completion of the

work shall be identified, documented in the risk assessment and
adopted if it is a safer practicable alternative for the work activity.

If there is no safer practicable alternative, proceed with hazard

identification for the work activity.

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 Identify Hazards
Hazard is defined as the property of a substance, situation or
practice with the potential to cause harm.
Hazard identification requires good understanding of the work
activity, work environment and cause-effect relationships of
various tasks and processes within the work activity or related to
the work activity. Identify hazards by step-by-step analysis of the
work activity.

Effective identification of hazards is a key factor in meaningful risk

assessments.

Each identified hazard, if not controlled by “barriers” can lead to an

“accident” (explosion of tank) which can have unwanted
“consequences” (e.g. loss of life, pollution, etc.)
6466
 List Potential Consequence(s)

List the Potential Consequence(s) of the loss of control of each

hazard during a work activity.

All the consequences arising out of the loss of control of each

identified hazard should be listed separately so that controls
can be identified and preserved during the work activity.

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 Identify and Implement Existing Preventive
and Mitigating Controls
Controls are:

− Preventive measures which serve as a “barrier” to prevent the

hazard causing an accident; and

− Mitigation (or recovery) measures which reduce the

consequences of an incident (e. g. response elements to limit the
impact of any unplanned occurrences) and accelerate
recovery processes after any unplanned occurrences.

Identify all Controls that are in place, or planned, which ensure

that the Hazard will not result in an unintended event
(accident/incident).

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 Controls include:
• Applicable regulations,
• Industry codes,
• Industry standards,
• Industry guidelines,
• Company procedures,
• Charterers’ instructions,
• Standing Orders.
• Training and experience of
relevant personnel,
• Protection, detection and
control systems (e.g. IGS,
Fixed Gas Detection
System etc.)
• Number of personnel,
• Level of Supervision
• Equipment used for the
activity,
• Maintenance,
• Communication/language
requirements,
• Personal Protective,
Equipment (PPE),
• Company concurrence (as
applicable),
• Operational Limits set for
Environmental Conditions, Etc.
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 Determine Risk
Determination of risk requires the determination of the
frequency (likelihood) of the unintended event
(accident/incident) occurring, and the severity of the
consequence(s) of an unintended event. SOM-06-30-Appendix
1- Risk Assessment Form, Page 2, shall be used.

To establish frequency of an unintended event, the adequacy

and/or reliability of existing or planned preventive controls for all
identified hazards shall be considered.

Similarly, for establishing the severity of the consequence of an

unintended event the adequacy and/or reliability of existing or
planned controls for all identified hazards shall be
considered.
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For shipboard risk assessments, if the determination
of risk results in the identification of significant risk or
safety deficiency that cannot be controlled effectively
or rectified by shipboard personnel, it shall be
immediately reported to the Superintendent.

In addition, a SMS Report shall be created and

submitted for a significant risk or deficiency. This will
ensure that a full assessment of the situation is
undertaken both by the shore and ship’s management
before the risk/deficiency is eliminated and the
operation can continue.
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 Establish and Implement Additional
Controls (if necessary)
Based on the outcome of a risk assessment, it should be decided
whether controls need to be improved, that is, Additional Controls
need to be implemented.

As guidance on selecting appropriate controls, the following is an

order of priority for minimizing the harmful effects of a hazard:
− Remove or eliminate the hazard, i.e., combat the risk at source.
This generally applies to
environmental hazards such as noise, heat, cold, dust, smoke etc.
− Contain the hazard, i.e. erect guards or barriers. Dedicated
locations for harmful or
dangerous substances
− Use technology to monitor the hazard i.e. gas detector /oxygen
analyzer etc
7072
- Adapt the individual to the work, i.e. train on the use of equipment or
control systems, language and communication requirements, physical
and mental suitability.
− Personal protective equipment: This is often viewed as a last resort,
i.e. accepting the hazard as all other control options have been
considered.
− Emergency response: Should controls fail and the hazard manifest
itself into an accident the only way to minimise the consequences is
the speed and effectiveness of emergency response.
− Re-design and re-equip: In many instances, controls are put in
place to protect the individual from the risks in bad design or bad and
faulty equipment or machinery.

In the above list, more than one option can be implemented if doing
so can further reduce risk.
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 Review Residual Risk
When reviewing Risk Assessment for any work activity, the
following points should be considered:

• all controls, existing or planned, should make the risks

tolerable.
• residual risk should be “as low as reasonably practicable”
(ALARP).
• any new hazards created are acceptable.
• feedback from personnel involved in the work activity on the
practicality of any existing or planned controls and suggestions
for improvement.

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 Implementation of Controls
Work shall not commence until all the identified Existing
Controls and Additional Controls are implemented.
Achievable targets shall be set for implementation of
preventive and mitigation controls identified in the risk
assessment.

For risk assessments from, sent to the Company, the vessel’s

Superintendent shall monitor the implementation of
preventive controls and mitigation (and recovery) controls and
investigate any delays so as to expedite the process.

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 Management of Change
What is it?
As a part of a management of change process (refer CSQEMM
3.04). All temporary and permanent changes to procedures or
equipment on board the vessel shall be subject
to risk assessment to evaluate the impact of proposed changes.
The risk assessment shall include the impact of the proposed
change upon all routine and non-routine tasks
related to the proposed change and establish controls to
mitigate the adverse effect of the proposed changes. If a
proposed change is not completed within a set time frame
then the change must be reviewed, the initial hazard
identification and risk assessment shall be revisited and re-
approval sought.
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 Management of Change
• Management of Change (MOC) process shall be
undertaken both on board and ashore especially for any
change that affects safety; however minor it may be.
• CSQEMM 3.04 – Appendix 1 – Management of Change
Form shall be used along with SOM 6.30 – Appendix 1 – Risk
Assessment (RA) during the MOC process.
• All supporting documentation to evidence the MOC
process shall be retained along with the MOC Form and
Risk Assessment for verification processes, both on
board and ashore in the Company for the respective
MOC processes conducted.

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Forms (QR-SQE-45)

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Forms (QR-SQE-45)

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78
Incident
Investigation
and
Root Cause
Analysis

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 Objectives of the Course
At the end of the Course, the trainees must be able to:

1. To state the basic principles of Incident Investigation.

2. To explain the need for Incident Investigation .
3. To demonstrate understanding and identify ways to assist in
the realization and review of SMS.
4. To demonstrate how to accomplish the following:
Incident Investigation
Data Gathering
Data Analysis
Root Cause Determination
Generating Recommendations
5. Reporting and Trending of Incident Investigation Results
6. To state successful implementation of the Company’s
System in the smoothest possible way .
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 Course Topics
1. Introduction and Basics of Accident Investigation

2. Investigations

3. Incident Analysis

4. Recommendations
5. Reports

6. Follow up of an investigation and closure of reports

7. Case studies and Hands-on Sessions

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Introduction and Basics of
Incident Investigation

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 Aim
To understand the need for Structured
Incident Investigation.

To help people and organizations learn

from past performance and develop
strategies to improve safety.

To comply with requirements of flag

administration, ISM etc.
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 Objectives
- Recognize the need for Marine Incident Investigation

-Carry out:

a. Incident Investigation
b. Data Gathering
c. Data Analysis
d. Root/Basic/Underlying Cause Determination
e. Generating Recommendations
f. Reporting of Incident Investigation Results

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 CAUSES OF ACCIDENTS

Accidents Consequences

Direct Cause Unsafe Act/Condition

Indirect Cause Job/Personal Factors

Root Cause Lack of Controls

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 Reactive Improvement
•LEARNING FROM EXPERIENCE

•Fixing smaller problems prevents a major

accident

•Iceberg Theory
–Visible tip (Results/Shortcomings)
Fire/Explosion
& fatalities

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 Proactive Improvement
•Melting of an Iceberg
–Heating the Tip or
–Heat the whole Iceberg

•Need to work on all levels

Unsafe Conditions & Situations
• Audits, Observations, Self-Assessments & Reviews
Near Misses
• Self Reporting & Near Miss Analysis
Incident
• Incident Investigation
Accidents
• Accident Investigation

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 Loss Event

•Undesirable consequences resulting from events or conditions

or a combination of these.

•The way the loss event is stated and understood will define
the scope of the incident analysis.

•Multiple loss events may be identified as part of a single

investigation.

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 Causal Factors

•Structural/Machinery/Equipment/Outfitting problems, human

errors and external factors that caused an incident, allowed an
incident to occur or allowed the consequences of the incident to
be worse than they might have been.

–For a typical incident, there are multiple causal factors.

–Each causal factor is an event or condition for which steps

should be taken to reduce or mitigate its occurrence.

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 The Need for Investigation
•The prevention of future accidents/incidents by learning from experience.

•Unstructured approaches often simply delay the recurrence (or change the
specifics) of the incident. - Being totally reactive

•Using a structured approach is a better option.

•The Accident/ Incident Investigation would identify Root cause(s) and the
ensuing corrective action would prevent future accidents, as the famous
adage goes…

“An ounce of prevention is worth a pound of cure”

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 Risk Assessment and Incident Investigation
Looking for What
Could Go Wrong…

Looking at What Has

Gone Wrong. 91
Depths of Analysis

92
Depths of Analyses

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 Structured Analysis Process
So the tradeoff is this:
Avoiding failures allows (vessel)
operations to run more smoothly,
allows personnel to plan with more
confidence and reduces the stress
associated with always having to “fight
the latest fire.”
In return, solve one problem
instead of many and avoid
future failures.

Do more work now to understand the

underlying causes and solve them.

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Investigations

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 IMO DEFINITIONS
Foundering- Includes ships which sink as a result of
heavy weather, springing leaks, breaking
in two, etc., but not as a consequence of
categories listed below.
Missing- After a reasonable period of time, no
news having been received from a ship
and its fate is undetermined, the ship is
posted as missing.
Fire/Explosion- Includes ships experiencing a fire and/or
explosion where it is the first event
reported- it therefore follows that
casualties where a fire and/or explosion
is the result of some other incident
category, such an incident is categorized
under that incident
Collision- The result of one ship being struck by
another, regardless of being whether
under way, anchored or moored.
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 IMO DEFINITIONS
Contact- The result of a ship striking an
external object– but not another ship
or the sea bottom. This includes
striking a drilling rigs/platforms.
Grounding/Wrecked/Stranded- Includes a ship touching
the sea bottom, sandbanks, shoals,
seashore etc., as well as being
entangled on underwater wrecks.
Hull/machinery- Failure of equipment or machinery,
immobilisation of the main engine.
Heavy weather Ice Damage- Significant damage caused
by heavy seas of the elements and ice
damage.
Other- Any casualty that is not included
above and may include war damage
being a deliberate act may not be
classified as a casualty.

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 COMPANY’S DEFINITIONS
An Accident is an occurrence where the safety of the crew,
cargo or environment has been jeopardised.
Accidents are classified, reported, investigated and depending on
the severity or potential severity of the occurrence
For the purpose of the CSQEMS, accidents are classified as
Serious Marine Incidents, Marine Incidents and non‐Serious
Incidents.
A Serious Marine Incident (SMI) involves
− Loss of life
− Severe Pollution (as evaluated by the coastal state or
Administration)
− Total loss of the ship
Serious Marine Incident (SMI) also involves Other irretrievable
damage or and extreme damage to the ship with a potential
severity of 5 (on a scale of 1 to 5), where 5 is maximum severity.98
 COMPANY’S DEFINITIONS
Marine Incident is an event or sequence of events that is not a
Serious Marine Incident and has occurred directly in connection
with the operation of the ship that endangered, or, if not corrected,
would endanger the safety of the ship, its occupants or any other
person or the environment, having a severity or potential severity
of 3 or 4.

Non‐Serious Incident is an event, sequence of events or

condition that is not a Serious Marine Incident or Marine
Incident and has/may lead to any interruption or unfavourable
deviation of process or normal operations

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 REPORTING & INVESTIGATION OF INCIDENTS
Reporting Requirements
Master shall initiate Shipboard Emergency Response for a Serious
Marine Incident in accordance with the Company’s Shipboard Emergency
Plan.
Master shall promptly notify the Company by the most efficient means
every time a Serious Marine Incident or Marine Incident occurs.
Additionally, the Master shall make necessary notifications as required by
rules and regulations related to the vessel and marine industry including
any regulatory reporting warranted by the nature of the incident.
Investigation and Cause Analysis
Marine Systematic Cause Analysis Technique (MSCAT) shall be used to
determine immediate cause and root cause and establish control actions
to avoid such incidents. Reference is made to CSQEMM 4.09 ‐ Appendix
1 and Appendix 2.

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 When should investigations be undertaken?
There are three types of incidents that should be analyzed in
depth.

• The first type is the large consequence incident.

- For these incidents, the actual consequences are
large enough that a single incident is intolerable to the
organization e.g. groundings, collisions, fatalities.

• The second type is a near miss to one of these large

consequence incidents.
-For these types of incidents, it is prudent to investigate
proactively before a large loss occurs.

• The third type of incident is actually a

set of incidents.
-In this case, there are a number
of small incidents that collectively
add up to something big.
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 Near Misses
•Near misses should be investigated or
trended when the potential consequences are
large enough.

•To get near misses reported, the

organization needs to specifically define what
a near miss is and address the barriers to
getting near misses reported.

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 Beginning the Investigation
•The investigation should begin as soon as possible.
Beginning the Investigation
•The loss events/conditions should be specifically identified.

•What equipment, personnel, systems were involved & what were the other
circumstances

•By having multiple loss events/conditions, it is ensured that the causes of

each are identified as part of the analysis.

•Loss events/conditions are the starting point for data gathering & analysis

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 Gathering and Preserving Data

•Data are vital for ensuring that an understanding can be reached about
what, how, and eventually, why the incident occurred.

•The aspects includes:

5 basic types of data
–People, Paper, Electronic, Physical and Position.

•Prioritizing data-gathering efforts

•Gathering, preserving and analyzing data

•Overall data collection plan

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 Overall Types of Data (5 basic types)
•People:
–interviews with or written statements from witnesses, participants, etc.
•Physical/Parts:
–parts, samples, PPE, structures, damaged areas etc.
•Paper/Records:
–hard copies of procedures, drawings, sketches, notes, performance
and operational data, analysis results, procurement specifications,
navigational charts, loading specifications, logs etc.
•Electronic:
–electronic copies of procedures, policies, administrative controls,
drawings, performance and operational data, analysis results,
procurement specifications, e-mail, navigational charts, loading
specifications, etc.
•Position:
–locations of people and physical data.

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 Prioritizing Data-gathering Efforts

Generally,
the data
types from
most fragile
to least
fragile are:
•People
•Electronic
•Position
•Physical
•Paper

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Interviewing Persons

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 Physical Data and Failure Analysis

General Testing:
Physical Data, Failure Analysis

Many different tests can be used by the

team to understand the underlying
causes of the failure.

i.e. Check the conditions of use etc.

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 Chain-of-Custody

•Chain-of-custody should be applied to data to ensure that the data

obtained is valid and true.
•Establish a data log to ensure the integrity of the data. (i.e. to ensure
that the team is examining the same documents that were in use
during the event)
•Number or tag each item collected and control access to and use of
data to prevent modification of the data and prevent destruction or
disposal of the items.
•Use of Outside Experts
The analysis of parts and materials can be a very complex
science. The use of outside experts may be required to adequately
perform the required analyses. An assessment of the costs of this
outside expertise should be balanced against the expected benefits
from the expert analysis.

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 Analysis of paper data

•Analysis of paper data often involves comparison of various

documents to determine the various methods specified for
performing a task.

•Comparisons can also be made between the descriptions in

the document and actual performance in the field.

•Documents should also be reviewed to determine if they

describe the proper methods to be used to perform the task.

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 Electronic Data

•Electronic data can be easily modified. Therefore, chain of custody

should also be applied to electronic data to ensure their integrity.
Controlling access to and the use of data will also help maintain their
integrity.

•A final issue unique to electronic data is the potential loss of the

data following an event because the data are not automatically
saved or are destroyed as a result of the incident.

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 Position Data

•Position data are often lost during the initial stages of the investigation.
•Weather and exposure can change the levels in tanks and the locations
and extent of stains and other markings.
•Like physical data, once the data are altered or disturbed, there may be
no way to recover the information.
DATA COLLECTION
•The easiest method to collect position data is through direct observation,
however, this does not produce a permanent record of the observations.
•Two common methods for recording position data are the still camera
and the video recorder.
•Reference items should be included in all photos and videos.
•Sometimes photos are not practical. In these cases, charts, maps and
drawings can be used to capture the required information.

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 Gathering and Preserving Data

•The investigator should not only look at what is present,

but also note what is not damaged.

•Questioning the obvious and looking at all of the physical

data is often the key to discovering important data.

•The investigation team should make a conscious effort to

determine what is absent that should be expected to be
present during the operations that were being conducted.

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Incident Analysis

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 Incident Analysis

There are various systems for Incident Analysis.

Marine Systematic Cause Analysis Technique (DNV M-SCAT)

Effective investigations can:

Describe what happened
Determine the real causes
Decide the risks
Develop controls
Define Trends
Demonstrate Managements concern

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 Incident Analysis

Six major phases of effective investigation

Respond to the Emergency

Collect pertinent information
Analyze and evaluate all significant causes
Develop and take corrective actions
Review findings and recommendations
Follow through

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 Incident Analysis

Description Evaluation of Type of Intermediate or

of Accident Loss Contact Direct Cause
or Incident Potential (IC)

Basic or
Underlying
Cause

Control Action
Needs (CAN)

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 Incident Analysis

Description of Accident or Incident

People
Process/Operation
Property
Environmental

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 Incident Analysis

Evaluation of Loss Potential if not controlled

Loss Severity Potential

Major
Serious
Minor
Probability of Recurrence
High
Moderate
Low

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 Incident Analysis

Type of Contact

Personal Injury/Illness
Falls, struck, caught, contact, stress

Property/Process/Environmental Damage
Collision, grounding, contact, fire, explosion, etc

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 Incident Analysis

Immediate/Direct Causes (IC)

Substandard acts/practices
Substandard conditions

Basic/Underlying Causes (BC)

Personal Factors
Job factors

Control Action Needs (CAN)

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Levels of the Analysis:

122
 Levels of the Analysis:

•Figure 7, shows the

typical progression of
the analysis down to
the root cause level,
consistent with the
view of the task
triangles examined
earlier.

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 Identifying Root Causes

Identifying root causes is one of the main goals of the

incident investigation process, but it is heavily dependent on
finding the causal factors.
For virtually every incident, some improvement(s) in
management systems could have prevented most (or all) of the
contributing events from occurring.
A root cause indicates a management system weakness
and addresses something over which management has
control.
Therefore, root causes, are intended to be as deep as
can reasonably be addressed with recommendations.
Identifying root causes that are outside the control of
management does not help resolve the issue and can often
lead to a sense of helplessness.

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 Identifying Root Causes

Finally, there is very rarely one cause for an incident.

When investigators try to find the single cause of the incident or

the primary cause of the incident, they usually end up missing significant
contributors.

Multiple safeguards exist to prevent or mitigate almost any

incident worth investigating.

Therefore, numerous failures of these safeguards have to occur

to generate an incident.

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 Identifying Root Causes

Root Cause Analysis Traps

There are several traps that investigators often fall into when thinking
about root causes. Some of these traps include the following:
Trap 1 – Hardware Problems
Trap 2 – Personnel Problems
Trap 3 – External Event Problems.

The M-SCAT, MARCAT, The Taproot Root Cause Tree etc are simply a
checklist, arranged in the form of a tree, to help investigators identify root
causes.
One of the primary advantages about structured formats is that it facilitates
consistency across all root cause investigations. By using a consistent coding scheme, it
supports trending of “root causes” and “categories” by using root cause codes.

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 Procedure for Identifying Root Causes

Multiple Coding
Most causal factors have more than one associated root cause. For example, a deckhand fails to
follow a procedure.

In investigating the incident, it was found that deckhands are taught to follow procedures,
there is even a policy for this. But the deckhands routinely take shortcuts to get the job done faster.

In other words, this particular policy has never been enforced. In addition, many of the
procedures are out of date. As a result, a lot of these procedures cannot be performed as written
because of changes that have occurred since the procedures were written.

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 Multiple Coding

In this case, there are two root causes.

First, the standard, policy or
administrative control (SPAC) that requires
procedures to be used is not enforced.
Second, the SPACs for procedure
updates do not address the procedures the
deckhands use.

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 Typical Problems Encountered When Using a
Structured Method
Many of these problems stem from differences in the use of certain terms.
Policies versus Procedures Figure 2, “Document Hierarchy,” shows a typical document
hierarchy.

Policies are the base of the hierarchy

and are the most general types of documents.
Standards describe the methods used to
measure acceptable performance to the policy.
Procedures are step-by-step
documents that describe how a task will be
accomplished.
Finally, Records or Proof documents
provide evidence that the policies and
procedures are implemented and the
standards are being met.

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 Advantages and Disadvantage of Using a Structured
Method
Advantages
Using a predefined list with numerous categories ensures that the
investigator will consider a minimum set of issues when identifying
underlying causes.
Using a predefined list can speed up the root cause identification
process by providing a starting point for the investigator.
Using a predefined list can encourage consistency in the
identification and coding of root causes. This increases the validity of
trending across investigations.
Using a predefined list can provide a uniform terminology for the
organization to use when discussing underlying causes.

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 Advantages and Disadvantages of Using a Structured Method

Disadvantages

Using a predefined list of categories can limit the brainstorming performed

by the individual or team.
If the team believes that the list is all-inclusive and that they do not have to
think, then this can be a significant limitation.

If there are underlying causes that the team does not identify because the
predefined list does not trigger them to think of the issue, then it can affect the
effectiveness of the recommendations that are identified.

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 Summary

The root cause identification process involves identification of underlying causes. The M-SCAT, MARCAT &
The Taproot Root Cause Tree provide guidance to help the investigator identify underlying causes.

They do not provide every possibility, but should provide sufficient triggers to ensure that the investigator
considers a broad range of possibilities.

Root cause identification is always performed for root cause analyses, but some root causes may also be
identified during an apparent cause analysis.

There are sometimes Generic Root Causes that are even deeper in the system & possibly affecting many
facets of it & finding & tackling these will give even greater results.

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Recommendations

133
 Developing Recommendations
•Recommendations are the most important products
of the investigation and are developed after the data
analysis and identification of underlying causes are
completed.
•These should be directly tied to causal factors and
their underlying root causes and the implementation
of the recommendation should eliminate them.
•They must be practical, feasible and achievable
and should be assigned to someone along with a
completion date.

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 Developing recommendations
•The recommendation may not be implemented by
the person who wrote it and hence must be clear,
precise and provide measurable completion criteria.
•Recommendations need to be reviewed as part of
a management of change process to ensure that
they solve more problems than they create.
•The objective is to implement recommendations
that have large benefits and minimal negative
impacts or costs. Proactive risk assessment
techniques should be used to assess the potential
impacts of recommendations.

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 Cost - Benefit Ratios
•Recommendations with the largest cost-
benefit ratios should be implemented first,
unless the cumulative benefit of
implementing several lower-cost items
provides a more attractive return-on
investment or the resources are simply not
available to implement relatively expensive
items.
•For relatively inexpensive items that seem
reasonable, management will often decide
to implement the recommendations
without detailed cost-benefit analysis
because detailed analysis costs may be
comparable to, or cost more than, the cost
of implementation.

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 Timing of Recommendations
Recommendations can be categorized in many different ways, here are three (3) examples:

1. Time-based recommendations- are generally put into one of three time-based categories
i) Short-term
ii) Medium-term
iii) Long-term
It should be noted that suggested changes should not conflict with other existing processes, procedures or policies
within the management system, even for a short time.

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 Levels of Recommendations

2. Depth of recommendation- there are four levels of

recommendations/actions.
Level 1 – Address the Causal Factor
Level 2 – Address the Intermediate Causes of the
Specific Problem
Level 3 – Fix Similar Problems
Level 4 – Correct the Process that Creates These
Problems
These recommendations are very proactive. They prevent future losses and keep organizations
from having to fix each problem as it arises (being totally reactive). If Level 4 recommendations are
not implemented, the organization usually has to implement many more Level 1, 2 and 3
recommendations. Level 4 recommendations are almost always long-term recommendations.

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 Types of Recommendations
3. How the recommendation attempts to eliminate or control the hazard
The most desirable recommendations are generally those that eliminate the hazard,
while the least desirable are those that perform emergency response after the
consequences of the incident have occurred.
•Eliminate the Hazard
•Make the System Inherently Safer/More Reliable
•Prevent the Occurrence of the Incident
•Detect and Mitigate the Loss
•Depending upon the situation, the organization may choose
to implement a number of different types of
recommendations.

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 Suggested Format for Recommendations

•Provide a general objective to be accomplished for each recommendation. This should be followed
by a specific example of how it could be successfully completed. This ensures that the
recommendation is clearly described, yet allows flexibility in meeting the general objective.

Special Recommendation Areas:

Restart/resumption/voyage continuation criteria may be important methods for controlling risks.

Disciplinary actions or commendations should generally be avoided unless specifically included within
the scope of the investigation.
“No action” may be an appropriate recommendation for certain instances in which the risk of
recurrence is very low (an acceptable risk) or the cause is beyond the control/influence of the
organization.

140
 Recommendations

Summary
•Developing recommendations is one of the last steps in the investigation
process. Recommendations can be categorized in many different ways,
including:
i) The time frame of the recommendation,
ii) The level of the recommendation, and
iii) The methods it uses to control the hazard.
•Disciplinary actions should generally be avoided as part of the investigation
process. Management has numerous responsibilities to resolve and
implement the recommendations. Recommendations can be prioritized by
using cost-benefit ratios as a guide. Finally, recommendation effectiveness
can be assessed by using a recommendation assessment strategy.

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 Completing the Investigation

•This Section presents four major issues that need to be addressed following the completion of an
investigation.

These four issues are:

i) Writing investigation reports

ii) Communicating investigation results
iii) Resolving recommendations and communicating
resolutions
iv) Evaluating the investigation process

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 Completing the Investigation
•Fault trees or 5-Whys trees and causal factor charts
should be included in the report or attached to the report.
•Photos of the scene and equipment can often be great
time savers.
•A formal report is anything that goes beyond completion of the
standard report form. Most incident investigations (medium-scale and
large-scale analyses) should have a formal report. However, even for
these analyses, a standard report form should be completed.
•In most cases, these tools, along with the three-column forms
showing causal factors, root causes and recommendations, should
provide the vast majority of the information needed in the report.
•An executive summary or synopsis can help more people get the
important points from the report without having to read all the details.
These are usually only written for medium- and large-scale analyses

143
144
 FOLLOW UP AND CLOSING OF REPORTS
• Focus of the investigation shall be to ascertain the root causes and factors
contributing to the casualty and to recommend corrective and preventive
actions.

• The Investigation Report shall be completed, reviewed and approved

within the timescale unless express extension is obtained from the
Managing Director due to unavoidable circumstances. Such extension
shall be recorded in the Control Sheet of the Investigation Report Form
(CSQEMM ‐ 4‐09 ‐ Appendix 1 ‐ Investigation Report format).

• The Investigation Reports shall include a proposed timescale for closing

out of corrective/preventive actions.
• Review of the Investigation Report shall be done a duly trained and
qualified Manager in the Company. The Investigation Report shall be
approved by the Managing Director.
• Managing Director shall review this timescale until all issues are resolved

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 Tips for Writing Reports
•Start Writing the Report at the Beginning of the Investigation

•Have the Report Reviewed

•Explain Any Contradictory Information

•Identify Facts, Conclusions, Hypotheses and Recommendations

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 Tips for Writing Reports

•Ensure that the Report Addresses the Needs of the

Audience
•Do not Fill up the Report with Unneeded Information
•Do not Use Names of Individuals
•Do not Downplay Sensitive Issues
•Use Supplemental Information as Needed
•Issue Reports as Controlled Documents or Records
•Properly Control Proprietary and Other Sensitive
Data
•Follow Generally Accepted Technical Writing
Guidelines

147
 Tips for Writing Reports

•Legal DO’s

i) Do follow through on each recommendation and document the final

resolution, including why it was rejected (if that is the final resolution).
ii) Do involve the legal department as soon as possible if the incident
appears to have potential liability for the organization.
iii) Do report, investigate and document near misses to demonstrate the
organization’s commitment to (1) learning where there are weaknesses
and (2) improving risk controls.

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 Tips for Writing Reports

•Legal DON’Ts
i) Don’t use inflammatory statements such as disaster, lethal, nearly electrocuted and
catastrophe.
ii) Don’t use judgmental words such as negligent, deficient or intentional
iii) Don’t assign blame.
iv) Don’t speculate about potential outcomes (for near misses and minor accidents),
lack of compliance, liabilities, penalties, etc.
v) Don’t offer opinions on contract rights, obligations or warranty issues.
vi) Don’t make broad conclusions that can’t be supported by the facts of this
investigation. (Let queries of the database demonstrate these conclusions as
necessary.)
vii) Don’t offer unsupported opinions, perceptions and speculations.
viii) Don’t oversell recommendations; allow for alternative resolutions of the problems
and weaknesses found.

149
 Media Considerations
•Following a major incident, it is best to have individuals deal with the media who
are specially trained in facing the media.

The following guidelines should help you avoid problems when

dealing with the media.
i) Avoid releasing names of victims until families are notified. Not only does this
avoid misleading and inaccurate information in the media, it also conveys the
organization’s concern for its personnel and their families.
ii) Always be truthful. It is not necessary to tell the media all that is known, but
whatever is said should be the truth. Do not speculate or guess about what is
not known. This could cause repercussions later.

150
iii) Avoid speculation. Avoid expressing opinions, beliefs, speculations and
hypotheses before completing the investigation. Describe only confirmed
events and solid conclusions. If asked to comment beyond the established
facts, highlight the work-in-progress nature of the investigation.
iv) Be prepared and willing to describe the investigation process and
methods. Tell them what you are doing to discover the underlying causes
of the incident to ensure that it does not happen again. Sometimes, being
organized will go a long way towards satisfying the public.
v) Do not bring up old history. Only discuss the incident under
investigation, not other incidents or other organizational problems. There
is no need to give them more ammunition to use against the organization.

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 Summary
•The goal of incident investigation is not only to understand the “what”
and “how” of an incident, but also why it happened.
•The analysis of an incident begins with the data, that are gathered,
organized and analyzed using M-SCAT, causal factor charting, fault tree
analysis, the 5-Whys technique or other appropriate tools.
•The goal is first to identify the causal factors for the incident. Causal
factors are those contributors (human errors, problems and external
factors) that, if eliminated, would have either prevented the occurrence
or reduced its severity.
•Once the incident is understood, root causes are identified for each
causal factor. Root causes are deficiencies of management systems that
allow the causal factors to occur or exist.
•Finally, recommendations are developed and implemented to eliminate
the root causes and prevent the causal factors from occurring again.

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 Where to Get More Information

•Mariner’s (Master’s) Role in Collecting Evidence

•“Code for the Investigation of Marine casualties

and Incidents”

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 LET’S DO THE ASSESSMENT…..

 ARE YOU READY??????

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