World Maritime University

Seminar on 1

Maritime Casualty
Investigations

Types of investigations

(c) Dr. Jens-Uwe Schröder World Maritime University

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• Types of investigations
• History
• Types of investigations
• National legislation 2

• Scope of investigations
• Appointment of investigators

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• Types of casualty investigations

• History
• UK
• 1838 British Parliament 3

Suggestion to establish a system of Courts of
Marine Inquiry (CMI) be established to
investigate:
o Causes of shipwrecks
o Censure ‘commanders’ and shipowners
o Suspend licences
o Reward acts of skill, humanity and courage
o Publicise the outcomes of such inquiries

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• Types of casualty
investigations
• History
• UK
4
• 1843 British Parliament

endorsed recommendations

publication of the evidence and the findings should
also act to prevent further casualties
• 1846 Steam Navigation Act

serious accidents reported to the Board of Trade and
provided for the appointment of suitably skilled and
qualified inspectors to inquire into and report on
such marine casualties

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• Types of casualty investigations

• History
• UK
• 1860 Objective of casualty investigation 5

“… not so much to punish anyone who may be

at fault, as to prevent wrecks in the future …”.

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• Types of casualty investigations

• History
• UK
• Merchant Shipping Act of 1876 6

Two tier system of inquiry
o Preliminary Inquiry
o Followed by a Formal Investigation before a
judge advised by specialist “assessors”

The Preliminary Inquiry was to establish
whether or not a Formal Investigation was
warranted

System still in place by many countries formerly
following British legislation

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• Types of casualty investigations

• UK system is a typical example of an
administrative framework
• Many traditional maritime countries have well 7
developed systems of inquiry
• Systems can vary

Forms
o Safety investigations
o Penal investigations

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• Safety investigations
• Stages
• Filing of an initial Casualty Report by or on behalf
of one or more of the directly affected parties, on 8
an official form provided by the Administration
• If deemed necessary by the Administration, an
informal Preliminary Inquiry (or Technical
Investigation), is normally conducted ‘in the field’
by an investigator on the permanent staff of the
Administration
• In cases of unusual complexity or significant
importance (“major” casualties in the words of the
Code), a Formal Investigation may be conducted

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• Safety investigations
• Preliminary Inquiry
• Technical Investigation

Different procedures apply to in different 9
countries
o TSB Canada distinguishes between
– Field phase, Post-Field phase and Report
Production phase
– The core values followed are competence,
openness, fairness, integrity and respect

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• Safety investigations
• Europe
• Investigators

Usually ex-seafarers and experts from relevant
professions (e.g. naval architects … - either full time 10

or consulted for particular accidents)

Portugal: Recruited from the navy
• Investigation boards

Separate (Sweden, Germany, Netherlands etc.)

Integrated (Greece, Italy, Portugal)

Independent (UK, Netherlands, Finland)

Part of the Administration (Denmark, Norway)

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• Safety investigations
• Summary
• “Dependent” vs. independent bodies

Guild apportioning vs. learning lessons
11

Independent investigations expect a higher
degree of information provided, openness and
honesty (not always confirmed in practice)

Boarders between dependent and independent
bodies in practice floating

Difficulty to separate a safety from a criminal
investigation

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• Safety investigations
• Formal investigations
• Costly legal affair
• Depending on the legal system in the country
• Justice Steyn 1987 Formal Investigation into the sinking of
12
the “European Gateway”.

“There is, however, not a great deal of dispute about the
purpose of such an inquiry. It is common ground that the
primary purpose of any such inquiry is … to assist in the
preservation of a reasonable standard of safety of life and
property at sea. The second purpose is to determine why
a casualty occurred. The third purpose is to consider
whether the casualty was caused by the wrongful act or
default of any person, and, if so, whether the court should
impose penalties on those at fault."

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• Most relevant requirements result

from domestic legislation
• Reporting of casualties
• Cooperation in accident investigation 13

• Purpose of investigations
• Scope of investigations

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• Duty to report accidents

• All flag State administrations require a
notification about an accident
• No matter if there is a criminal or a safety 14
investigation
• Cooperation in accident
investigations
• Similar as above
• Penalties for
non-compliance

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• Independent bodies
• Members in the maritime field

Australia, Canada, Finland, The Netherlands,
New Zealand, Sweden, UK, USA
15

www.itsasafety.org

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• International cooperation

• MAIIF
• ITSA 16

• NTSB Academy

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• Scope of investigations
• Depending on national requirements
• Criterion

Severity of accidents 17

Examples:
o UK
– Preliminary inquiries for minor accidents
– Formal investigations for high impact accidents
o Germany
– Investigation depends on severity of accident

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• Overview about some major flag

States
• UK
• Accident investigation body 18

Marine Accident Investigation Branch (MAIB)

Southampton

www.maib.gov.uk
• Legal Basis

Accident investigation since 1838

Currently according to Merchant Shipping
(Accident Reporting and Investigation)
Regulations 2005
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• Overview about some major flag

States
• UK
• Other institutions involved 19

Health and Safety Executive (HSE)

Maritime Coastguard Agency
• Reporting requirements

Art. 6 Merchant Shipping (Accident Reporting
and Investigation) Regulations 2005

Reporting form on webpage

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• Overview about some major flag States
• UK
• Merchant Shipping Act, 1995
• Section 267
20

Appointment of inspectors of marine accidents with
powers to investigate marine accidents

Marine Accident Investigation Board (MAIB) under a
Chief Inspector responsible for investigating all
marine accidents

Acting independently of the government

On completion of an investigation, the MAIB submits
a report to the Secretary of State for Transport

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• Overview about some major flag

States
• UK
• Merchant Shipping Act, 1995 21

• Section 268

Formal Investigation may be made in certain
circumstances

Under the control of the UK Attorney General

Secretary of State of Transport can still call for
a Formal Investigation

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• Overview about some major flag

States
• Germany
• Accident investigation body 22

Bundesstelle für Seeunfalluntersuchung

Hamburg

www.bsu-bund.de
• Legal Basis

Accident investigation since 1877

Currently according to Seesicherheits-
Untersuchungs-Gesetz (SUG), 2002

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• Overview about some major flag

States
• Germany
• Other institutions involved 23

Seeamt

See-Berufsgenossenschaft (SeeBG)

Wasserschutzpolizei

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• Overview about some major flag

States
• Germany
• Reporting requirements 24

BSU
o § 7 Verordnung für die Sicherung der Seefahrt

Classification
o § 4 SUG

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• Overview about some major flag

States
• Germany
• Reporting requirements 25

Reporting form on webpage

Details
o Ship details
o Details about reporting person
o Cargo details
o Other ships involved
o Damage
o Risk of environmental pollution

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• Types of investigations
• Depending on domestic law

Judicial criminal

Civil administrative (safety) 26
• Examples

Denmark

Finland

Norway

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• Example: Denmark
The introductory investigation phase is carried out “on the spot” by the OKE
(Casualty Investigation and Supervision Board). A Master’s report is prepared.

A preliminary report is prepared by the OKE. 27

This report is forwarded to the persons directly involved for comments.

If no comments are received within 14 days, a final report is produced.

The final report will be sent to the persons directly involved

and a few days after to other interested parties including the news media.

If the OKE finds that there is ground for legal proceedings,

the final report is sent to the Legal Division within the Maritime Authority.

Source: CASMET, 1999

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• Example Finland
The Master sends a Casualty Reporting Form to the Finish Maritime Administration.
Rescue Services informs the Accident Investigation Board (AIB).

The Maritime Administration informs AIB which decides on the level of investigation.
28
Minor accidents are investigated by the permanent staff of the AIB.
Major accidents are investigated by an Investigation Commission.

A confidential investigation is carried out. The investigators may

hire outside experts and use services of other government agencies.

The investigators prepare an Investigation report which aims at

preventing accidents and not at apportioning blame or assigning responsibility.
Possible legal actions are initiated by the Public Prosecutor. In case of major
accidents the report is forwarded to the Government which decides further actions.
In case of minor accidents the report is delivered to the Ministry of Justice.

The report is made public. IMO is informed.

Source: CASMET, 1999

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• Appointment and role of investigators

• How do you find out about accidents?
• Different sources

Official notification 29

o Forms
– Examples Germany
– Examples MAIB

Media reports

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• Appointment and role of investigators

• How do you find out about accidents?
• Coastal vs. flag State

Example Collision between MV Germa and 30
MV Esteclipper in Kiel Canal
on 13 October 2003

Germa – Luxembourg

Esteclipper – Cyprus

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• Appointment and role of investigators

• How do you find out about accidents?
• Interested parties

Example “Rockness” 19 January 2004 31

Crew from the Philippines, Germany, Norway

and the Netherlands

Norwegian flag

German Ship owners

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• Appointment and role of investigators

• Issues to be considered prior to an
investigation
• Does the case require investigation, taking 32

into account your national and international

obligations?
• Are there any (safety related) lessons to be
learnt from the case?
• Do you have the required resources to
investigate the case?

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• Investigation
process

33

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• Appointment and role of investigators

• Initial considerations by
administrations
• Appoint an investigator or an investigating 34

team, depending on the seriousness of the

event and dispatch them to the scene.
• Contact Owners, Managers, Classification
Society, and Port State officers to inform them
that investigators are en-route and elicit their
co-operation. If possible provide them with
the names of the investigator(s) and their
travel arrangements.

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• Appointment and role of investigators
• Initial considerations by administrations
• Contact emergency response agencies that may be
involved at the scene. Inform them that an
investigation is being undertaken and seek their 35
cooperation and assistance in preserving evidence at
the scene.
• Contact any other “interested states” that might be
involved with a view to a co-operative investigation.
• If the incident is a major one, prepare an initial press
release and nominate someone with experience to deal
with media queries.

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• Appointment and role of investigators

• Qualifications of investigators
• No international standards on the qualification
and training of casualty investigators 36

• IMO model course 3.11 (not binding)

• IMO e-learning (not binding)
• Many countries – “learning by doing”

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37

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• Appointment and role of investigators

• Number of investigators
• Depending on the severity of the accident
• Team 38
• Lead investigator

Manages the investigation

Directs the efforts of the team

Different professionals will be in the team

Team dynamics have to be observed

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• Appointment and role of investigators

• General qualification criteria for
investigators
• An inquisitive nature 39

• Dedication to this kind of work

• Diligence and patience
• A sound working knowledge of ship operations
• Technical skill
• Perseverance and logic
• Humility, integrity, and respect for human
dignity.

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• Appointment and role of investigators

• Team guidance and ground rules
• Member relationship

Poor team member relationships can influence 40
the conduct of the investigation
• Decision processes

There should be agreement how decisions are
made in the team (e.g. by the team leader, by
vote etc.)
• Role and responsibilities

Clear assignment of functions and duties in the
team helps avoiding duplication of work

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• Appointment and role of investigators

• Team dynamics
• Teams pass certain phases before an effective
team is formed 41

Forming (group appraisal)

Storming (establishing roles)

Norming (how to behave)

Performing (working together)

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• Appointment and role of investigators

• Team building
• Forming

Team members get acquainted
42

Understand their purposes

Define their roles and responsibilities

Members are polite at this stage, and conflict is
rare

Lead investigator can speed this stage by
formally organizing the group
o By defining goals, roles, and responsibilities; and
by encouraging members to become comfortable
with one another.

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• Appointment and role of investigators

• Team building
• Storming

Team members begin to realize the amount of
43
work to be done

May get into conflict regarding roles, planned
tasks, and processes for accomplishing the
work

The team focuses energy on redefining work
processes

The lead investigator can speed this phase by
o Encouraging open discussion of methods and
responsibilities and promoting non-defensive,
solution-focused communication

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• Appointment and role of investigators

• Team building
• Norming

The team develops norms about roles, planned 44
tasks, and processes for working together

Team members start to become productive and
assist one another

The lead investigator can speed this stage by
o Formalizing new norms, methods, and
responsibilities and by encouraging relationship
development

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• Appointment and role of investigators

• Team building
• Performing

The team settles into clear roles, understands
45
the strengths of different members

Begins to work together effectively

The lead investigator can help maintain this
stage by
o Encouraging open communication, a "learning
from mistakes" philosophy, and recognizing
progress

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• Case study
• Part 2 – Preparation of casualty
investigations
46

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