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Maritime Risk Management & Incident Investigation

The document discusses a course on maritime risk management and incident investigation. It provides learning objectives which include risk management, investigation process principles, evidence gathering, human factors, root cause analysis methods and reporting. It also discusses definitions related to hazards, safety, accidents, near misses and incidents.

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Pradyumna Jena

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0% found this document useful (0 votes)

97 views

Maritime Risk Management & Incident Investigation

Uploaded by

Pradyumna Jena

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

You are on page 1/ 107

Maritime Risk Management

and Incident Investigation

SAFER, SMARTER, GREENER

MARITIME ACADEMY

Risk Management & Incident Investigation - MSCAT

© DNV GL SAFER, SMARTER, GREENER

Organisation

Course Materials
 Handout
 Activities
 Photo Record

Practical Incident
Investigation & RCA

Practical information

Knowledge &
Smoking Mobile Emergency Time experience
Restrooms Certificate
policy phones exits keeping sharing

Practical Incident Investigation & Root Cause Analysis

2 © DNV GL Rev. 4.0

Expectations

Practical Incident Investigation & Root Cause Analysis

3 © DNV GL Rev. 4.0

Course Structure
N
4. Theory & Activity
1. Navigator W E

S
2. Objectives

5. Summary & Feedback

3. Scenario

Practical Incident Investigation & Root Cause Analysis

4 © DNV GL Rev. 4.0

After this course, you will have learnt about…

• Risk Management
• Investigation process principles and tools
• Application of investigation tools
• Methods for Gathering evidence
• Human element theory
• Interviewing
• Root cause analysis methods

• Reporting and follow up

Practical Incident Investigation & Root Cause Analysis

5 © DNV GL Rev. 4.0

Incident 2: Pump room explosion MT Sinkfast – Study Incident

Report

The company is based at Limassol, Cyprus, and is managing and operating 10

smaller Product Tankers. Besides ISM, TMSA has been implemented. The ships are
sailing under the flags of Cyprus and Antigua and Barbuda.
On 17 December 2015, when the ship was alongside an explosion took place in the
pump room, when a fitter tried to repair a leaking pump seal.

Tanker “SINKFAST”

Practical Incident Investigation & Root Cause Analysis

6 © DNV GL Rev. 4.0

Practical Incident Investigation & Root Cause Analysis

7 © DNV GL Rev. 4.0

Objectives : Hazard Identification - Incident Investigation

- Root Cause Analysis - MScat

M-SCAT = “Marine Systematic Cause Analysis Technique”

based on DNV GL’s Proprietary Protocol ISRSTM {International Safety Rating System}
A safety and sustainability rating system; Purpose designed for aiding in Incident
Investigation, to arrive at the Cause(s) responsible for an undesirable event.

 Know and assimilate the basic concepts of events and loss causation

 Know evidence collection to support the M-SCAT approach.

 Understand and Actively use M-SCAT as an ‘Event Cause Analysis’ tool.

Marine Systematic Cause Analysis Technique (MSCAT)

8 © DNV GL

HAZARD
A source of potential harm or damage or a situation with potential
for harm or damage

A pre-existing condition having the capability and potential to

cause harm or loss to personnel, property or environment

It includes illness, damage to property, products or the

environment.

SAFETY

Freedom from Harm or Loss = of Life - of property - to environment

Control of Harm or Loss / Prevention of Harm or Loss

Marine Systematic Cause Analysis Technique (MSCAT)

9 © DNV GL

Some definitions
Loss – (can result from an Incident)

The SAME Incident can simultaneously result in different types of Losses

e.g. a MAJOR Oil Spill can lead to

– Large Scale Pollution and Destruction of Local Fauna / Flora

– Death (by drowning or if flammable vapours catch fire with people nearby)
– Major / Minor Personal Injuries
– Property Damage (e.g. as a result of a fire arising out of the oil spill)
– Financial / Business / Production / Reputation Losses

Marine Systematic Cause Analysis Technique (MSCAT)

10 © DNV GL

 Accident: A SURPRISE EVENT WITH LOSS

an unplanned event or chain of events, which has caused injury or

illness and/or damage (loss) to people, property, the environment or
reputation.

Near Miss: A SURPRISE EVENT WITHOUT LOSS

an unplanned event or a chain of events, which potentially

could have caused injury or occupational illness and or damage (loss)

to people, property, the environment or reputation, but which did not.

Marine Systematic Cause Analysis Technique (MSCAT)

11 © DNV GL

Incidents …

INCIDENT An event which could, or does, result in unintended harm or damage

(i.e. a Near-Miss or an Accident).

ACCIDENT
Contact above
Expensive Learning The LOSS has
Thresh-hold
Value already occurred
(LOSS)

FREE Learning NEAR MISS FREE Learning

Contact below NEAR MISS
There is NO LOSS Thresh-hold NO Contact
There is neither
despite some Value (NO LOSS) any ‘contact’ nor
kind of ‘contact’ (NO LOSS) any LOSS

Report ALL Incidents - JUST Culture (NO BLAME Culture)!

Benefits of INCIDENT Reporting and Analyzing using M-SCAT
Marine Systematic Cause Analysis Technique (MSCAT)

12 © DNV GL

(c) DNV GL 6
Some definitions
 Risk = Effect of uncertainty on objectives
consequence of an action taken in spite of uncertainty.

 Risk Matrix = Likelyhood of Occurrence

versus Severity of Consequences

Assessment = Pocess of risk identification, risk analysis

and risk evaluation.
Hazard recognition

 Risk Management = Coordinated activities to direct and control an

organization with regard to risk
Implementation of effective Controls
 Control = A measure to modify or Mitigate risk
Marine Systematic Cause Analysis Technique (MSCAT)

13 © DNV GL

Some definitions

 Immediate Causes: may be attributed to Hazards in the workplace as

a result of Substandard Acts (Practices) and/or

Substandard Conditions.

 BASIC /ROOT CAUSES CAUSAL FACTORS THAT :

1. CAN BE IDENTIFIED

2. CAN BE RECTIFIED

 Basic (Root) Causes: result from Personal Factors and/or

Job / System Factors.

Marine Systematic Cause Analysis Technique (MSCAT)

14 © DNV GL

Source: MODEL COURSE 3.11 MARINE ACCIDENT AND INCIDENT INVESTIGATION TRAINING MANUAL

Practical Incident Investigation & Root Cause Analysis

15 © DNV GL Rev. 4.0

The Accident Sequence – Marine Casualties

Hazards
External Influences

Incidents Accidents Consequences Effects

Causes
Safeguard Failures

• Risk Assessment (RA) and Incident Investigation (II) are the two key
components of any safety management system. Together RA and II ensure
continuous improvement of safety through risk management.

PROACTIVE REACTIVE

Risk Assessment Incident Investigation

SAFETY
ALARP MANAGEMENT
SYSTEM

• Risk Assessment is about being • Incident Investigation is about

proactive, avoiding incidents before being reactive, learning from
they occur through proper planning incidents in order to ensure that
and preparation of an operation. they do not happen again in the
Practical Incident Investigation & Root Cause Analysis
future.

17 © DNV GL Rev. 4.0

Incident prevention and control

Safety Management System

Administrative

Physical

Supervisory

Responsible Persons

Threat 1 Outcome 1
Hazard
Consequences
Causes

Threat 2 Top
Events

Threat 3 Outcome 2
Preventing Mitigating
Barriers Barriers
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RESPONSE TO CHANGES

 MEN
 MATERIALS
 MACHINES
 METHODS

ADDRESSED BY MANAGEMENT OF CHANGE {MOC}

=======

“IF A TASK IS NOT SAFE ?

 STOP !
 MAKE IT SAFE !
 COMPLETE IT SAFELY !

ZERO IS ATTAINABLE !”
19 © DNV GL

Hierarchy of Control Measures

ELIMINATE
{Physically remove the Hazard}

SUBSTITUTE
{replace a hazard with something less hazardous}

ENGINEERING CONTROLS
{isolate people from hazards-Gaurds – Barriers}

ADMINISTRATIVE CONTROLS
{control the way people work. Procedures – Permit Culture – training,- signage

PERSONAL PROTECTIVE EQUIPMENT

{Task specific protective equipment}
20 © DNV GL

Source: MAIIF Investigation Manual

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Sequence of events leading to a casualty occurrence

RESOLUTION MSC.255(84)
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The team consisting of managers

of HSE, Operation, Insurance, the
DPA, CSO, and Superintendents
are meeting.
To get the team members to the
same level of knowledge it has
been decided to identify principles
of incident investigation

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Accident Ratio
ACCIDENT RATIO STUDY

1 Fatality / Catastrophic Damage

10 Serious Injury / Serious Damage

Minor Injury & Minor

30
Thresh-hold Property Damage
Limit
600 Near Misses

HAZARDS > 600 (Immediate Causes)

Marine Systematic Cause Analysis Technique (MSCAT)

24 © DNV GL

25 © DNV GL

26 © DNV GL

 INSTANT FAME IN PHOTO FRAMES IS HARMFUL !

“WE ARE PRESENTLY INVOLVED IN CONTAINING THE

SITUATION.
PLEASE CONTACT OUR OFFICE ON PHONE No.:____ .
THEY WILL FURNISH YOU WITH ALL DETAILS.
THANK YOU!”

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27 © DNV GL Rev. 4.0

Activity 1

Principles of incident investigation

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• Obligations according to international law

• Obligations according to flag State
• Improve the arrangements and procedures in a shipping company
in order to avoid similar accidents in future

http://www.imo.org/en/OurWork/MSAS/Casualties/Pages/Default.aspx

Practical Incident Investigation & Root Cause Analysis

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Incident Investigation Cycle

When / how / what

Development and to report / who to
implementation of report to, and
safety measures, reporting format
disseminating of
lessons learnt
Safety Reporting
Measures
Prevent Recurrence

Event and causal factor Analysing Investigating Collecting occurrence

charting, identification of data, gathering evidence,
human elements and organizing the data,
contributing factors, visiting the scene,
identification of root causes interviewing witnesses

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Allocate resources

Evidence Collection

Systemizing facts

Analyse causes

No Yes
Need for more
information?

Findings and Report

Follow-up
Practical Incident Investigation & Root Cause Analysis

31 Rev. 4.0

Protecting the scene of the incident

Immediately after an incident you should:

Restrict the Loss

– The first priority is to protect life, property and the environment

BUT

Try not to unnecessarily

disturb the evidence

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When a report of an incident is received a decision on whether an investigation is

warranted and justified has to be made by consideration of the following:

 Safety improvement benefits;

 Obligations and commitments;

 Public expectations;

 Availability of resources.

Evaluation of loss potential !

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Information sources

 Initial report from a vessel;

 Media releases – including social media;

 Expert advice;

 Ship details and past records;

 VDR, ECDIS, GPS information resources;

 AIS information sources, e.g. AISLive, SafeSeaNet;

 Environmental/hydrology conditions – National Meteorological Offices;

 Nautical publications, e.g. almanacs, charts, tidal data, pilot books;

 …..

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 It is 0830hrs and you are at your desk with notes made after a telephone call
from the Master of the MT Sinkfast / MV Navigator earlier that morning reporting
a grounding / an incident.
 There seems to be over 50 new emails on the screen since you logged off
yesterday evening ……….

 And the telephone is already ringing……….

 …….and you haven’t even had a coffee yet!!!

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Scenario 2 – Determine loss potential

Level

The superintendent informs the emergency

Analyse

response team of the accident. Based on

the available information an immediate risk
evaluation is carried out to identify the
potential loss of the accident.
ID
Stop
Risk

Evaluate Full
risk if not Analysis
controlled if high
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(c) DNV GL 18
Risk Investigation PROBABILITY/ FREQUENCY
Highly Unlikely Possible Likely Highly Likely
Low local investigation
Unlikely
5% 15% 35% 75% 95+%
Medium Full investigation, discussion &
follow-up by management Never Occurred in Occurs in Occurs in Predicted to
occurred Industry Industry &/or Industry &/or occur during

High Management
involvement in
in Industry
over> 5
once during
last 5 years
Company
Annually
Company
X times/year
course of the
work
investigation & follow-up years

Health/ Assets Others 1 2 3 4 5

Injury Environm.
Reputation
S A No Injury No Asset No Impact
(Scratch- Damage
E type)
V B First Aid Damage Spill <5ltr
Medical <X$ Local reputa-
E Treatment tion impact
R C Lost Time Damage Spill <50 ltrs
I Injury < 10X $ Regional
coverage
T D Permanent Damage Spill <500 ltrs
Disability
Y < 20X $ National media
coverage

E Single Damage Spill >500 ltrs

Fatality < 50X $ National
Headlines
F Multiple Damage Catastrophic
fatality > 50X $ Spill Coverage
Internationally

37
37 © DNV GL

Activity 2

Determine loss potential

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1. Members of the investigation team:

Control the scene a) Have an open mind
b) Know and understand the operations
where the event happened
Allocate resources
c) Creativity to form hypothesis that can
be tested during the collection of
evidence
Evidence Collection d) Able to reject a false hypothesis
e) Focus on chain of events and
manageable causes
Systemizing facts f) Knowledgeable about incident
investigation techniques
g) Able to document findings in writing
Analyse causes h) Have authority to get access to
relevant information.
No Yes 2. Normally management and senior officers
Need for more conduct most investigations.
information?
3. Supervisors and key-personnel from the
involved departments
Findings and Report 4. Shore based personnel (involvement
dependent on severity)

39
Follow-up

Investigator equipment

 Suitable identity documents;

 High-visibility and protective waterproof jacket;
 Steel toe-capped, non-slip working boots;
 Safety helmet;
 Ear/hearing protection devices;
 Safety goggles/glasses;
 High-visibility vest;
 Automatic inflatable lifejacket;
 Working gloves;
 Overalls (reusable and disposable types);
 Dust mask;
 other?

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Fact finding includes the following activities:

• Analysing reports and statements
• Inspection of the location
• Gathering or recording physical evidence
• Interviewing witnesses
• Reviewing documents, procedures and records
• Identifying conflicts in evidence
• Identifying missing information
• Recording additional factors and possible underlying factors

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41 © DNV GL Rev. 4.0

Evidence collection

Control the scene 1. Secure the scene: Identify sources of

information
Allocate resources 2. Preserve evidence from alteration or
removal
Evidence Collection
Sources of information are:
• Parts Information
Systemizing facts
• Position Information
Analyse causes • Paper Information

Yes • Electronic Information

No Need for more
information? • People Information

Findings and Report

Who, What, Where and When

42
Follow-up

Suitable
Damage for the Safeguards
task

Previous Labels
Damage Wear and
tear Signs
Markings

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Position Information

Before,
During, Use
drawings,
After
sketches,
the incident maps

Take
photographs
or video

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Direct or real evidence

Practical Incident Investigation & Root Cause Analysis

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47 © DNV GL Rev. 4.0

Taking photos

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View from
4 points
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What to take pictures of...

 Long Range shots

– All inclusive area of incident

 Medium Range shots

– Records orientation of item

 Short Range…Detailed shots

– Close up of failed or damaged items

Practical Incident Investigation & Root Cause Analysis

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• Place a ruler/scale in picture

• Place item on an appropriate background
• Place people in the photo

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Paper Information

Certificates
Maintenance
Training
Records
records Licenses

Minutes of
Meetings
Permits
Job Statements
procedures

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Paper information
Evidence provided by documented
information such as:
– Charts
– Checklists
– Records
– Logbooks
– Bell books
– Letters
– Manuals

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Electronic Information

VTS
VDR GPS

CCTV
UMS
ECDIS Fire
Protection

Practical Incident Investigation & Root Cause Analysis

54 © DNV GL Rev. 4.0

Voyage Data Recorder

• Date & Time
• Position
• Speed
• Bridge Audio
• Vhf
• Radar
• Echo sounder
• Main alarms
• Heading
• Etc.
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55 © DNV GL Rev. 4.0

Scenario 3 – Investigation checklist

Because of the severity of the accident it has been decided to send two
investigators to the scene to collect evidence and interview crew members.
Based on the “Statement of Facts” the two investigators prepare a checklist for the
investigation.

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Investigation checklist

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Objectives of human factors investigation

• Discovering how mismatches between system requirements and human capacity could
have caused or contributed to the occurrence,

• Identifying safety hazard (engineering, administration and personal protection)

mitigation strategies that result in conditions that are likely to exceed human
operational capacity, or reinforce behavioural risk adaptation,

• Making recommendations designed to eliminate or reduce the severity or likelihood of

consequences resulting from mismatches between system operating requirements
and human physiological, perceptual or cognitive abilities.

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Acts/Practices Conditions

80%: DIRECT Human Failure

“ Sub standard Acts/Practices”
20%: “Sub standard Conditions”

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Human Errors

Practical Incident Investigation & Root Cause Analysis The Generic Error Modelling System (GEMS) (James Reason 1990)

60 © DNV GL Rev. 4.0

What are the most common

human errors at the
workplace?

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Human Errors & Human Factors

MAIIF Investigation Manual

Practical Incident Investigation & Root Cause Analysis

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What factors influence

human performance?

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Human Evidence

There are four components to the SHEL model:

Liveware - L

Hardware - H

Software - S

Environment - E

AMENDMENTS TO THE CODE FOR THE INVESTIGATION OF MARINE CASUALTIES AND INCIDENTS
Practical Incident Investigation & Root Cause Analysis RESOLUTION A.849(20)

64 © DNV GL Rev. 4.0

Use of the SHEL model as an organizational tool for the investigator's workplace

data collection helps avoid downstream problems because:

1. it takes into consideration all the important work system elements;

2. it promotes the consideration of the interrelationships between these work

system elements;

3. it focuses on the factors which influence human performance by relating all

peripheral elements to the central liveware element.

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Module 6 – Activity 8 - Human element

66 © DNV GL

Human factors

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People Information - Interview considerations

Where to Follow up
interview after the
Condition
of people incident
at the
scene

Who to How to
interview handle
multiple
witnesses

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 Create list of witnesses,

 Do not wait with an interview– 50-80% details are lost within first 24hrs,

 Avoid creation of questions list – be open minded,

 Bias is predisposition of prejudice,

 Consider location of an interview,

 Witness rights,

 Think about applicable interview technique,

 Consider cultural sensitivity

 ………..

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Potential witness

 Person directly involved in the incident

or affected by its consequences;

 Eyewitnesses;

 Emergency response team;

 Technical experts;

 Company personnel;

 External personnel directly involved;

 ……

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 They have a personal interest

 They know the people and conditions

 They know best how and where to get the information needed

 They will start or take action

 They benefit from investigating.

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Opening meeting

 Explain the purpose of interview;

 Ask permission for making notes;

 Explain interviewee’s rights and seek

confirmation of understanding;

 Present your role as interviewer;

 Procedures must be followed;

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 Open

 Closed

 Analysing
EASY HARD
 Clarifying

 Critical

 Precise

 Leading

 Collaborative attitude

 Interview as opposed to Interrogation

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Open Questions Half Open Questions

Questions

Closed Questions

74 Rev. 4.0

1st layer Visible behaviour, e.g.

artefacts, produced goods,
rituals, myths

2nd layer Sense of right and wrong,

collective values

3rd layer Basic assumptions:

character, relationship with
nature and others,
organisation of time and
activities

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Non-verbal Communication

 Facial expression  Gesture

 Body language  Motion
 Eye contact  Body contact
 Appearance  Behaviour

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Non-verbal communication

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Fair treatment of seafarers

“All seafarers from whom evidence is sought shall be informed of the nature and basis of
the marine safety investigation. Further, a seafarer from whom evidence is sought shall be
informed, and allowed access to legal advice, regarding:
1. any potential risk that they may incriminate themselves in any proceedings
subsequent to the marine safety investigation;
2. any right not to self‐incriminate or to remain silent;
3. any protections afforded to the seafarer to prevent the evidence being used
against them if they provide the evidence to the marine safety investigation.”

Casualty Investigation Code

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 Cognitive – witness unaware of his role

 Witness as the central element of the interview;

 Interview revolves around witness knowledge;

 Information gained vs. questions asked.

https://www.youtube.com/watch?v=3HwcMEwgWqQ

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The developed CI technique

1. Introduce yourself; 9. Ask questions related to

2. Show that you care; the witness’s activated
3. Clearly request witness knowledge;
to generate info.;
4. Ask open-ended 10. Encourage witness to think
questions first and after on event from different
free narration; angles;
5. Avoid interrupting the 11. Do not ask leading
witness;
questions;
6. Allow time for long
pauses; 12. Discourage guessing;
7. Recreate the context; 13. Be flexible;
8. Encourage witness to
14. Extend effective session
close their eyes;
time.

Slides used with permission by Kevin T. Ghirxi

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The two investigators are now on board to get some more information regarding
the events leading to the accident. The investigators have decided to interview the
Pump Man (MT Sinkfast) / Chief Officer (MV Navigator) to clarify open items and to
collect evidence (pros and cons).

Open Questions

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Activity 5

Conducting an Interview

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Control the scene

E.g. : Sequential Time Events
Plotting (STEP)
Allocate resources

Evidence Collection

Systemizing facts Method :

Loss Causation Model
Analyse causes

No Yes
Need for more
information?
Who, What, Where, When, How & Why
Findings and Report

87
Follow-up

Root cause analysis

the most basic cause that can be reasonably identified

and that management has control to fix
Paradies and Busch (1988)

Root causes analysis is simply a tool designed to help incident

investigators describe what happened during a particular incident, to
determine how it happened and to understand why it happened.

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88 © DNV GL Rev. 4.0

(c) DNV GL 44
Incident investigation techniques (1)
Purpose 1:
Obtaining a full description of the sequence of events which led to the failure
Methods:
• Events and Causal Factors Charting
• Multiple Events Sequencing (MES)
• Sequentially Timed Events Plotting Procedure (STEP)

Purpose 2:
To ascertain the critical events and actions, and thus the direct causes of the incident
Methods:
• Barrier Analysis
• Change Analysis
• Fault Tree Analysis

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Incident investigation techniques (2)

Purpose 3:
To identify the root causes of the incident and develop remedial actions to be
effective in the long term
Methods:
• MANAGEMENT OVERSIGHT AND RISK TREE (MORT)
• SAVANNAH RIVER PLANT (SRP) ROOT CAUSES ANALYSIS SYSTEM
• TAPROOTTM
• HUMAN PERFORMANCE INVESTIGATION PROCESS (HPIP)
• CAUSAL TREE METHOD (CTM)
• REASON® ROOT CAUSE ANALYSIS
• EVENT ROOT CAUSE ANALYSIS PROCEDURE (ERCAP)
• HUMAN PERFORMANCE EVALUATION SYSTEM (HPES)
• SYSTEMATIC CAUSE ANALYSIS TECHNIQUE (SCAT)
• TECHNIC OF OPERATIONS REVIEW (TOR)
• SYSTEMATIC ACCIDENT CAUSE ANALYSIS (SACA)
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Personal
factors??? Condition
Job factors???

Substandard Condition
conditions???

Event Event Event Incident Substandard

acts???
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Events and causal factor charts (example)

Event No.1 Event No.2 Event No.3 Condition

Start-up Tank Tank

Switch Compressor Pressure at
Activated Runs Increases 300 psi

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Building the STEP diagram

• Use “post it note” to represent the events on a blackboard

• Move vertically to the actor
• Move horizontally to the correct (relative) point in time
• Mark missing blocks/uncertain information with a “post it note” in
for example different colour
• If necessary: increase the level of detail (actors or events)
• Ensure continuity (look at each actors role as a film for your inner
eye)
• Establish connections between the events
• Test: Would the end-event have happened without the preceding
events?

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Ca.18.00 18.45 19.25

Time
Actors:
Sails through narrow 25-30 Cleared the a
SHIP waters in dark but meters from marker buoy with
nice weather shoreline small margins

Judge the Makes a starboard

Tried to Stop because course to be and then a port
MASTER instruct the the CO knows too close to avoidance
chief officer all equipment shoreline manoeuvre

Enters ship Was in Alter Focus on

CHIEF OFFICER for the first charge on his course to electronic
time first watch port charts STEP =
Sequential
Time
CHIEF OFFICER Meet new chief
officer on the Events
(off-signing) gangway Plotting
Actors: Persons or items that actively contributed to the accident/near miss
Practical Incident Investigation & Root Cause Analysis

Event: What an actor does, or how the actor is a part in the chain of events
95 © DNV GL Rev. 4.0

Scenario 6 – What are the causal factors?

The investigators are back in the office and start with the cause analysis.
The first step now is to visualize and organize the available accident data.

CONDITIONS
EVENTS

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STEP Diagram

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Barrier Analysis

SAFETY BARRIERS VICTIMS

ENERGY SOURCE

HAZARD
ENERGY
EQUIPMENT

PROCEDURES

BEHAVIOUR

3 types of barriers / defences:

Technological (e.g. Equipment)
Organisational (e.g. Procedures)
Human (e.g. behaviour)
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SAFETY BARRIERS
ENERGY SOURCE VICTIMS

HAZARD
ENERGY

Quality winch and drums

Quality ropes and wires

Checklist and procedure

PPE: Gloves, non-slip shoes
Good communication
Proper training
Stress in ropes Squeezes
Heavy shackle Falls
Slippery deck Damage to assets

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Barrier Analysis

Advantages Disadvantages
• Easy to use • Basic tool
• Efficient • Not for complex systems
• Further evaluation has to be done
Example: using other tools

Hazard: Lack of oxygen in the cargo tank Target: Tank washing AB

• What were the • How did each • Why did the barrier • How did the
barriers? barrier perform? fail? barrier affect
the accident?
Oxygen content has Not sufficient, the The measuring device In a very severe
to be checked prior to oxygen content was was defective for way. This is a
the tank cleaning checked but the unknown reasons. It critical barrier that
device was defective was still displaying data has to function. It
so that the failure was is recommended
not detectable. to revise the
procedure for
oxygen measuring

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100

Based on the information available the two investigators establish a list with the
major findings, evidence related to the findings (pro and con) and source of
evidence.

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Activity 7

Evidence matrix

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• Lists the major findings,

• Shows the evidence related to the findings,
• Sources of evidence
• Location of where evidence may be found.

MAJOR FINDING EVIDENCE SOURCE

OR CAUSAL COMMENTS
ELEMENT (Both Pro and Con) OF EVIDENCE

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Fact Tree Analyses

Benefits of Using Fact tree:

– Guides the collection of evidence
– Missing evidence is identified
– Ensures that all possibilities are scrutinized
– Provides guidance to Root cause identification

 Agreed Facts, no interpretations

 First identify all facts, consequently construct the fact tree
 Fact tree construction preferably in a group
 Team effort of personnel with insight in accident and contributing
factors.
 Multiple facts leading to one “end-fact”

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 A Tool to identify basic / root causes, ref M-SCAT causes.

 Investigation to collect facts.
 Facts are results of other facts and together they have
contributed to the incident.
 Facts used to construct Fact tree are based
on two questions: Fire

1. What is needed? Oxygen Fuel Ignition

2. Is it enough?

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Fact Tree Analysis

Collecting Facts
Schematic structure of the tree by asking the following
questions every time:
• What was needed?
• Was this necessary?
• Was this enough?

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106

 For an explosion:
– Explosive Mix
– Ignition
– Oxygen
 For a grounding:
– Limited ship’s draft
– Depth shallower than ship’s draft
– Route crossing through shallow waters

C= A + B; just like that!

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What was Necessary?

• Some facts are “necessary”, but not “needed”:

• Inspection not done, but irrelevant for the incident
• Some facts are “necessary” and also “needed”
(absence of an obvious safeguard):
• Explosion in pump room not only “needs” direct facts,
like “Mix” and “Ignition”, but also failure of “necessary”
equipment, like Ventilation and Gas Detection

Always consider evidence of absence or failure of

standards & safeguards, supposed to be present.

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Verify that the facts needed for the event really are enough to
get that result.

If A = B + C

then B + C must deliver A

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Scenario 8 – What are the facts?

The incident investigation team is meeting.

The accident has been investigated and several immediate and basic causes have
been identified. The team is now performing a fact tree analysis based on the
available accident data.

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1 Needed

Necessary
but not Needed

Needed and
3 4 5 2 6 Necessary

Irrelevant
1: Explosion in pump Room
2: Explosive Atmosphere
3: Pump Room 7 8 9
4: Ship Alongside
5: Ignition
6: Survey Overdue
7: No Ventilation
8: No Gas detection
9: Gas leak
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Activity 8

Creating Fact Tree

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Control the scene Using M-SCAT as an example:

 Classify information into five stages:
Allocate resources
 Losses
Evidence Collection  Incidents or contacts
 Immediate causes
Systemizing facts
 Basic causes, and

Analyse causes  Lack of control areas

No Yes
Need for more
information?

Findings and Report

113
Follow-up

113

Human Failure: at what level?

1.Direct Causes

2. Basic Causes /Factors

3.Root Causes/” System”

4.Soil Factors
Practical Incident Investigation & Root Cause Analysis
/”Environment”
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114

 Immediate Causes:
– the first thing to identify
– sub-standard ACTS/ PRACTICES or CONDITIONS
– E.g.

 Basic Causes:
– may be JOB factors or PERSONAL factors
– also called “basic-causes”

 System Control:
– the formal or informal SYSTEM to manage the factors
– also called “root-causes”
– elements of the system (IMS)

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DNV GL Loss Causation Model

Root Causes Immediate

Basic Causes Causes Barriers LOSS
/CONTROLS

Job Sub-
Factors Standard
Acts/
Policies
Job Subst
Practices
Controls
Factors Acts/
80% Practices
80%
Inadequate

Systems
Personal
Standards
Factors Sub-
Compliance
Standard
Conditions

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LACK OF BASIC IMMEDIATE

CAUSES CAUSES INCIDENT LOSS
CONTROL

Inadequate Personal
• System Acts or Event Unintended
Factors Practices or Harm
• Standards
• Compliance Contact or
Job or Conditions Damage
System
Factors

Why it happened

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117

What is Loss?
Threshold Limit

LACK OF BASIC IMMEDIATE

CAUSES CAUSES INCIDENT LOSS
CONTROL

Inadequate
• System Personal Acts or Event Unintended
• Standards Factors Practices or Harm
• Compliance Contact or
Job or Conditions Damage
System
Factors

People: Fatality, lost time injuries, first aid, etc.

Process: Logistic chain, off hire, delays, etc.
Property: Cargo, ship, equipment, tools, etc.
Environment: Spill, etc.
Loss of reputation is considered as an indirect effect of these losses.
118 © DNV GL Rev. 4.0

118

LACK OF BASIC IMMEDIATE

CAUSES CAUSES INCIDENT LOSS
CONTROL

Inadequate
• System Personal Acts or Event Unintended
• Standards Factors Practices or Harm
• Compliance Contact or
Job or Conditions Damage
System
Factors

Personnel injury / illness:

Falls from elevation, Falls on same level, Contact with heat Etc...
Property/ Process / Environmental damage:
Collision, Grounding, Contact Damage, Fire/Explosion, Etc.….
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Threshold Limit

Immediate Causes
Symptoms

LACK OF BASIC IMMEDIATE

CAUSES CAUSES INCIDENT LOSS
CONTROL

Inadequate
• System Personal Acts or Event Unintended
• Standards Factors Practices or Harm
• Compliance Contact or
Job or Conditions Damage
System
Factors

 Acts / Practices  Conditions

- Operating without permission - Inadequate PPE
- Failure to Warn - Defective Tool / Equipment
- Failure to secure - Poor House keeping
- Removing Safety devices

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120

LACK OF BASIC IMMEDIATE

CAUSES CAUSES INCIDENT LOSS
CONTROL

Inadequate
• System Personal Acts or Event Unintended
• Standards Factors Practices or Harm
• Compliance Contact or
Job or Conditions Damage
System
Factors

 Human Factors  Job Factors

- Mental or Physiological Stress - Inadequate Work standards
- Frustrations, Emotional overload - Inadequate Maintenance
- Improper Motivation - Inadequate Purchasing
- Proper performance is punished - Abuse or Misuse
- Lack of Knowledge
121 DNV GL © 2013
- Misunderstood
Rev. 4.0
Directions

121

Lack of Management Control

LACK OF BASIC IMMEDIATE

CAUSES CAUSES INCIDENT LOSS
CONTROL

Inadequate Personal
• System Acts or Event Unintended
Factors Practices or Harm
• Standards
• Compliance Contact or
Job or Conditions Damage
System
Factors

Inadequate System:
Too few system activities or System activities are inadequate
Inadequate Standards:
Standards not specific enough, not clear enough and/or not high enough.

Inadequate Compliance with existing standards:

System is not effectively implemented
122 © DNV GL Rev. 4.0

122

Inadequate Undesired People

•System Personal
Acts Event That Property
•Standards Factors
Conditions Could/Does Environment
•Compliance Job
Lead to a Loss Process
Factors

Control Action Basic Causes Immediate Type of

Needs Causes Contact
Administration Personal factors Substandard Acts Personnel injury / Description of
Leadership training illness accident or incident
Planned inspection Physical capability Failure to … Falls from elevation
Task analysis Incident Mental capability …follow rules
Physical Stress Falls on same level
investigati. Work ... use ppe properly
performance Emer. Mental Stress Struck against Caught
… repair instruction in Contact with
preparedness Safety Knowledge Skill
Motivation … warn heat Etc...
rules Incident
analysis Skill training Job Factors … secure Property/ Process / Evaluation of loss
Protective equipm. Leadership Etc. Environmental potential if not
Occupational health Engineering Substandard
damage controlled
System review Purchasing Conditions
Inadequate barriers Collision
Change managem. Maintenance
Defective equipm. Grounding
Communication Tools& Equipment
Work standards Defective ppe Contact Damage
General promotion
Recruitment Wear &Tear Abuse Adverse weather Fire/Explosion
Purchasing Off‐ or misuse Poor housekeeping Etc.….
the‐job‐ safety Etc.
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Activity 9

Using the M-SCAT Chart

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LACK OF BASIC CAUSE IMMEDIATE INCIDENT LOSS

CONTROL CAUSE
Xxx Xxx Xxx Xxx Xxx
Yyy Yyy Yyy Yyy Yyy
Zzz Zzz Zzz Zzz Zzz

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Need for more information

Control the scene  Is all relevant information considered?

 Is the STEP complete and its events in
Allocate resources agreements?
 Is it enough information to complete the
Evidence Collection
analysis of causes?
 Would the conclusions of the
Systemizing facts
recommendations be stronger if new
information was added?
Analyse causes

No Yes
Need for more
information?

Findings and Report

126
Follow-up

126

Control the scene  Corrective Actions

 Corrections
Allocate resources
 One should keep in mind, “What can I do
right now to keep this from happening
Evidence Collection
again?”
 Most corrections correct only the
Systemizing facts
symptoms — the actions and conditions.
 Permanent Actions are needed
Analyse causes
- To truly solve the problem
No Yes - Deal with basic causes
Need for more
- Treat the oversights and omissions in
information?
programs, standards and compliance

Findings and Report

127
Follow-up

127

Safety recommendations

• Focused on system barriers that have failed or are non existant

• Practical in application,

• Consist of possibilities for effectiveness monitoring,

• Costs vs Benefits balanced,

• Cannot be misinterpreted,

• Are consistent with reasoning from the report.

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128

Desired Situation Current situation

 Inadequate system

 Inadequate system standards

Needed Changes
 Inadequate compliance with standards

ISRS
Action Plan
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129

The 15 ISRSTM Processes – “Control Areas for Improvement Actions”

The “Controls” of the M-SCAT Model are based on the 15 ISRSTM Processes:
1. Leadership POLICY (Set Expectations)
2. Planning
3. Risk Evaluation
4. Human Resources PLAN
Continual Improvement

5. Compliance Assurance
6. Project Management
7. Training and Competence
8. Communication and Promotion
9. Risk Control
DO (Implement & Operate)
10. Asset Management
11. Contractor Management and Purchasing
12. Emergency Preparedness
13. Learning from Events
CHECK (Monitor & Measure)
14. Risk Monitoring
15. Results and Review ACT (Review)
Marine Systematic Cause Analysis Technique (MSCAT)
130

130

Control the scene  The investigation report should reflect the

findings and facts uncovered by the
Allocate resources investigation team.
 It should contain information such as
Evidence Collection names, dates, and relevant statistical data,
as best suited to the control systems of the
organisation.
Systemizing facts
 It should lead the investigator through the
structured investigation process, ensuring
Analyse causes that immediate and basic causes are
considered, which in turn should lead to the
No Yes clear identification of controls.
Need for more
information? http://www.imo.org/en/OurWork/MSAS/Casualties/D
ocuments/MSC-MEPC.3-Circ.3.pdf
Findings and Report

131
Follow-up

131

Findings and Report

Control the scene Minimum contents are:

 Identifying information
Allocate resources
 Evaluation; real potential for loss
Evidence Collection  Description; what happened
 Cause analysis; symptoms and basic
Systemizing facts causes
 Action plan
Analyse causes

No Yes Management to consider the

Need for more
information? recommendations of the investigation, and
ensure implementation of the corrective
actions.
Findings and Report

132
Follow-up

132

The incident investigation team is meeting.

The incident investigation has been completed and the team is working on
constructing of safety recommendations.

Practical Incident Investigation & Root Cause Analysis

133

Activity 10

Safety recommendations

Practical Incident Investigation & Root Cause Analysis

134

Thank you very much for attending!

We hope to welcome you again soon

Maritime Academy COUNTRY – Creating Perspectives

www.dnvgl.com

SAFER, SMARTER, GREENER

Practical Incident Investigation & Root Cause Analysis

135

International Organizations
Name Homepage Remark
International Summaries of MSC and MEPC
Maritime meetings (amendments of
www.imo.org
Organisation conventions), description major
(IMO) conventions, status of instruments
European
Maritime Safety www.emsa.europa.eu Marine casualties and incidents
Agency (EMSA)
Oil Companies OVMSA Guide
International TMSA Guide
www.ocimf.org
Marine Forum
(OCIMF)
International Interpretations ISM, STCW, MLC
Chamber of www.ics-shipping.org
Shipping (ICS)
International Quality Management Standards
Standardization
www.iso.org
Organization
(ISO)
UK P&I Club Claims and incidents
www.ukpandi.com

The Marine Investigations, lessons learnt, job

Accident aids for investigators
Investigator’s www.maiif.org
International
Forum

Classification Societies
Name Homepage Remark
Rule application and guidelines,
IACS www.iacs.org.uk description tasks of CS`s, IACS
membership
Classification rules,
surveys and certificates, class
DNVGL www.dnvgl.com
notations, authorizations on
behalf of flag states

Reference Literature

Subject Source Version

Conventions SOLAS Consolidated Edition IMO, 2014

MARPOL Consolidated Edition IMO, 2011

STCW including 2010 Manila IMO, 2011

Amendments
Maritime Labour Convention ILO, 2006

Codes ISM Code IMO,2014 Edition

Casualty Investigation Code IMO, 2008

Guidelines Guidelines on the Application of ICS/ ISF, 2010

the ISM Code, 4th Edition

Guidelines on the IMO STCW ISF, 2011

Convention including the 2010
“Manila Amendments”, 3rd Edition

Guidelines on the Application of ISF, 2012

the ILO Maritime Labour
Convention, 2nd Edition

Offshore Vessel Management and OCIMF, 2012

Self Assessment (OVMSA) 1st
Edition
Tanker Management and Self OCIMF, 2008
Assessment (TMSA) 2nd Edition
Just Culture- Essential for Safety IMO, 2010
(MSC 88/16/1)
IACS Recommendation No.127 IACS, 2012
A Guide to Risk Assessment in
Ship Operations

Page 2 of 2

Standards (DIN EN) ISO 9001:2015 ISO, 2015

ISO 31000:2009 Risk ISO, 2009

Management, Principles and
Guidelines

ISO Guide 73:2009 Risk ISO, 2009

Management, Vocabulary
BS OHSAS 18001:2007 BSI, 2007
Occupational Health and Safety
Management Systems
Press Articles Safety and Shipping Review 2015 Allianz Global
Corporate and
Speciality, 2015

Risk Focus Consolidated 2016, UK P&I Club,

identifying major areas of risk 2016
Books Managing Risks in Shipping The Nautical
A Practical Guide Institute, 1999

The Mariners Role in Collecting The Nautical

Evidence 3rd Edition Institute, 2006
Derivatives and Risk Management Witherby
in Shipping Publishing Group
2006

Marine Systematic Cause Analysis Technique
An Introduction

Marine Systematic Cause Analysis Technique (MSCAT)
MSCAT helps you and your organisation learn from
maritime accidents and near-misses to prevent
further human injury, environmental damage and
quality losses.

MSCAT is a simple but powerful tool to investigate

the causation of loss events. MSCAT is used by
operational staff to quickly identify the corrective
actions necessary to prevent similar events
happening in the future.

MSCAT is available as a poster and software. With

the MSCAT charts and guidance, it’s never been
easier to effectively respond to loss events.

• MSCAT is based on DNV GL’s loss causation model

• All accidents are the result of similar basic causes
• Accidental losses are mainly due to management system failures
• The DNV GL Loss Causation Model helps us to understand why accidents
are caused and what must be done to control these causes

T
H
R
Control Basic Immediate
Incident E Loss
Areas
Lack Causes
Lack Causes
Lack Lack S
Lack
H
O
of
Inadequate: of
Personal of
Substandard ofEvent L ofPeople
Factors Acts/Practices D Property
Contr
• Programme Contr Contr Contr L
Contr
Equipment
• Standards Job/System Substandard Process
ol
• Compliance ol
Factors ol
Conditions ol I
M ol
Environment
I
T

Use this simple software on your phone, tablet or desktop and begin driving down
your accident rates and improving organisational performance.

ANALYSE LEARN TEST CHART

Events with high Simple guidance Test your Download MSCAT

potential for loss on learning from knowledge of Chart and print as
need to be events, incident learning from posters for
assessed using reporting, events to earn reference and to
root cause analysis investigation, and achievement explain root cause
and improvement analysis. badges. analysis to others.
actions identified,
so these events
are not repeated.

MSCAT software is provided using

DNV GL’s HiPo software platform. Available for desktop, android and
apple devices

Tried and tested analysis Learn the keys steps of Understand the root Test your knowledge
tool incident investigation causes of high potential
events

MSCAT is supplied under license. The benefits of having an MSCAT license are:
• MSCAT chart customised with your own logo in PDF format
• MSCAT manual explaining how to use MSCAT for incident investigation
• Unlimited users on MSCAT Software

Employees in Organisation Annual Fee

Up to 100 employees £550

Up to 200 employees £1,100

Up to 500 employees £2,200

Up to 1000 employees £3,300

Up to 2000 employees £4,400

Up to 3000 employees £5,500

Up to 5000 employees £7,700

Up to 10000 employees £13,200

> 10000 employees To be negotiated

www.dnvgl.com/isrs

SAFER, SMARTER, GREENER

Objectives
To review the key terminology used in incident investigation
To focus on the main principles of marine safety investigation.

Material

• Extract from Casualty Investigation Code on the following pages

Task Description

• Group work,
• Each group must prepare and present selected sections from CIC,

Duration
Time: 15 min for preparation

@ DNV GL Incident Investigation | Rev. 1.0 Page 1 of 7

Casualty Investigation Code
Chapter 1

Purpose
1.1 The objective of this Code is to provide a common approach for States to adopt in
the conduct of marine safety investigations into marine casualties and marine
incidents. Marine safety investigations do not seek to apportion blame or
determine liability. Instead a marine safety investigation, as defined in this Code,
is an investigation conducted with the objective of preventing marine casualties
and marine incidents in the future. The Code envisages that this aim will be
achieved through States:
.1 applying consistent methodology and approach, to enable and encourage a
broad ranging investigation, where necessary, in the interests of uncovering
the causal factors and other safety risks; and
.2 providing reports to the Organization to enable a wide dissemination of
information to assist the international marine industry to address safety
issues.

1.2 A marine safety investigation should be separate from, and independent of, any
other form of investigation. However, it is not the purpose of this Code to preclude
any other form of investigation, including investigations for action in civil, criminal
and administrative proceedings. Further, it is not the intent of the Code for a
State or States conducting a marine safety investigation to refrain from fully
reporting on the causal factors of a marine casualty or marine incident because
blame or liability, may be inferred from the findings.

1.3 This Code recognizes that under the Organization’s instruments, each flag State
has a duty to conduct an investigation into any casualty occurring to any of its
ships, when it judges that such an investigation may assist in determining what
changes in the present regulations may be desirable, or if such a casualty has
produced a major deleterious effect upon the environment. The Code also takes
into account that a flag State shall* cause an inquiry to be held, by or before a
suitably qualified person or persons into certain marine casualties or marine
incidents of navigation on the high seas. However, the Code also recognizes that
where a marine casualty or marine incident occurs within the territory, including
the territorial sea, of a State, that State has a right** to investigate the cause of
any such marine casualty or marine incident which might pose a risk to life or to
the environment, involve the coastal State’s search and rescue authorities, or
otherwise affect the coastal State.

* Reference is made to the United Nations Convention on the Law of the Sea (UNCLOS),
article 94 or requirements of international and customary laws.

** Reference is made to the United Nations Convention on the Law of the Sea (UNCLOS),
article 2 or requirements of international and customary laws.

@ DNV GL Incident Investigation | Rev. 1.0 Page 2 of 7

Chapter 2

Definitions

When the following terms are used in the mandatory standards and recommended
practices for marine safety investigations they have the following meaning.
2.1 An agent means any person, natural or legal, engaged on behalf of the owner,
charterer or operator of a ship, or the owner of the cargo, in providing shipping
services, including managing arrangements for the ship being the subject of a
marine safety investigation.
2.2 A causal factor means actions, omissions, events or conditions, without which:
.1 the marine casualty or marine incident would not have occurred; or
.2 adverse consequences associated with the marine casualty or marine
incident would probably not have occurred or have been as serious; or
.3 another action, omission, event or condition, associated with an
outcome in .1 or .2, would probably not have occurred.
2.3 A coastal State means a State in whose territory, including its territorial sea, a
marine casualty or marine incident occurs.
2.4 Exclusive economic zone means the exclusive economic zone as defined by
article 55 of the United Nations Convention on the Law of the Sea.
2.5 Flag State means a State whose flag a ship is entitled to fly.
2.6 High seas means the high seas as defined in article 86 of the United Nations
Convention on the Law of the Sea.
2.7 Interested party means an organization, or individual, who, as determined by
the marine safety investigating State(s), has significant interests, rights or
legitimate expectations with respect to the outcome of a marine safety
investigation.
2.8 International Safety Management (ISM) Code means the International
Management Code for the Safe Operation of Ships and for Pollution Prevention as
adopted by the Organization by resolution A.741(18), as amended.
2.9 Marine casualty means an event, or a sequence of events, that has resulted in
any of the following which has occurred directly in connection with the operations
of a ship:
.1 the death of, or serious injury to, a person;
.2 the loss of a person from a ship;
.3 the loss, presumed loss or abandonment of a ship;
.4 material damage to a ship;
.5 the stranding or disabling of a ship, or the involvement of a ship in a
collision;
.6 material damage to marine infrastructure external to a ship, that could
seriously endanger the safety of the ship, another ship or an individual; or
.7 severe damage to the environment, or the potential for severe damage
to the environment, brought about by the damage of a ship or ships.
However, a marine casualty does not include a deliberate act or omission, with the
intention to cause harm to the safety of a ship, an individual or the environment.

2.10 A marine incident means an event, or sequence of events, other than a marine
casualty, which has occurred directly in connection with the operations of a ship
that endangered, or, if not corrected, would endanger the safety of the ship, its
occupants or any other person or the environment.

@ DNV GL Incident Investigation | Rev. 1.0 Page 3 of 7

However, a marine incident does not include a deliberate act or omission, with the
intention to cause harm to the safety of a ship, an individual or the environment.
2.11 A marine safety investigation means an investigation or inquiry (however
referred to by a State), into a marine casualty or marine incident, conducted with
the objective of preventing marine casualties and marine incidents in the future.
The investigation includes the collection of, and analysis of, evidence, the
identification of causal factors and the making of safety recommendations as
necessary.

2.12 A marine safety investigation report means a report that contains:

.1 a summary outlining the basic facts of the marine casualty or marine incident
and stating whether any deaths, injuries or pollution occurred as a result;
.2 the identity of the flag State, owners, operators, the company as identified in
the safety management certificate, and the classification society (subject to any
national laws concerning privacy);
.3 where relevant the details of the dimensions and engines of any ship involved,
together with a description of the crew, work routine and other matters, such as
time served on the ship;
.4 a narrative detailing the circumstances of the marine casualty or marine
incident;
.5 analysis and comment on the causal factors including any mechanical, human
and organizational factors;
.6 a discussion of the marine safety investigation’s findings, including the
identification of safety issues, and the marine safety investigation’s conclusions;
and
.7 where appropriate, recommendations with a view to preventing future marine
casualties and marine incidents.
2.13 Marine safety investigation Authority means an Authority in a State,
responsible for conducting investigations in accordance with this Code.
2.14 Marine safety investigating State(s) means the flag State or, where
relevant, the State or States that take the responsibility for the conduct of the
marine safety investigation as mutually agreed in accordance with this Code.
2.15 A marine safety record means the following types of records collected for a
marine safety investigation:
.1 all statements taken for the purpose of a marine safety investigation;
.2 all communications between persons pertaining to the operation of the ship;
.3 all medical or private information regarding persons involved in the marine
casualty or marine incident;
.4 all records of the analysis of information or evidential material acquired in the
course of a marine safety investigation;
.5 information from the voyage data recorder.
2.16 A material damage in relation to a marine casualty means:
.1 damage that:
.1.1 significantly affects the structural integrity, performance or operational
characteristics of marine infrastructure or a ship; and
.1.2 requires major repair or replacement of a major component or
components; or
.2 destruction of the marine infrastructure or ship.
2.17 A seafarer means any person who is employed or engaged or works in any
capacity on board a ship.
2.18 A serious injury means an injury which is sustained by a person, resulting in
incapacitation where the person is unable to function normally for more than72hours,
commencing within seven days from the date when the injury was suffered.

@ DNV GL Incident Investigation | Rev. 1.0 Page 4 of 7

2.19 A severe damage to the environment means damage to the environment which,
as evaluated by the State(s) affected, or the flag State, as appropriate, produces a
major deleterious effect upon the environment.

2.20 Substantially interested State means a State:

.1 which is the flag State of a ship involved in a marine casualty or marine incident;
or
.2 which is the coastal State involved in a marine casualty or marine incident; or
.3 whose environment was severely or significantly damaged by a marine casualty
(including the environment of its waters and territories recognized under international
law); or
.4 where the consequences of a marine casualty or marine incident caused, or
threatened, serious harm to that State or to artificial islands, installations, or
structures over which it is entitled to exercise jurisdiction; or
.5 where, as a result of a marine casualty, nationals of that State lost their lives or
received serious injuries; or
.6 that has important information at its disposal that the marine safety investigating
State(s) consider useful to the investigation; or
.7 that for some other reason establishes an interest that is considered significant by
the marine safety investigating State(s).
2.21 Territorial sea means territorial sea as defined by Section 2 of Part II of the
United Nations Convention on the Law of the Sea.
2.22 A very serious marine casualty means a marine casualty involving the total loss
of the ship or a death or severe damage to the environment.

Chapter 16
PRINCIPLES OF INVESTIGATION
16.1 Independence: A marine safety investigation should be unbiased to ensure the
free flow of information to it.

16.1.1 In order to achieve the outcome in paragraph 16.1, the investigator(s) carrying
out a marine safety investigation should have functional independence from:
1. the parties involved in the marine casualty or marine incident;
2. anyone who may make a decision to take administrative or disciplinary action
against an individual or organization involved in a marine casualty or marine
incident; and
3. judicial proceedings;

16.1.2 The investigator(s) carrying out a marine safety investigation should be free of
interference from the parties in 1, 2 and 3 of paragraph 16.1.1 with respect to:
1. the gathering of all available information relevant to the marine casualty or
marine incident, including voyage data recordings and vessel traffic services
recordings;
2. analysis of evidence and the determination of causal factors;
3. drawing conclusions relevant to the causal factors;
4. distributing a draft report for comment and preparation of the final report; and
5. if appropriate, the making of safety recommendations.

16.2 Safety focused: It is not the objective of a marine safety investigation to

determine liability, or apportion blame. However, the investigator(s) carrying out a
marine safety investigation should not refrain from fully reporting on the causal factors
because fault or liability may be inferred from the findings.

@ DNV GL Incident Investigation | Rev. 1.0 Page 5 of 7

16.3 Co-operation: Where it is practicable and consistent with the requirements and
recommendations of this Code, in particular chapter 10 on Co-operation, the marine
safety investigating State(s) should seek to facilitate maximum co-operation between
substantially interested States and other persons or organizations conducting an
investigation into a marine casualty or marine incident.

16.4 Priority: A marine safety investigation should, as far as possible, be afforded the
same priority as any other investigation, including investigations by a State for criminal
purposes being conducted into the marine casualty or marine incident.

16.4.1 In accordance with paragraph 16.4 investigator(s) carrying out a marine safety
investigation should not be prevented from having access to evidence in circumstances
where another person or organization is carrying out a separate investigation into a
marine casualty or marine incident.

16.4.2 The evidence for which ready access should be provided should include:
1. survey and other records held by the flag State, the owners, and classification
societies;
2. all recorded data, including voyage data recorders; and
3. evidence that may be provided by government surveyors, coastguard officers,
vessel traffic service operators, pilots or other marine personnel.

16.5 Scope of a marine safety investigation: Proper identification of causal factors

requires timely and methodical investigation, going far beyond the immediate evidence
and looking for underlying conditions, which may be remote from the site of the marine
casualty or marine incident, and which may cause other future marine casualties and
marine incidents. Marine safety investigations should therefore be seen as a means of
identifying not only immediate causal factors but also failures that may be present in the
whole chain of responsibility.

@ DNV GL Incident Investigation | Rev. 1.0 Page 6 of 7

GUIDELINES TO ASSIST INVESTIGATORS IN THE IMPLEMENTATION OF THE
CASUALTY INVESTIGATION CODE (RESOLUTION MSC.255(84))

@ DNV GL Incident Investigation | Rev. 1.0 Page 7 of 7

ACTIVITY 2: DETERMINE LOSS POTENTIAL

Objectives

With this exercise, you will learn how:

• To identify loss potential of an incident

• To decide on the scope, timing and resources needed for the investigation

Material
• Statement of facts
• Worksheet for the risk assessment
• Risk matrix

Scenario
See relevant „Statement of Facts“

Exercise

Task: Identify the loss potential of the incident in order to decide on:

• The resources needed,

• The seniority of the investigators,

• The size and composition of the team and the degree of detail of the investigation

@ DNV GL
Activity 2 | Rev. 1.0
SINKFAST - Ship Details

Name SINKFAST Ship’s official number 256789

Type Chemical/Product Tanker Call Sign 5BCX5
Flag Cyprus IMO No. 4567890
Port of Registry Limassol Class DNVGL
Registration date: 01.01.2002 DOC issued by DNVGL
Length o.a. 166,50 m SMS issued by DNVGL
Length p.p. 164,00 m ISSC issued by DNVGL
Moulded breadth 23,40 m Crew
Depth to main deck 14,80 m Crew 14

Draught 15,00 m Crew Agency Marlow

Speed 16,0 kn Operator OSCO
Tonnage 22000 tdw Master Ukrainien
Pumps 4 / 4100 cbm Crew Polish/Russian/Indian

Cargo Pump Room

The cargo pump room is situated between the forward engine room bulkhead and the after bulkheads
of No 5 Port, Centre and Starboard Cargo tanks and extends upwards from keel plate to poop deck
level.

@ DNV GL Maritime Academy | Rev. 1.0

SMM Section: 9

LOGO Safety Management Manual

Incident Report
Doc. No.: Form 9-01
Rev.: 03/2015
Page:1 of 1

 Security Incident  Safety Incident  Non Compliance  Near Miss

M.V. SINKFAST Date: 18.09.2015
Master: Ronald Smith Location: Fawley Esso Marine Terminal
Voyage from: Amsterdam to: Southampton
Type of incident: Explosion Persons and areas affected: Fitter, pump room

Wind: SW 3 Sea: -- Weather: Partly clouded, Air Temperature: 23°C

On watch: Chief Officer, Chief Engineer, Pump Man

Statement of facts:
The vessel departed from Amsterdam in a loaded condition at approximately 14:15 hrs on 17 September 2015
bound for the Esso Fawley Refinery Marine Terminal, Southampton. The cargo consisted of 5,358.5 tonnes of
gasoil and 12,511.7 tonnes of naphtha.

18 September 16:36 arrival at terminal and tied up; 16:50 satisfactory completion of ship/shore safety checklist;
16:53 commenced sampling and ullage taking; 18:10 cargo discharge plan approved; 19:15 all checks
completed; 19:30 line and valve setting completed, ready for discharging;
20:00 commenced discharging with Nos 1 and 2 cargo pumps discharging naphtha via No 2 manifold and No 3
cargo pump discharging gasoil via No 3 manifold. Chief Officer handed over the watch to the Third Officer and
the Pump Man.
At 24:00 the watch was taken over by the 12-4 Second Officer together with an AB. For handover both the
Pump Man and the 12-4 Second Officer inspected the pump room and noted a small leakage at pump No.
3 seal. During the next four hours two more visits were made to the pump room to have a look at the
leakage of No. 3 pump seal. At 04:00 the Chief Mate was informed about the leakage. At 06:00 the Chief
Officer asked the Chief Engineer to have look at No. 3 pump. At 06:30 discharging of gasoil with No. 3
pump was completed. 06:45 gasoil discharging lines flushed 07:45 discharging of naphtha completed but
the cargo lines were still partly filled up with cargo 07:50 Chief Engineer ordered the fitter to assist the pump
man in a few small repair jobs in the pump room. 08:05 Pump Man instructed the fitter to start loosening the
bolts of the seal of no 3 Cargo pump, which had been used to discharge gas oil and was already drained and
emptied by him. 08:10 Pump Man left pump room for line and valve setting. 08:20 Explosion in the pump room.
08:30 Master called shore for assistance; 08:40 Fire brigade equipped with SCBA equipment entered pump
room to search for the fitter; 08:50 Fitter found close to the forward pump room bulkhead with severe injuries
08:55 Shore rescue team arrived 09:00 Fitter evacuated to ship’s hospital and after first aid was hospitalized.

Personnel injuries, damage to ship and/or equipment, environment, other property

The fitter has been thrown by the shock wave against the forward bulkhead causing severe injuries.

What was the cause for the incident?

An explosion took place in the pump room, when the fitter tried to repair a leaking pump seal. Lack of
supervision by the pump man.

Immediate corrective action

Treatment of the fitter

Recommended corrective- preventive action/improvements in order to avoid reoccurrence of the

incident:
Safety meeting

Signature of Master Ronald Smith Date: 19.09.2015

Evaluation of the DPA:

Name and signature of DPA Date:

© DNV GL Activity 2
Activity 2 –Identify loss potential
The objective is to identify the potential loss and to decide on the scope and timing of the investigation.

Hazard
Risk
(Activity and Consequences
condition (Loss Potential) Timing of Scope of Resources
Event Probability (if not
prior Investigation Investigation required
incident) controlled)
Low Medium High

@ DNV GL Incident Investigation | Rev. 1.0 Page 1 of 3

Guide notes
All undesired events should be evaluated to determine those with high potential for major or serious loss. When an event is reported, risk assessment should be
applied to evaluate the loss potential. The information received during the initial notification should be sufficient for the company to make an assessment on the
seriousness of the incident and whether it warrants further investigation. Every effort should be made to gather the information necessary to determine the seriousness
of the incident as soon as possible, as deciding to start an investigation too late can seriously limit its scope and thoroughness.

Evaluation of loss potential starts with identification of a hazards which are represented by safety significant activities leading up to the incident. The activities are
analyzed to determine what actions occurred or conditions were present during the time leading up to the event and present an unacceptable level of risk.
Such actions and/or conditions are identified as hazards and risk assessments are carried out.

Risk is assigned to hazard by determining probability of the hazard occurring and the consequences of that hazard.

With respect to probability, following may be taken in the consideration:

1. Is there a history of event like this one or is this an isolated case? (in the organization, in the industry)
2. How many similar events were there under similar circumstances in the past?
3. How many pieces of equipment are there that might have similar defects?
4. How many operating or maintenance are following or are subject to the practices or procedures in question?
5. To what extent are there organizational, management, or regulatory implications which might reflect larger systemic problems?
6. What percentage of the time is the suspect equipment or the questionable procedure or practice in use? (regular practice, main activity on board)

With respect to adverse consequences, following may be taken in the consideration:

1. How many persons could be affected by the risk?

2. What could be the extent of property damage?
3. What could be the environmental impact?
4. What is the potential commercial impact?
5. What could be the public and media interpretation?

@ DNV GL Incident Investigation | Rev. 1.0 Page 2 of 3

@ DNV GL Incident Investigation | Rev. 1.0 Page 3 of 3
ACTIVITY 4: HUMAN FACTORS

Objectives
To learn application of SHELL model during human factors analysis.

Material
• Statement of facts from Ac_2
• Ac4_SHELL model definitions from the next page

Task Description
Read description of SHELL model elements.
Read provided sample situations and assign them to appropriate component from the SHELL
model.

Duration
Time: 10 min for preparation

@ DNV GL Incident Investigation | Rev. 1.0 Page 1 of 3

ACTIVITY 4: SHELL MODEL – DEFINITIONS AS PER RES. A.884 (21)

Software, Hardware, Environment & Liveware

The SHEL model is typically depicted graphically to display not only the four categories or
components of the maritime transportation system, but also the relationships or "interfaces"
between the elements and the people (liveware) at the heart of the model.
SOFTWARE - The information and support systems guiding people. Software elements
include checklists, manuals, publications, procedures, regulatory requirements, training,
education, maps, and charts.
HARDWARE - The ships, facilities, machinery, cargo, equipment, and material people work
with. Hardware elements include all machinery, gear, electronics, switches, controls, and
displays.
ENVIRONMENT - The internal and marine environment in which people work. Environment
elements include the internal environment such as workplace environment, room
temperature, ventilation, lighting, pitching and yawing, and the marine environment such as
sea state, wind, ice, precipitation, and visibility.
LIVEWARE - The people themselves. Liveware elements include all of the people involved in
the accident both directly and indirectly.
The rough edges between the components in the SHEL diagram are symbolic of the fact that
the mismatch between an individual and these components is important. These possible
mismatches warrant special attention by the marine investigator because mismatches in the
system may point out safety deficiencies.

@ DNV GL Incident Investigation | Rev. 1.0 Page 2 of 3

Sample situations
1. Lookout did not report navigational lights flashing on the starboard bow to the OOW.
He was told only to report these events which were representing threat to safety of
the ship.
2. The interface of ECDIS functionalities was not easy to use. Master had several
problems with allocating functionalities responsible for route checking or safety
parameters setting.
3. The pump man was confident that fitter is familiar with the arrangements in the
pump room.
4. Recent ship’s trade is very hectic. It is not possible to maintain regular resting
periods of the crew.
5. Enclosed space entry procedure did not specify the rank of crew responsible for
preparation of permit to work.
6. There is not enough room in the area of cargo pump no 2 to perform maintenance on
the pump with use of standard set of tools.
7. Chief engineer’s health condition did not allow him to climb on too many stairs.
8. There is excessive number of alarms on the bridge. The crew started to acknowledge
them without verification of the source.
9. There is no system for controlling distribution of revisions to SMS. Results from
internal audits confirmed that crew was not aware about the latest revision to critical
equipment maintenance procedure.
10. There is no procedure for testing gas detection system in the pump room.
11. Alleyway walls on the poop deck are covered with excessive number of posters and
warnings. The crew stopped to read them.
12. Master reminded to the crew requirements for reporting near misses. There is no
evidence that he did report one during his contract.

@ DNV GL Incident Investigation | Rev. 1.0 Page 3 of 3

ACTIVITY 6: CREATING A STEP DIAGRAM

Objectives

With this exercise, you will learn how:

• To construct s STEP diagram

Material
• Statement of facts from Activity 2 (both cases)
• Pump room explosion summary
• Grounding summary
• Flip chart paper + sticky notes

Method

Group exercise. With use of Materials create STEP diagram. Guidelines from slide 96 are
to be used for references.

@ DNV GL Activity 6 | Rev. 1.0

ACTIVITY 6

Pump Room Explosion - Result of the interviews

The Russian fitter was only 2 days on board and not yet familiar with the pump room lay
out. The Indian pump man told him to start loosening the bolts of the seal of no 3 Cargo
pump, which had been used to discharge gas oil and was already drained and emptied by
him. The pump man told him the tools were in the pump room and went to the deck store
for a small chainblock.
The fitter went down and found some tools close to the third pump from sb side, assuming
this was cargo pump number three. In reality however, the first two pumps on sb side
were the ballast pumps, thus the pump, the fitter choose was cargo pump no 1, which had
unfortunately been used to discharge Gasoline. Being familiar with repairing seals, he
climbed down under the floor plates and tried to loosen the bolts, which were heavily
corroded. Apart from this, the working position was difficult, which prevented him to
exercise enough power on the spanner. As he had still a lot of jobs to do, he was in a
hurry and decided to use a steel hammer to exercise extra impact power in the spanner,
thinking the cargo not being explosive (gas oil).
As he hit the spanner a few times, suddenly the bolt broke and at the same time an
explosion
During the investigation interviews it appeared that the Indian pump man had told him to
take the cargo pump on the port side, which was obviously not understood by his
colleague. It also appeared that:
The ventilation was not switched on, because it was out of order for some time.
The Chief Engineer had ordered the necessary spares already a few months ago, but the
purchasing dept. tried to find a cheaper alternative.
The amount of spares needed for this old vessel was such, that the budget was already
was exceeded after 8 months and the Company tried to save money as much as possible.
Only critical items (needed for the operation of the ship) were ordered without delay, for
the other items, cheaper alternatives had to be found. The spares for the ventilator were
not on any list of critical items.
This list was just a standard list, copied from the list for the general cargo ships; there
was not yet much experience with tankers in the company; in fact this was the first and
only tanker.
Special tools were available, but in a special locker in the pump room; which the fitter was
not aware of.
After further investigation it also appeared that the fitter had only experience on board of
dry cargo vessels. He had made a general safety familiarization tour with the third mate,
but there had not yet been enough time to familiarize him on his jobs
He was hired because of a high turnover rate of personnel in the company. This was
influenced by long contracts in combination with a demanding trade (frequent and short
voyages in the North Sea area )
Lack of skilled manpower was discussed during safety meetings, the Master and senior
officers being aware of the hazards, had requested extra skilled repairmen to get the most
critical jobs done, this was discussed with the superintendent, who found it a delicate
matter. And had told the captain to discuss it with the crewing department
The DPA, being the Technical Manager (and the superior of the superintendent), promised
to try and get things done during next dry-dock.
A work permit system was in use, but only issued by the chief officer, who did not know
anything about this repair.

@ DNV GL Maritime Academy | Rev. 1.0

ACTIVITY 7: EVIDENCE MATRIX

Objectives

With this exercise you will learn:

• How to use the evidence matrix to document evidence as pro or con for
an incident hypothesis

Material
• Statement of facts from previous activities
• Results of the Interviews
• Flipchart and pens

Exercise

Establish the pro and con evidence for YOUR accident hypothesis:
Read the accident scenarios and fill in the evidence matrix and ask yourself how the
hypothesis can be supported or denied.

@ DNV GL Maritime Academy | Rev. 1.0

MAJOR FINDING OR CAUSAL EVIDENCE
SOURCE OF EVIDENCE COMMENTS
ELEMENT (Both Pro and Con)

@ DNV GL Maritime Academy | Rev. 1.0

ACTIVITY 8: CREATING FACT TREE

Objectives
To practice creation of fact tree.

Material
• Ac_7_evidence_matrix

Task Description
Group work.
Task1
Read description of fact tree analysis from the page below. Perform provided
exercises to improve your understanding of the process.
Task2
In groups, create fact tree to MT Sinkfast and/or MV Navigator cases using all
available materials.

Duration
Time: 45 min for preparation

@ DNV GL Incident Investigation | Rev. 3.0 Page 1 of 7

ACTIVITY 8 - HOW TO CONSTRUCT A FACT TREE?

Remember the 2 questions: WHAT IS NEEDED? And IS THAT ENOUGH?

EXAMPLE

Fact 1 - Brakes were not maintained (seen in records)

Fact 2 - Cannot stop in time (car hits wall)
Fact 3 - Driving 100 km/hr (speedometer indication)
Fact 4 - Brakes work insufficiently (braking distance)

The fact tree is constructed as follows: 2

1. First find the END FACT: in this case : Cannot stop in time

2. What was required to cause this fact? Fact 4: Brakes work insufficiently

3. Is this required at this stage? Yes, if the brakes work properly you can stop in
time.

4. Is this enough to cause the fact? Yes, properly working brakes will assure you
can stop in time.
So: fact 4 is to be placed before fact 2.
4 2

5. Now fact 4 Breaks work insufficiently becomes the End fact

6. What is required to get poorly functioning brakes? They do not function properly
because of 1. Brakes were not maintained.

7. Is this fact 1 enough to cause the consequence 4?

No, when you are not driving the car it does not matter that the brakes are not
maintained. You need to be driving and in this case: driving 100 km/hr. At slower
speed the poor brakes would still be working sufficiently to stop the car. So we
need both facts 1 and 3 to cause fact 4.

4 2
EXERCISE
3
1. Mr. X who’s standing in the elevator, panics
2. Mr. X gets unwell
3. The elevator gets stuck between two floors
4. Mr. X has a heart condition

@ DNV GL Incident Investigation | Rev. 3.0 Page 2 of 7

TASK1: SELECT THE RIGHT FACT TREE: MAKE THE RIGHT CHOICE

In each of the following exercises four facts are given in random order. Three possible
fact trees are given (marked A, B and C respectively). Only one of these trees is correct.
Choose the correct tree of exercise.

1. Chemical suits were not inspected with frequency required by the manufacturer.
2. OS was not able to use the chemical suit of his size because of defective zipper.
3. OS experienced skin burns during sampling of corrosive cargo.
4. No chemical suit was used during sampling operation.

1 2 4 3

3 3
1 4

B 2 2 4

1
C

@ DNV GL Incident Investigation | Rev. 3.0 Page 3 of 7

Tree 1

1. Crew was involved in very hectic trade.

2. Ship run aground.
3. Ship’s route on ECDIS was drawn across a safety contour.
4. Audible alarm on ECDIS was disabled.

3
3

2 4
B 2

1
1 4 C

1 3 2 4

Tree 2

1. Permit to work not effective 4 3

2. Missing results of atmosphere check

3. Not acknowledged by those performing the job A 1

4. No safety culture on board

4 2 3 1
B 2
C
@ DNV GL Incident Investigation | Rev. 3.0 Page 4 of 7
1 4
Tree 3

1. Explosive atmosphere present in the p/room 2

2. Leakage of cargo pump no 2

3. Gas detection unit not operational 3 1

4. Leakage considered not danger by OOW A

1
2 1
4 3
3 B
2
C

Tree 4

1. Cultural issue 1 4

2. Cardinal light snot reported to OOW

A 2
3. Not experienced lookout

4. Previous reports ignored or not acknowledged

1
B

4 2 1

4 2

3 3
C

@ DNV GL Incident Investigation | Rev. 3.0 Page 5 of 7

Tree 6

1. Route not properly verified

2. Draught exceeds depth

3. Track passing shoal position

4. Unexperienced OOW with route planning

5. Route planning not supervised by Master

6. Vessel aground

C
2 3 6

B 4
4 6
1
1 3 5

@ DNV GL Incident Investigation | Rev. 3.0 Page 6 of 7

TASK 2: CONSTRUCT A FACT TREE for MV NAVIGATOR/MT SINKFAST CASES

Construct the Fact Tree, starting with the End Fact (or End Facts) working your way
back from cause to cause using available information.

FACTS TREE

@ DNV GL Incident Investigation | Rev. 3.0 Page 7 of 7

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