1、MODEL COURSE 3,aa MARINE ACCIDENT AND INCIDENT INVESTIGATION TRAINING MANUAL IMO International Maritime Organization Model Course No: 3.11 Marine Accident and Incident I nves t i gat i o n Training Manual IMO First published in 1988 by the INTERNATIONAL MARITIME ORGANIZATION 4 Albert Embankment, Lon
2、don SE1 7SR Revised edition 2000 Printed by Ashford Open Learning Ltd 2 4 6 8 10 9 7 5 3 ISBN 92-801 -5095-2 IMO PUBLICATION Sales number TA31 1 E Copyright O IMO 2000 All rights reserved. No part of this publication may, for sales purposes, be produced, stored in a retrieval system or transmitted i
3、n any form or by any means, electronic, electrostatic, magnetic tape, mechanical, photocopying or otherwise, without prior permission in writing from the International Maritime Organization. CONTENTS Foreword Part 1 Part 2 Part 3 Part 4 Part 5 Part 6 Part 7 Part 8 Part 9 Part 10 Part 11 Course Intro
4、duction International Shipping - Shipping Casualties and Public Perceptions Investigations International Conventions, Requirements, etc. Setting Up an Investigation Interviewing Elements of a Casualty Human Factors Collecting Evidence Determining Occurrence Sequence, Analysing Evidence Reporting v 1
5、 3 7 17 110 116 , 132 147 177 183 196 Foreword These notes have been compiled as a reference for this course and also as a working document for use when faced with the need to investigate. The thrust of the course is directed towards achieving a system of investigation aimed at establishing the circ
6、umstances and causes of a marine casualty, to learn and promulgate the safety lessons. The course does not deal with blame or liability and only briefly refers to more formal court or inquiry procedures. The course is centred on the International Maritime Organization Assembly Resolution A.849(20),
7、the Code for the Investigation of Marine Casualties and Incidents and amendments to the Code as annexed to Resolution A.884(21).The course also will stress the need for reporting to IMO under the provisions of MSC Circ. 827/MEPC Circ. 333. No two accidents are ever precisely the same. However, the c
8、ourse sets out to show that while the causal factors may be diverse, the underlying generic structure of any casualty or accident, whether marine, road, rail or aviation, can be seen to have a common structure. Much of the course is centred on role playing and case studies. Participants should use t
9、heir experience and judgement to make the roles as realistic as possible; by so doing participants should complete the course with a clear concept of systemic investigations and their role in improving the safety of life at sea and protecting the marine environment. 1 Course Introduction 1.1 Introdu
10、ction Annexed to IMO Resolution A.847(20) are guidelines to provide flag States with a means to establish and maintain measures for the effective application and enforcement of IMO Conventions. Part 7 of the annex refers to flag State investigations. “7. FLAG STATE INVESTIGATIONS 7.1 In addition to
11、providing qualified surveyors, the flag State should provide qualified investigators. Consistent with article 94.6 and articles 21 7.4,5 and 6 of UNCLOS and with the provisions of the relevant IMO conventions, investigations should be carried out following a marine casualty or pollution incident. Th
12、e flag State should ensure that individual investigators have a working knowledge and practical experience in those subject areas pertaining to their normal duties. Additionally, to assist individual investigators in performing duties outside their normal assignments, the flag State should ensure re
13、ady access to expertise in the following areas, as necessary: navigation and the Collision Regulations flag State regulations on certificates of competency .I .2 .3 causes of marine pollution .4 interview techniques -5 evidence gathering .6 evaluation of the effects of the human element 7.2 Any acci
14、dent involving personal injury necessitating absence from duty of three days or more and any deaths resulting from occupational accidents and casualties to ships of the flag State should be investigated, and the results of such investigations made public. Ship casualties should be investigated and r
15、eported on in accordance with UNCLOS, relevant I MO Conventions, and the Guidelines currently being developed by IMO. Casualty investigations should be conducted by suitably qualified investigators, competent in matters relating to the casualty. The report of the investigation should be forwarded to
16、 IMO together with the flag States observations, in accordance with the Guidelines referred to above. It is important, therefore that flag and coastal State administrations have in place an effective and internationally acceptable system for investigating marine accidents. 1.2 The purpose of the cou
17、rse The purpose of this course is to introduce you to the philosophy, processes and procedures required to support a marine casualty investigation in accordance with IMO Assembly Resolution A.849(20) and the Code for the Investigation of Marine Casualties and Incidents. The Code seeks to introduce t
18、o the international shipping community uniform objectives and procedures for investigating casualties which occur in this most international of industries. The international aviation industry has subscribed to such a code (Annex 13 of the International Civil Aviation Organization Convention) for som
19、e years and the systems approach into air accidents is credited with contributing to the safety of the civil aviation industry. The IMO Code is aimed at a safety outcome to identify the circumstances under which a casualty occurred and to determine the causes of such an accident. 1 MARINE ACCIDENT A
20、ND INCIDENT INVESTIGATION: TRAINING MANUAL This course is designed to introduce potential flag State investigators with an introduction to accident investigations and accident investigation methodology. The course will be focused on the IMO Code. The course also provide administrators with an insigh
21、t into what is required in conducting a casualty investigation, supporting the investigator in the field and what an investigation should achieve. Investigations are an “official function of a flag or coastal State”. When investigating in your own country your own national laws will apply. You will
22、have to bear these laws in mind when dealing with certain parts of the course, this will apply particularly to Part 5. 1.3 Course structure The course is divided into eleven learning objectives or “parts”, as outlined in the program. It will be centred on group activities and lecture sessions. Recom
23、mended reading and references Reason, J. (1 990) Human Error, Cambridge University Press, Cambridge (UK). ISBN O 521 31419 4 Reason, J. (1 997). Managing the Risks of Organizational Accidents, Ashgate, ISBN 1 84014 105 O Reason, J. Corporate Culture and Safety. NTSB Symposium on Corporate Culture an
24、d Transportation Safety, Washington, 1997 Moore-Ede, M., The Twenty-Four Hour Society, Random House Australia, 1993 ISBN O O9 182755 8 Perrow, C., Normal Accidents - Living with High-Risk Technologies, Basic Books, Inc. New York Elizabeth F boftus, Eyewitness Testimony, Harvard University Press, 199
25、6.) Rushbrook.R., Rushbrooks Fire Aboard, Third Edition, 1998, Brown, Son Jan Heweliusz- capsized in the Baltic, 14/1/93, 55 deaths; Estonia - capsized in the Baltic 28/9/94, 852 deaths; Cebu City- sank after a collision in Maila Bay on 2/12/94 with the loss of 140 lives; Gurita, stranded and sank o
26、n 19/1/96, Banda Archipelago (Indonesia) with loss of 338 lives; Bukoba capsized on Lake Victoria in May 1996 with loss of 869 lives; Princess of Orient - sank in tropical storm Vicki on 21/8/98, at least 150 deaths. Harta Rimba - sank in central Indonesian Archipelago on 6/2 99 with loss of approx.
27、 300 lives. The loss of the Estonia and the ferry tragedies over the previous years prompted the Secretary General and the Chairman of the Maritime Safety Committee to seek approval of the 18th Assembly for the formation of a group of experts to consider the issues of ro-ro safety. This group met on
28、 8 occasions resulting in a Diplomatic Conference in 1995, which approved 30 amendments to SOLAS 74 dealing with ro-ro safety. 2.3 Accidents as an iceberg Action ratio study What can we learn from accident investigations and analysis? Which incidents should be investigated? Quite obviously no marine
29、 authority has the resources to investigate all minor accidents and near misses (sometimes referred to as “incidents”). However, in an ideal world we would look at even the most minor incident. Accidents can be seen as the part of an iceberg above the sea surface. Beneath the surface there are a myr
30、iad of minor accidents and near misses which are largely unreported and whether they are investigated or not may rely on the company safety culture and ethic. A study of industrial accidents undertaken by Frank E Bird, Jr. and George L Germain (1 969)2 analysed 1,753,498 accidents reported by 297 co
31、mpanies from 21 industrial groups over covering a period of 3 billion man hours. In comparing the severity of accidents they discovered that for every reported major injury (death, disability, lost time or medical treatment) there were 9.8 minor injuries requiring first aid. 2 Bird F. and Germain G.
32、, (1 986) Practical Loss Control, Leadership Institute Publishing, Loganville, Georgia. 5 MARINE ACCIDENT AND INCIDENT INVESTIGATION: TRAINING MANUAL For each major injury there were 30.2 property damage accidents and 600 incidents. property damage accidents incidents with no visible damage Bird and
33、 Germain pointed out that to prevent the major accident occurring it would be more productive to attack the lesser incidents. North of England P this leader is reproduced by kind permission of Lloyds List. 9 MARINE ACCIDENT AND INCIDENT INVESTIGATION: TRAINING MANUAL Those who drafted the report ref
34、er to only those which took place in the North Sea or Baltic, but it is surely reasonable to suppose that there have been others over the years, since administrations and classification societies judged that a drive through ship with a large bow opening was a safe option. The Estonia report admits t
35、hat the list is by no means complete, as it contains only Finnish and Swedish vessels. Some of these incidents, and they stretch back to the early 197Os, were very serious and potentially lethal, although it appears that prompt action by those in charge of the ships slowing or stopping, turning the
36、vessels out of the weather and returning immediately to the safety of port prevented water getting onto the cardecks. Additionally the availability of a watertight door inside the visor or clamshell doors provided the necessary level of insulation and saved the day. But the point is, and the questio
37、n must be asked, just how widely knowledge about these these accidents was promulgated by those who had knowledge of them? The Finnish and Swedish authorities would have been in possession of the full facts, and it is reasonable to suppose that those operating ships under these flags would have been
38、 made aware of the incidents. A number of the major classification societies were also clearly informed about accidents which had taken place aboard ships they had responsibility for. Presumably the individual owners, after an accident, made very sure that they closely inspected the fastenings and h
39、inges of bow doors in other vessels of their fleets. But who else learned about such accidents throughout the world, bearing in mind that drive- through ships are a more or less universal ferry type of today? Were naval architects working on designs for big ferries ordered by Japanese operators made
40、 aware of the problems that had been experienced? Were owners of ex-Baltic boats working in the Eastern Mediterranean or Far East ever told about the problems that were experienced by the operators of the Finlandia or Viking Saga, or the fright that the watchkeeper of the Wellamo received when he sa
41、w the bow visor lifting as he ran down from Helsinki to Stockholm in a storm one night in 1975? There were drive through ships designed in North America and the United Kingdom, Italy and France - did any of their designers ever learn about the incident in which heavy seas tore off the clamshell door
42、s of the Finnhansa in a storm off the Finnish coast in 1977? Did the administrations which were busily approving plans for bigger and more sophisticated ferries with enormous passenger loads ever learn about these and other incidents? Were the Japanese or Canadian or British or French government sur
43、veyors ever made aware of these operational problems? And indeed, was there any proper mechanism available for the transmission of accident information between one ferry owner and his competitor down the road, or owners of similar ships throughout the world? Did the International Maritime Organisati
44、on ever become engaged in the receipt, study, or promulgation of information about such incidents? The answer to all these questions, Im afraid, is probably a resounding no, because the mechanisms for the transmission of such important operational information was not generally available. Indeed, the
45、re is some evidence that the seriousness of such incidents, and the possible consequences for these ships if water had got onto their cardecks was not properly contemplated. In the event, the officers aboard the ships reacted promptly and properly, the ships went back to port, were repaired to every
46、ones satisfaction and returned to service. The incident had effectively ended, and what lessons that were drawn from it were probably confined to a very small number of people. Perhaps, in fact, the potential seriousness of the incidents were not fully comprehended, perhaps it was merely assumed tha
47、t the secondary safety appliances would continue to be adequate, as they had been in these accidents. This inability of the maritime industry to construct and maintain a system for the prompt and international promulgation of important safety information has worried a number of thoughtful 10 INVESTI
48、GATIONS people over the years, but there is still very little that is done about it. The classification societies have probably gone rather farther than most, in establishing formal systems for alerting each other to elements prescribed by their rules which have been shown to give trouble, but there
49、 is very little else. There is certainly nothing even approaching the systems in the aviation world which, if a bolt fails in the tailplane of a 737, alerts every operator of similar aircraft to this failure in a trice. The fatal bow door damage the Estonia, for whatever reason, is merely the worst possible example of this maritime industry system failure, which extends into every area of shipping. It is made infinitely worse by the fragmention of the industry into so many different sectors, and the emergence of the flag of convenience and corresponding weakening of the traditional fl
