25/06/2024

How can Harbour Authorities, and owners of marine facilities, learn from marine accidents or incidents to help prevent reoccurrence?

Marine accidents and incidents can happen at any time. Understanding why they happened allows actions to be taken to prevent reoccurrence.

While the Marine Accident Investigation Branch (MAIB) will investigate the most serious cases, the vast majority of accidents and incidents will be investigated by port and harbour staff. 

It is therefore vital to have a skilled internal investigator to understand the chain of events leading to an accident or incident, and identify safety measures that can be implemented.

But how can organisations ensure their investigations are sufficiently robust to help prevent accident or incident reoccurrence?

Understand the anatomy of an accident or incident

To understand the anatomy of an accident or incident, it is important to recognise that:

• Accidents and incidents are rarely caused by a single event; they usually are trigged by several factors that could be totally unrelated, and often occur over a lengthy period
• Human factors or errors feature in nearly all accidents and incidents
• Accidents and incidents occur when safety barriers and risk prevention measures fail

The anatomy of an accident or incident is the combination of three factors: each cause event, when they occurred, and whether or how they are linked.

Recognise human factors

Human error accounts for 75% of marine liability; by far the most important factor in marine liability claims and losses.

Because of their prevalence, it is essential to collect comprehensive evidence into how human factors contribute to accidents and incidents.

Knowing how to identify different types of human factors, and considering how each interact, will provide an understanding of the conditions that might have influenced the human error behind an accident or incident.

Gather sufficient evidence

The quality of evidence collected directly reflects the quality of an investigation; it is important to gather anything that can help you understand the process and causes behind an accident or incident.

There are four categories of evidence:

1. Physical evidence
2. Documentary evidence
3. Electronic evidence
4. Witness evidence

1. Physical evidence

It is important to preserve the physical evidence. This means ensuring the scene of the accident or incident, and related items, are not tampered with, are documented through photos, plans/drawings made by witness and samples collected onsite.

For accuracy and tracking, these need to be cross-referenced into an evidence register.

2. Documentary evidence

Documentary evidence can include:

• Safety procedures and risk assessments
• Charts, logbooks, paper recordings and standing orders,
• Operating procedures, plans and manufacturer manuals
• Photos

3. Electronic evidence

Electronic evidence can include:

• CCTV
• Computers
• Portable Pilot Units (PPUs)
• Mobile and satellite phones
• VTS radar and VHF recordings
• On board Voyage Data Recorders (VDRs), chart plotters and machinery diagnostics
• Automatic identification system (AIS) and long-range identification and tracking (LRIT) data

4. Witness evidence

Human evidence from witnesses has the potential to provide the most insight, but it is also the most fragile, and potentially unreliable, form of evidence. Gathering optimal witness evidence requires speed, skill and preparation in the form of interviews.

Carry out thorough interviews

Investigation interviews are made up of five stages:

1. Plan and prepare
2. Engage and explain
3. Account, clarify and challenge
4. Close
5. Evaluate

For each stage, there are a specific set of actions that will help you make the most of the interview process, and gather sufficient witness evidence to support your investigation.

Deliver a robust report and recommendations

Investigation reports provide a permanent record of the investigation; the Port Marine Safety Code states that the Duty Holder may well require a robust and rigorous examination of the incident for assurance purposes.

Reports are also used to share safety lessons with those involved, and will inform risk assessment reviews. 

A marine accident or incident report is intended to:

• Communicate what the accident or incident involved, and how and why it happened
• Persuade others to learn the safety lessons arising from the accident or incident
• Satisfy the public’s demand for information
• Meet the port authority’s duty in legislation
• Publicise recommended actions

There are many considerations for quality reports, including a standard structure and specific guidance for each section. Following such guidelines will help you produce a quality report that succeeds in these goals.

Putting it all together

Before undertaking accident or incident investigations, you should ask yourself the following questions:

• Do I understand the anatomy of an accident or incident?
• Do I know how to collect comprehensive evidence, especially human factor evidence?
• Can I deliver a robust report and recommendations?

If you are new to marine accident and incident investigation, these questions can be intimidating. But being able to answer ‘yes’ to all of them will ensure you can deliver a robust investigation that will put your organisation in the best possible position to prevent reoccurrence.

So how can individuals gain the required knowledge to support robust accident and incident investigation?

Marine Accident and Incident Investigation Training

ABPmer’s Marine Accident and Incident Investigation Training delivers the core knowledge required to:

• Understand the cause factors leading to an accident
• Collate the required information
• Compile an investigation report with recommendations for improving safety

Designed specifically around the needs of the ports industry, the course covers the basic skills necessary to carry out a safety investigation after any maritime or occupational accident, using real-world examples and exercises.

By the end of the course, attendees will understand:

• How and why accidents occur
• The essential importance of a safety investigation
• What is meant by organisational accidents
• How to recognise and avoid bias during an investigation
• How to recognise and collect human factors evidence
• How to use a basic accident analysis tool
• How to form good safety recommendations
• The structure and content of a good investigation report

Want to learn more about the Marine Accident and Incident Investigation Training course?
Contact us or visit our dedicated training page.

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