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MARINE ACCIDENT

INVESTIGATIONMARITIME SAFETY THROUGH INVESTIGATIONSAND CO-OPERATION

Human Factors & Safety Seminarin Espoo13th February 2006

Martti Heikkil

Accident Investigation Board, Finlandwww.onnettomuustutkinta.fi


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BACKGROUND FOR MARINE ACCIDENTINVESTIGATIONS

Historically the maritime safety has improved

through learning by experience. The practises

and rules for shipping and shipbuilding have

developed after catastrophic accidents.

Some of the notorious ones - also in the Baltic

Sea...


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THE DEVELOPMENT OF MARITIME SAFETYDURING 130 YEARS

1870 HMS CAPTAIN (500 victims) - the importance of stability

width and freeboard1912 TITANIC (1572 victims) - the number of lifeboats and thefirst SOLAS-treaty

1934 MORRO CASTLE (124 vict ims) and 1963 LAKONIA (128

victims) - the development of fire safety rules1956 ANDREA DORIA (46 vict ims) - unsymmetric flooding andlarge heel which prevented the use of starboard side lifeboats,

radar assisted collision

1987 HERALD OF FREE ENTERPRISE (188 victims) - ISM-Code and safety management systems

1994 ESTONIA (852 victims) - the stability of roro passengerferries, requirement of FRB and MOB boats


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THE INTERNATIONAL BACKGROUND OFMARINE ACCIDENT INVESTIGATIONS

The statutory obligation to investigate marine casualties is inall main IMO/ILO Conventions.

The IMO Code for the investigation of marine casualties and

incidents A.849(20) is from 1997 and it is widely applied in

accident investigations although the code is only a

recommendation.

The Code has has achieved to become a generally accepted

procedure and practice and especially to become a basis forthe international co-operation in investigations.

Last year a working group was established to review of the

Code and

- to suggest solutions to implementation of a mandatory code- suggest an appropriate format.


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THE EUROPEAN BACKGROUND OF MARINEACCIDENT INVESTIGATIONS

The IMO Code for the investigation of marine casualties and

incidents A.849(20) has been defined to be applied in two

EU directives (1999/35/EY and 2002/59/EY).

As part of the ERIKA III maritime safety package the

preparations for a directive of marine accident investigations

have been started by the EU commission.

The role of the new European Maritime safety Agency

EMSA is partly open but the harmonisation of investigations

and gathering and analysing accident statistics have been

started.


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THE FINNISH ACCIDENT INVESTIGATIONSYSTEM

THE ACT AND DEGREE FOR ACCIDENTINVESTIGATIONS 1986 AND 1996

Originally (1986) this system covered only very serious

accidents but it was applied to any kind of accident including

all transport modes. The investigations were to beindependent from any administrative authority and they were

aimed only to improve the safety.

In 1996 the Accident Investigation Board of Finland (AIBF)

was formed and all accidents in air, rail and sea wereincluded in the agenda. The AIBF is still one of the few

independent multimodal accident investigation organisations

in the world although especially in Europe the number

similar systems has increased lately.


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THE FINNISH ACCIDENT INVESTIGATIONSYSTEM

In accident investigation we have three questionswhich will be answered:

What happened?

Why did it happen?

What can be done to prevent the reoccurrence of

similar situation?

We believe that through systematic accident

investigations it is possible to develop preventive

safety culture.


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INTERNATIONAL CO-OPERATION INDIFFERENT FORUMS

IMO International Maritime Organisation

EU/EMSA - European Maritime Safety Agency

MAIIF - Marine Accident InvestigatorsInternational Forum

EMAIIF - European MAIIF

Annually we have had several cases of co-

operation in investigations.


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INVESTIGATED MARINE ACCIDENTS1997 - 2006

Altogether 115 marine accident investigations

have been initiated during 1997 - 2006 and 92

have been completed (February 2006).

About 150 safety recommendations have been

issued - most to the Finnish Maritime

Administration.

Examples of the investigated cases...


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ms OCEAN PRIDE, GROUNDING 6.3.2000


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mt NATURA, GROUNDING 13.10.1998


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TRAWLER LEA, SINKING 12.4.1999


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ms SUOMENLINNA II, GROUNDING AND SIXINCIDENTS IN 2004


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A SAFETY STUDY

is carried out when

safety deficiencies have been observed in anarea

negative interrelations of similar circumstances,

actions or accidents has been identified.

Safety studies aim at spreading information of the

results to selected parts of shipping industry.

An area which had been observed earlier are the

faults in automated control systems. These have

been acted upon with research studies and

planned administrative action.


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HOW THE INVESTIGATIONSCHANGE / DEVELOP IN THE FUTURE?

(1)

Electronic equipment such as - VTS, VDR,

AIS, ECDIS or ENC - which have widely

taken into use both on board and land-based,provide the investigators information of ship

motions, control systems and co-operation

on the bridge.

With the availability of accurate recorded

data in accident investigation it is faster than

before to answer the question - What

happened in the accident.


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HOW THE INVESTIGATIONSCHANGE / DEVELOP IN THE FUTURE?

(2)

But the even more important question -

Why did the accident happen?

is still difficult to answer and the available

detailed data facilitates - and often alsorequires - a deeper and/or wider investigation

than before.


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SAFETY CULTURE

A definition:

The prevailing goals, principles and procedures

in an organisation, which can safeguard against

errors and when errors are encountered through

which it is possible to react with subsequentchanges in practises before serious incident or

accident occurs.

Accident investigation is part of the maritimesafety culture - a reactive one - but an excellent

observer point.


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dangers

errors

violations

accident

serious

incident

SMScontents

Adm

Industry Safety Culture

International conventions,National legislation, Rules

training

company defences

preventive reactive

Riskanalysis

Accidentinves-

tigation

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ACCIDENT INVESTIGATIONS AS PART

OF THE MARITIME SAFETY CULTURE


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THE AREAS OF INVESTIGATION

Technical investigation

Human factors -investigation

Organisational investigation

(includes the role of regulations)


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INVESTIGATION METHODS(1)

Help to figure out the complete case.

The observation of influencing factors.

The definition of influence chains and cross

influence - visibility of gaps.


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INVESTIGATION METHODS(2)

Better assessment of the influence of the

safety recommendations.

The complicated nature of the system canbe presented in a no-blame way.

Serves thus the basic principles of the

accident investigations.


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ms ISABELLA

grounding inland20.12.2001


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The start point of an investigation: Factors contributing to

the work stress of the pilot examinee.

Maritime culture and official regulations

Ship owner

Ship owner

Bridge co-

operation BRM

Mate(pilot examinee)Ext.Conditions

(Wind)

Training etc.

Autopilot system and

its limitations

Ship and its

manoeuvrability

Pilotage Authority

Pilotage exam

AN INDIVIDUAL IN A SAFETY CULTURE


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-Beginning

-Control

-Adjustment

TASK

ALLOCATION

-monitoring

PRACTISES

-norms, limits

COMMUNICATION

CONTROL OF

AUTOMATION

Turn

The activities on the bridge were assessed from the

point of view of the personnel. This assessment was

divided into: communication within the team, routines

used, control of the automation and task allocation aswell as the observation of the dynamics of the vessel.

This assessment was made at five selected time points.


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TUG PEGASOS CAPSIZING AND

SINKING OFF HELSINKI 13.11.2003


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IMO

NATIONAL LEGISLATION

MARITIME ADMINISTRATION

SHIP OWNERS

PILOTAGE ORGANISATION

THE SHIPS PILOT STATION

Masters Pilots

international

level

national

level

administration

level

organisation

level

local level:

work place

persons

Obligatory

regulationsSupervisory

role

Port

organisation

T

R

A

I

N

I

N

G ?

RESPONSIBLE ORGANISATIONS IN A

SAFETY CULTURE


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COMPANY

CULTURE

OWNERSHIP &

CONTROL

REGULATORY

INFLUENCE

POLITICAL

INFLUENCE

LABOUR

RELATIONS

SAFETY

MANAGEMENT

ORGANISATIONAL

STRUCTURE

CONTRACTING

STRATEGY

MARKET

INFLUENCE

SOCIETAL

INFLUENCE

COMPANY

PROFITABILITY

POLICY LEVEL

ENVIRONMENTAL LEVEL

P1 P2 P3 P4 P5 P6 P7

E1 E2 E3 E4

DIRECT LEVEL

COMPETENCE

D1

MOTIVATION /

MORALE

D2

TEAMWORKING

D3

SITUATIONAL

AWARENESS / RISKPERCEPTION

D4

FATIGUE /

ALERTNESS

D5

COMMUNICATIONS

D7

AVAILABILITY OF

INFORMATION /

ADVICED8

COMPLIANCE

D9

AVAILABILITY OF

SUITABLE

RESOURCESD10

INSPECTION &

MAINTENANCED11

HEALTH

D6

WORKPLACE

ENVIRONMENTD13

EXTERNAL

CONDITIONS

D14

EQUIPMENT

OPERABILITYD12

ORGANISATIONAL LEVEL

COMMUNICATIONS

O7

SAFETY CULTURE

O8

EQUIPMENT

PURCHASING

O9

INSPECTION &

MAINTENANCE

O10

DESIGN

O11

PAY AND

CONDITIONSO12

RECRUITMENT &

SELECTIONO1

TRAINING

O2

PROCEDURES

O3

PLANNING

O4

INCIDENT

MANAGEMENT &

FEEDBACKO5

MANAGEMENT /

SUPERVISIONO6

HARDWARE EXTERNALHUMAN

ACCIDENT

PPE

D15


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Thank you for your attention

www.onnettomuustutkinta.fi

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