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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