IMO Assembly Resolution A.884 (2.1)

4 February 2000

AMENDMENTS TO THE CODE FOR THE INVESTIGATION OF MARINE CASUSLTIES AND INCIDENTS (RESOLUTION A.849(20))

THE ASSEMBLY

RECALLING Article 15(j) of the Convention on the International Maritime Organization concerning the functions of the Assembly in relation to regulations and guidelines concerning maritime safety and the prevention and control of marine pollution from ships,

CONSIDERING that practical advice for the systematic investigation of human factors in marine casualties and incidents will promote, where appropriate, effective analysis and preventive action,

RECOGNIZING the need for development of practical guidelines for the investigation of human factors in marine casualties and incidents,

HAVING CONSIDERED the recommendation made by the Maritime Safety Committee at its seventy-first session and by the Marine Environment Protection Committee at its forty-third session,,

ADOPTS amendments to the Code for the Investigation of Marine Casualties and Incidents incorporating the Guidelines for the Investigation of Human Factors in Marine Casualties and Incidents, as set out in the Annex to the present resolution;

APPENDS the Guidelines as an annex to the Code for Investigation of Marine Casualties and Incidents;

INVITES Governments concerned to implement the guidelines as soon as practicable, as far as national laws allow;

AUTHORIZES the Maritime Safety Committee to keep the guidelines under review and to amend them as necessary.

ANNEX

GUIDEL1NES FOR THE INVESTIGATION OF HUMAN FACTORS IN MARINE CASUALTIES AND INCIDENTS

CONTENTS

1 Introduction - Purpose of the Guidelines
2 Investigation procedures and techniques

A systematic approach

2.2 General

2.2.1 Timing of the investigation
2.2.2 The Occurrence Site
2.2.3 Witness Statements
2.2.4 Background Information
2.2.5 The Investigation Sequence
2.2.6 Fact Finding
2.2.7 Conducting Interview
2.2.8 Selection of Interviewees
2.2.8.1 On Site(those newest the incident)
2.2.8.2 Remote from the Occurrence Site

2.3 Topics to be covered by the investigator

2.3.1 People factors
2.3.2 Organization on board
2.3.3 Working and living conditions
2.3.4 Ship factors
2.3.5 Shore side management
2.3.6 External influences and environment

2.4 Analysis
2.4.1 Fact-finding and analysis

2.5 Safety action

3 Reporting procedures

4 Qualifications and training of casualty investigators

APPENDICES

APPENDIX 1 The ILO/IMO Process for Investigating Human Factors
APPENDIX 2 Human Factors Questionnaire
APPENDIX 3 Definitions - Common Human Element Term
APPENDIX 4 Selected bibliography of UNCLOS/ILO/IMO requirements and recommendations related to investigations of human factors in marine casualties and incidents.

SECTION 1

INTRODUCTION - PURPOSE OF THE GUIDELINES

The purpose of these Guidelines is to provide practical advice for the systematic investigation of human factors in marine casualties and incidents and to allow the development of effective analysis and preventive action. The long term intent is to prevent similar casualties and incidents in the future.*

1.2 Ships operate in a highly dynamic environment; frequently the people on board follow a set routine of shift work disrupted by arrival at, working in, and sailing from port. This is an existence which involves living in the place of work for prolonged periods creating a unique form of working life which almost certainly increases the risk of human error.

1.3 Historically, the international maritime community has approached maritime safety from a predominantly technical perspective. The conventional wisdom has been to apply engineering and technological solutions to promote safety and minimize the consequences of marine casualties and incidents. Accordingly, safety standards have primarily addressed ship design and equipment requirements. Despite these technical innovations, significant marine casualties and incidents have continued to occur.

1.4 Analyses of marine casualties and incidents that have occurred over the past 30 years have prompted the international maritime community and the various safety regimes concerned to evolve from an approach which focuses on technical requirements for ship design and equipment to one winch seeks to recognize and more fully address the role of human factors in maritime safety within the entire marine industry. These general analysis have indicated that given the involvement of the human in all aspects of marine endeavours including design, manufacture management, operations and maintenance, almost all marine casualties and incidents involve human factors.

1.5 One way the maritime community has sought to address the contribution of the human factor to marine casualties and incidents has been to emphasize the proper training and certification of ships' crews. It has become increasingly clear, however, that training is only one aspect of human factors. There are other factors which contribute to marine casualties and incidents which must be understood, investigated and addressed. The following are examples of these factors relevant to the maritime industry: communication, competence, culture, experience, fatigue, health, situational awareness, stress and working conditions.

1.6 Human factors winch contribute to marine casualties and incidents may be broadly defined as the acts or omissions intentional or otherwise which adversely affect the proper functioning of a particular system, or the successful performance of a particular task. Understanding human factors thus requires the study and analysis of the design of the equipment; the interaction of the human operator with the equipment and the procedures the crew and management followed.

1.7 It has been recognized that there is a critical need for guidance for accident investigators which will assist them to identify specific human factors which have contributed to marine casualties and incidents. There is also a need to provide practical information on techniques and procedures for the systematic collection and analysis of information on human factors during investigations. These Guidelines seek to fulfil those needs. They include a list of topics which should be considered by investigators and procedures for recording and reporting the results.

*For the purpose of these Guidelines, the term "marine casualties and incidents" includes occupational accidents resulting in loss of life or serious personal injury.

1.8 These Guidelines should result in an increased awareness by all involved in the entire marine industry of the role human factors play in marine casualties and incidents. This awareness should lead to proactive measures by the marine community which in turn will result m the saving of lives, ships, cargo and the protection of the marine environment, improvements to the lives of marine personnel and more efficient and safer shipping operations.

1.9 These Guidelines apply, as far as national laws allow, to the investigation of marine casualties or incidents where either one or more interested States have a substantial interest in a marine casualty involving a ship under or within their jurisdiction.

SECTION 2

INVESTIGATION PROCEDURES AND TECHNIQUES

2.1 A systematic approach

The following is a process that provides a step-by-step systematic approach for use in the investigation of human factors. The process is an integration and adaptation of a number of established human factor frameworks. The process can be applied to any type of marine casualty and incident and consists of the following steps:

1. collect occurrence data;
2. determine occurrence sequence;
3. identify unsafe acts (decisions) and unsafe conditions,

and then for each unsafe act (decision),

1. identify the error type or violation;
2. identify underlying factors; and
3. identify potential safety problems and develop safety actions.

This process is detailed in Appendix 1

A systematic approach to Step 1 is crucial to ensure that critical information is not overlooked or lost and that a comprehensive analysis is possible.

Step 2 describes a process involved in organizing the data collected in Step 1 to develop a sequence of events and circumstances.

In Step 3, the information gathered and organized is used to initiate the identification of occurrence causal factors, ie., unsafe acts, decisions or conditions. When an unsafe act, decision or condition is identified, the process shifts to determining the genesis of that particular act, decision or condition.

Step 4 is initiated for each identified unsafe act or decision in order to specify the type of error or violation involved.

In Step 5, the focus is placed on uncovering the underlying factors behind the unsafe act decision or condition. Fundamental to the process is the notion that for each underlying factor, there may be one or more associated unsafe act, decision or condition. The re-examination each step of the process emphasizes the iterative nature of this process in that it may show where further investigation is necessary.

Finally, Step 6 requires the identification of potential safety problem and proposed safety action based on the identified underlying factors.

2.2 General consideration

An occurrence may result in serious damage or impact and sometimes all four. The purpose of a marine casualty or occurrence safety investigation is to prevent recurrence of similar occurrences by identifying and recommending remedial action. All minor occurrences of high potential in terms of credible result should be subject of full investigation. Studies have shown that occurrences can have many casual factors and that underlying causes often exist remote from the incident site. Proper identification of such causes requires timely and methodical investigation, going far beyond the immediate evidence and looking for underlying conditions which may cause other future occurrences. Occurrence investigation should therefore be seen as a means to identify not only immediate causes, but also failures in the total management of the operation from policy through to implementation. For this reason investigations, must be broad enough to meet this overriding criteria.

2.2.1 Tuning of the investigation

An investigation should be carded out as soon as possible after an occurrence. The quality of evidence, particularly that relying on the accuracy of human recollection, can deteriorate rapidly with time, and delayed investigations are usually not as conclusive as those performed promptly. A prompt investigation is also a good demonstration of commitment by all those concerned.

2.2.2 The occurrence site

Where possible, the site of the occurrence should be left unchanged until the investigation team has inspected it. Where this is not possible, for instance to make essential and immediate repairs following serious structural damage, the scene should be documented by photographs audio visual recordings or sketches or any other relevant means available with the object of preserving vital evidence and possibly recreating the circumstances at a later date. Of particular importance is the recording of the position of individuals at the site, the condition and position of equipment supervisory instructions, work permits and recording charts. Damage or failed components should be kept in a secure location to await the arrival of the investigation team who may require detailed scientific examination of certain key objects. Such key objects should be carefully

2.2.3 Witnesses

Once the situation in the immediate aftermath of an occurrence has been stabilised and the threat to people, plant and the environment has been removed, individuals involved should commit their recollections to paper in the form of a written statement to assist in preserving their memory of events.. In the event that local authorities take over responsibility for the investigation, the organisation/company involved should nominate a focal point to liaise with the authorities and to assist in assembling the information they require. Where necessary legal assistance should be provided.

2.2.4 Background information

Appropriate background information should be obtained before the occurrence location. Such information might include but is not necessarily limited to:

• procedures for the type of operation involved;
• records of instuctions / briefings given on the particular job being investigated;
• location plans;
• command structure, and. persons involved;
• messages, directions, etc., given from base/headquarters concerning the work.;
• vessel particulars and plans; and
• any other relevant information that may allow the investigator to understand the context of the incident

2.2.5 The Investigation sequence

The method for fact-finding while conducting an investigation includes but is not necessarily limited to the following activities:

• inspecting the location;
• gathering or recording physical evidence;
• interviewing witnesses taking into account cultural and language differences (on-site and external);
• reviewing of documents, procedure and records;
• conducting specialised studies (as required);
• identifying conflicts in evidence;
• identifying missing information; and
• recording additional factors and possible underlying causes

Following the fact-finding a typical marine casualty or incident investigation includes analyses of the facts, conclusions and recommendations.

2.2.6 Fact-finding

The objective of this stage of the investigation is to collect as many facts as possible which may help understanding of the incident and the events surrounding it. The scope of any investigation can be divided into five areas:

• people
• environment
• equipment
• procedures
• organization

Conditions, actions or omissions for each of these may be identified, which could be factors contributing to the incident or to subsequent injury damage or loss.

During the initial stages of every investigation, investigators should aim to gather and record all the facts which may be of interest in determining causes. Investigators should be aware of the danger of reaching conclusions too early, thereby failing to keep an open mind and considering the full range of possibilities. With this in mind, it is recommended that the fact-finding stage of the investigation process itself be kept separate from the complete analysis of the collected evidence leading to conclusions and recommendations, and that a structured methodology he adopted to ensure the effectiveness of that analysis. Having said that, the analysis may well help to identify missing pieces of evidence, or different lines of enquiry that may otherwise have gone undetected.

Investigation checklists can be very useful in the early stages to keep the full range of enquiry in mind, but they cannot cover all possible aspects of an investigation, neither can they follow all individual leads bad to basic casual factors. When checklists are used, their limitations should be clearly understood.

The initial stages of an investigation normally focus on conditions and activities close to the incident and only primary causes also called "active failures", are usually identified at this stage. However, conditions or circumstances underlying these causes also called "latent failures", should also be investigated.

A factor to consider during an investigation is. recent change. In many cases it has been found that some change occurred prior to an occurrence which, combining with other causal factors already present, served to initiate the occurrence. Changes in personnel, organisation, procedures, processes, and equipment should be investigated, particularly the hand-over of control and instructions, and the communication of information about the change to those who needed to know.

The effect of work cycles and work related six could have an impact on individuals' performance prior to an occurrence. The impact of social and domestic pressures (so-called error enforcing conditions) related to individual's behaviour should not be overlooked.

Information should be verified wherever possible. Statements made by different witnesses may conflict and further supporting evidence may be needed. To ensure that all the facts are uncovered, the broad questions of "who?, what?, when?, where?, why?, and how?" should be asked.

2.2.7 Conducting interviews

An interview should start with the introduction of the interviewing party, the purpose of the investigation and of the interview, and the possible future use of the knowledge and material obtained during the interview. Investigators must be guided by the requirements of national law regarding the presence of legal advisers or other third parties during an interview.

People should be interviewed singly and be asked to go step-by-step through the events surrounding the occurrence, describing both their own actions and the actions of others. The interviewer should take into account the culture and language of the interviewee.

Notwithstanding; any previously made written statements the value of a witness's statement can be greatly influenced by the style of the interviewer, whose main task is to listen, to the witness's story and not to influence him.

If the investigation is a team effort care must be taken not to make a witness feel intimidated by too many interviewers. Experience has shown that interviews can be effectively conducted by two interviewers and if appropriate, the witness could be accompanied by an independent "friend".

It should be remembered that an investigation team is often seen in a prosecuting role, and there may be reluctance to talk freely if people think they may incriminate themselves or their colleagues. An investigator is not in the position to give immunity in return for evidence, but must try to convince interviewees of the purpose of the investigation and the need for frankness.

In addition to requiring both patience and understanding, successful interviewing requires the existence of a "no-blame" atmosphere in which the witness can be made to feel comfortable and is encouraged to tell the truth. It is not the role of the interviewer, or indeed the investigation team, to apportion blame. Their role is to establish the facts and to establish why the occurrence happened.

At the end of an interview the discussion should be summarised to make sure that no misunderstandings exist. A written record may be made of the interview and this may be discussed with the witness to clarify any anomalies. Subject to any national law, it may be possible to provide the interviewee with a copy of the written record.

2.2.8 Selection of interviewees

Established marine casualty and incident investigation procedures should be taken into account when determining whom to interview following a marine casualty. Safety concerns should be paramount in the scheduling of interviews.

The emphasis must always be to get the investigation team to the site of the occurrence as soon as possible and to interview those most closely involved, which in the marine sense will always be the ship first. When that is not possible due to external factors such as the geographical location of the occurrence or other political factors, it may be possible to nominate a local representative to carry out an interim investigation. From an investigation management point of view, it should still be possible to start the process by carrying out at least some of the interviews of individuals ashore.

It may not be possible to speak directly with Port or Pilotage Authorities in some parts of the world. Where that is so then every effort should be made to obtain at least a transcript of the Pilot's statement if one is involved. In the event of a collision in enclosed waters, evidence from the operators of shore based electronic surveillance equipment can be particularly useful.

Thee are no "hard and fast" rules for selecting who to interview and the following is offered as an example only:

2.2.8.1 On site (those nearest the incident)

Generally it is beneficial to begin the interview process with the ship management team including the Master and Chief Engineer who typically can provide an overview of the occurrence..

• First hand witnesses present at the occurrence site at the time of the occurrence itself, regardless of rank/position in the organisation;
• First hand witnesses present at the occurrence site at the time of the occurrence itself, but from outside the organisation. Examples could be berthing or mooring assistants or visiting personnel such as agents or contractors;
• First hand witnesses present at the time of the occurrence but not at the occurrence location itself. Examples could be ship's staff on the bridge of a ship witnessing a mooring occurrence on the main deck below;
• First hand witnesses present at the time of the occurrence but not at the occurrence location itself and. from outside the organization. Examples could be a pilot on the bridge witnessing a mooring occurrence on the main deck below;
• Those not involved with the occurrence itself but involved in the immediate, aftermath of an occurrence especially those engaged in the recovery process. Examples could be those involved in damage control, shipboard fire-fighting or first-aid medical treatment;
• Tug, mooring boat or pilot cutter crews;
• Search & Rescue personnel including helicopter crews;
• Shore-based fire-fighters;
• Jetty/Terminal Staff;
• Other vessels in the immediate vicinity; and
• Operators of Vessel Traffic Services (VTS) or Monitoring Systems.

2.2.9.2 Remote from occurrence site

• Designated Person under the ISM Code;
• Ship Operators ashore;
• Technical Superintendents ashore;
• Company General Managers ashore;
• Specialists Consultants (relevant to the occurrence);
• Port State Inspectors;
• Flag State Inspectors;
• Regulatory authorities;
• Classification Societies Representatives;
• Safety committee members including am representatives; and
• Designers, shipbuilders, manufacturers and repairers.

2.3 Topics to he covered by the investigator**

The diagram below shows a number of factors that have a direct or indirect impact on human behaviour and the potential to perform tasks.

The headings; in the diagram are expanded below:

_______________________________________________________________________________
**Appendix 2 provides appropriate areas of inquiry and appendix 3 provides definitions of common human element terms.

2.3.1 People factors

• ability, skills, knowledge (outcome of training and experience)
• personality (mental condition, emotional state)
• physical condition (medical fitness, drugs and alcohol, and fatigue)
• activities prior to accident/occurrence
• assigned duties at time of accident/occurrence
• actual behaviour at time of accident/occurrence
• attitude

2.3.2 Organization on board

• division of tasks and responsibilities
• composition of the crew (nationality/competence) -- manning/level
• workload/complexity of tasks
• working hours/rest hours
• procedures and standing orders
• communication (internal and external)
• on board management and supervision
• organization of on board training and drills
• teamwork including resource management
• planning (voyages, cargo, maintenance)

2.3.3 Working and living conditions

• level of automation
• ergonomical design of working, living and recreation places and equipment
• adequacy of living conditions
• opportunities for recreation
• adequacy of food
• level of ship motion, vibrations, heal and noise

2.3.4 Ship factors

• design
• state of maintenance
• equipment (availability, reliability)
• cargo characteristics including securing, handling and care -certificates

2.3.5 Shore side management

• policy on recruitment
• safety policy and philosophy (culture, attitude and trust)
• management commitment to safety
• scheduling of leave periods
• general management policy
• port scheduling
• contractual and/or industrial arrangements and agreements
• assignment of duties
• ship-shore communication

2.3.6 External. Influences and environment

• weather and sea conditions
• port and transit conditions (V1S, pilots etc)
• traffic density
• ice conditions
• organizations representing shipowners and seafarers
• regulations, surveys and inspections (international, national, port, classification societies, etc)

2.4 Analysis

Once facts are collected, they need to be analyzed to help establish the sequence of events in the occurrence, and to draw conclusions about safety deficiencies uncovered by the investigation. Analysis is a disciplined activity that employs logic and reasoning to build a bridge between the factual information and the conclusions.

The first step in analysis is to review the factual information to clarify what is relevant, and what is not, and to ensure the information is complete. Thus, this process can give guidance to the investigator as to what additional investigation needs to be carried out.

In normal investigation practice, gaps in information that cannot be resolved are usually filled in by logical extrapolation and reasonable assumptions. Such extrapolation and assumptions should be identified and a statement of the measure of certainty provided.

Despite best efforts, analysis may not lead to firm conclusions. In these cases, the more likely hypotheses should be presented.

2.4.1 After fact finding and analysis it should be possible to give a description of the occurrence, its background, tuning, and the events leading to it

The description should include such factual items as:

• the weather conditions;
• the operation(s) involved;
• the equipment in use, its capabilities, performance and any failures;
• the location of key personnel and their actions immediately before the incident;
• the pertinent regulations and instructions;
• uncontrolled hazards;
• changes of staff, procedures, equipment or processes that could have contributed to the occurrence;
• what safeguards were or were not in place to prevent the incident;
• response to the occurrence (first-aid, shut-down, fire-fighting, evacuation, search and rescue);
• medical treatment actions taken to mitigate the effects of the occurrence and the condition of injured parties, particularly if disabling injuries or death ensured;
• damage control including salvage;
• inventory of all consequences of the occurrence (injury, loss, damage or environmental damage); and general ship's condition.

It should also be possible to identify active and underlying factors such as:

• operational deviations;
• design aspects of hull structural failure;
• defects m resources and equipment;
• inappropriate use of resources and equipment;
• relevant personnel skill levels and their application;
• physiological factors (eg. fatigue, stress alcohol, illegal drugs, prescription medicine);
• why safeguards in place were inadequate or failed;
• role of safety programmes;
• problems relating to the effectiveness of regulations and instructions;
• management issues; and
• communication issues.

2.5 Safety action

The ultimate goal of a marine investigation is to advance maritime safety and protection of the marine environment. In the context of these guidelines, this goal is achieved by identifying safety deficiencies through a systematic investigation of marine casualties and incidents, and then recommending or effecting change in the maritime system to correct these deficiencies.

In a report that clearly lays out the facts relevant to the occurrence, and then logically analyzes those facts to draw reasoned conclusions including those relating to human factors, the required safety action may appear self-evident to the reader.

Recommended safety actions in whatever form should clearly identify what needs to be done, who or what organization is the agent of change, and, where possible, the urgency for completion.

Continued...

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