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GUIDANCE NOTES ON
THE INVESTIGATION OF MARINE INCIDENTS
JUNE 2005
American Bureau of Shipping
Incorporated by Act of Legislature of
the State of New York 1862
Copyright
2005
American Bureau of Shipping
ABS Plaza
16855 Northchase Drive
Houston, TX 77060 USA
This Page Intentionally Left Blank
Foreword
The marine industry experiences incidents that range from major accidents to near misses. These
incidents should be investigated since many flag administration regulations require it; international
agreements mandate it (such as the IMO “International Safety Management Code”); and industry
initiatives encourage it. Incident investigation is a process that is designed to help organizations learn
from past performance and develop strategies to improve safety.
The ABS
Mar
ine
R
oot
C
ause
A
nalysis
T
echnique (MaRCAT) provides an effective and efficient
approach for investigating marine incidents of any magnitude. ABS developed the MaRCAT
methodology by customizing and combining the best techniques available and by proving and
improving the overall approach through MaRCAT’s application during numerous investigations. The
ABS MaRCAT approach to incident investigation caters to the unique needs of the marine industry,
including human element; machinery and engineering; structural and security concerns. The
objectives of the ABS MaRCAT approach are as follows:
•
Provide ABS clients with a technique that will guide incident investigators in the conduct of root
cause analyses and in identifying, documenting and trending the causes of accidents and near
misses.
•
Assist clients with the investigation of a variety of types (e.g., groundings, collisions, fires, etc.)
and sizes of incidents (minor to major, including near misses) related to their vessels and facilities
(ashore and at sea).
•
Allow analysis of losses whether they are related to safety, the environment, human element
concerns, security, reliability, quality or business losses.
•
Support Class-related activities such as ABS Safety, Quality and Environment (SQE) notation, as
well as the International Safety Management Code (ISM Code) and the International Ship and
Port Facility Security (ISPS) Code.
•
Provide a technique that is sufficiently flexible to allow customization to a client’s own
management system, Health, Safety and Environment (HSE) programs or related initiatives.
These Guidance Notes provide instructions for the performance of incident investigation activities,
including:
•
Incident Investigation Initiation
•
Data Gathering
•
Data Analysis
•
Root Cause Determination
•
Generating Recommendations
•
Reporting and Trending of Incident Investigation Results
The ABS
Guidance Notes on the Investigation of Marine Incidents
provide a structured approach to
the investigation of incidents and near-miss events. The information contained can also assist with
identifying and documenting root causes as required by the ISM Code. These Guidance Notes
describe an incident investigation methodology that was expressly developed for the maritime
industry, and so it reflects those elements of maritime operations and incident causation particular to
the industry.
ABS
GUIDANCE NOTES ON THE INVESTIGATION OF MARINE INCIDENTS
.
2005
iii
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GUIDANCE NOTES ON
THE INVESTIGATION OF MARINE INCIDENTS
CONTENTS
SECTION 1 Introduction ............................................................................ 1
1
Background............................................................................1
2
The ABS Incident Investigation Model: MaRCAT..................2
3
Scope of the Guidance Notes................................................2
4
Contents of the Guidance Notes............................................3
5
Terminology ...........................................................................4
5.1
Incident ............................................................................. 5
5.2
Consequences .................................................................. 5
5.3
Loss Event ........................................................................ 5
5.4
Accident ............................................................................ 6
5.5
Near Miss .......................................................................... 6
5.6
Event................................................................................. 6
5.7
Condition ........................................................................... 6
5.8
Causal Factor.................................................................... 7
5.9
Structural/Machinery/Equipment/Outfitting Problems........ 7
5.10
Human Errors.................................................................... 7
5.11
External Factors ................................................................ 7
5.12
Intermediate Cause........................................................... 7
5.13
Item-of-Note (ION) ............................................................ 8
5.14
Root Cause ....................................................................... 8
5.15
Management System (MS) ............................................... 8
5.16
Safeguard ......................................................................... 8
5.17
Recommendation .............................................................. 8
5.18
Resolution ......................................................................... 8
5.19
Root Cause Analysis (RCA) .............................................. 9
5.20
Apparent Cause Analysis (ACA) ....................................... 9
FIGURE 1 ABS Incident Investigation Model ................................2
FIGURE 2 Relationship of Incident Investigation Terms ...............4
ABS
GUIDANCE NOTES ON THE INVESTIGATION OF MARINE INCIDENTS
.
2005
v
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