the_investigation_of_marine_incidents.pdf

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

American Bureau of Shipping

ABS Plaza

16855 Northchase Drive

Houston, TX 77060 USA

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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

Background............................................................................1

The ABS Incident Investigation Model: MaRCAT..................2

Scope of the Guidance Notes................................................2

Contents of the Guidance Notes............................................3

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

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