CANADIAN COAST GUARD AUXILIARY - PACIFIC ACCIDENT INVESTIGATION CANADIAN COAST GUARD AUXILIARY - PACIFIC June 2010

CANADIAN COAST GUARD AUXILIARY - PACIFIC Accident Investigation

CANADIAN COAST GUARD AUXILIARY - PACIFIC Accident Investigation The CCGA-P encourages all members to report all accidents on board, or related to our operations to the CCGA-P Safety Officer. This is to allow a proper investigation, publishing of the results, to hopefully prevent an accident happening again.

CANADIAN COAST GUARD AUXILIARY - PACIFIC Accident Investigation This investigation may be run directly by the CCGA-P Safety Officer, or through that position requesting help from an ARTE Team Member, where time is important or evidence may be lost.

CANADIAN COAST GUARD AUXILIARY - PACIFIC Error Chains

CANADIAN COAST GUARD AUXILIARY - PACIFIC Error Chains In marine and aviation accidents, a chain of events, often called the error chain, is a term specifically referring to the concept that many contributing factors typically lead to an accident, rather than one single event.

CANADIAN COAST GUARD AUXILIARY - PACIFIC Error Chains This illustrated by the swiss cheese diagram. Each slice has holes in different places, each slice representing something which can fail. Providing the holes on the cheese never line up the accident won’t happen. However when they do line up ……...

CANADIAN COAST GUARD AUXILIARY - PACIFIC Error Chains

CANADIAN COAST GUARD AUXILIARY - PACIFIC Error Chains This results in the belief that removal of any one of these precursor events, and that accident would not have happened.

CANADIAN COAST GUARD AUXILIARY - PACIFIC Error Chains - Causes There are many possible cause of accidents including: 1. Fallible decisions 2. Unsafe acts 3. Precursors of unsafe acts 4. Line management fallibility 5. Failure to recognise personal limitations 6. Fatigue

CANADIAN COAST GUARD AUXILIARY - PACIFIC Error Chains - Causes 7. Failure to follow procedures / cutting corners 8. Succession of bad decisions reducing the number of options available 9. Lack of teamwork to make important decisions 10. Lack of proper analysis to make important decisions Etc., Etc.

CANADIAN COAST GUARD AUXILIARY - PACIFIC An Example of An Accident The Sinking of a Rescue Vessel

CANADIAN COAST GUARD AUXILIARY - PACIFIC An Example of An Accident In late 2009 a rescue vessel was found sunk alongside its berth, with only the tubes actually keeping it afloat. After pumping out all compartments, and a short investigation, it was found that the bilge pump float switch was on a breaker. This had tripped and therefore the bilge pump was not working.

CANADIAN COAST GUARD AUXILIARY - PACIFIC An Example of An Accident However the precursor events could be listed as follows.

CANADIAN COAST GUARD AUXILIARY - PACIFIC An Example of An Accident 1. New larger heavier 4 stroke engines fitted (greater draft aft), and bottom of elephant trunks closer to the waterline Cause:?

CANADIAN COAST GUARD AUXILIARY - PACIFIC An Example of An Accident 2. Modifications made to increase flotation aft by welding underwater additions on box. However recesses above water to allow elephant’s trunk also filled in (more weight above water). Greater draft aft. Cause:?

CANADIAN COAST GUARD AUXILIARY - PACIFIC An Example of An Accident 3. Bilge pump rewired with float switch connected to a breaker. Only a few people informed. Cause:?

CANADIAN COAST GUARD AUXILIARY - PACIFIC An Example of An Accident 4. Elephants ears no longer fit. Replaced by floating ball type non return valves. Not watertight Cause:?

CANADIAN COAST GUARD AUXILIARY - PACIFIC An Example of An Accident 5. Plastic hatch with designed seat, replaced by clamp in style. Cause:?

CANADIAN COAST GUARD AUXILIARY - PACIFIC An Example of An Accident 6. Breaker blew - date unknown. Cause:?

CANADIAN COAST GUARD AUXILIARY - PACIFIC An Example of An Accident 7. Heavy rain allowed accumulations of water in boat to grow, allowing the non return valves to leak. All this water got in past after deck hatch. Cause?

CANADIAN COAST GUARD AUXILIARY - PACIFIC An Example of An Accident 8. Vessel found partially flooded and pumped out. No investigation. Pump and equipment put away by other crew. No investigation. Cause?

CANADIAN COAST GUARD AUXILIARY - PACIFIC An Example of An Accident 9. Further heavy rain. Vessel reported sunk at dock, engines trimmed up, forward ends of motorhead underwater. Pumped out and investigation. The Accident

CANADIAN COAST GUARD AUXILIARY - PACIFIC An Example of An Accident Result: Total loss of both engines, and the vessel being out of action for weeks while the insurers did their investigation. A very expensive lesson

CANADIAN COAST GUARD AUXILIARY - PACIFIC Lessons Learned 1. ?

CANADIAN COAST GUARD AUXILIARY - PACIFIC Any Other Examples?

CANADIAN COAST GUARD AUXILIARY - PACIFIC Questioning Skills

CANADIAN COAST GUARD AUXILIARY - PACIFIC Questioning Skills Always use the 6 question words to ask a question, in order to get a full answer. “Who”,”What”,”When”,”Where”,”How”, Which” If you ask questions which push a Yes or No answer, the investigation will take a long time.

CANADIAN COAST GUARD AUXILIARY - PACIFIC Questioning Skills Keep written notes

CANADIAN COAST GUARD AUXILIARY - PACIFIC Ooops