1. Procedures and Technics of Investigation in the United Kingdom TAIEX Workshop on Marine Casualty Investigation 5-6 September 2012 David Wheal Principal Inspector of Marine Accidents UK Marine Accident Investigation Branch

2. Content UK investigative body Safety investigation criteria Scope and conduct of safety investigations Learning the lessons

3. Herald of Free Enterprise (1987) Independent investigation Separation from regulator Functional independence Safety focus

4. Independent investigation Secretary of State for Transport Maritime and Coastguard Agency Shipping Policy Ports All other DfT functions Based in Southampton, UK 35 staff 35 staff

5. Aims To improve safety of life at sea To satisfy the public in general, and the maritime community in particular, that marine accidents are properly investigated To fulfil the requirements of the IMO Casualty Investigation Code and EU Directive 2009/18/EC

6. The sole objective of an MAIB safety investigation of an accident is the prevention of future accidents through the ascertainment of its causes and circumstances. It is not the purpose to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame. Objective

7. Merchant Shipping Act 1995 and The MS (Accident Reporting & Investigation) Regulations 2012 Inspector powers - Access - Witness/material evidence Investigation and reporting procedures - Confidentiality

8. MAIB’s remit Marine casualties and marine incidents UK vessels worldwide Other vessels within UK waters Merchant vessels Fishing vessels Leisure craft

9. Safety investigation stages Notification Preservation of evidence Decision to investigate Deployment and follow-up Final analysis review Safety recommendations Report consultation Report publication

10. Notification Notification Master/Skipper Shipowner Maritime and Coastguard Agency Port Authority Flag/Coastal State Police Royal National Lifeboat Institution Members of the public 24-hour reporting line +44 23 8023 2527

11. Preservation of evidence Voyage data recorders GPS / electronic recordings AIS / radar / radio / CCTV VTS / Coastguard / Port Witness information Other material evidence Police

12. Decision to investigate Very serious / serious marine casualty Likely benefit of a safety investigation Actual / potential consequences Ship type / nature of cargo Public / official concern Other investigating bodies Staff and resources

13. Pre 1989 High profile accidents Focus on hardware Focus on regulation Witness reliance Conflicting evidence Analytical limitation Isolated approach

14. Post 1989 More investigations Regulation testing Increased inspector deployment Advances in recorded evidence Increased focus on “why” Improved interviewing techniques

15. Post 1989 Evolution of human factors awareness “Organizational” safety issues Stakeholder discussion and consultation Confidence in data Increased depth of analysis Data collation and abstract analysis Incentive for safety improvements

16. MAIB publications Safety investigation report standard / concise / simplified Safety bulletin (early alert) Safety flyer Safety Digest Safety study

17. Thank you for your attention www.maib.gov.uk