1. Incident/Accident Investigation Safety today Definition Ships in Service Training Material 2009

2. Events Non Events Ships in Service Training Material A-M CHAUVEL

3. Ships in Service Training Material A-M CHAUVEL Events Non Events

4. Ships in Service Training Material A-M CHAUVEL Events Unhappiness Happiness Indifference

5. Ships in Service Training Material A-M CHAUVEL Events Distress Stress Eustress

6. Ships in Service Training Material A-M CHAUVEL Events Unexpected Predictable

7. Hazards Dangers In any System Risks Exist Potential Breaches in the System Operative Protective Measures Ships in Service Training Material A-M CHAUVEL Unwanted Event

8. Inoperative Protective Measures Hazards Danger An Unwanted Event may occur Ships in Service Training Material A-M CHAUVEL Breaches in the System Unwanted Event

9. CausesConsequences Social Loss of lives Loss of jobs Environmental Air pollution Water & Land pollution Economic Loss of the ship Cargo damages Ship damaged Ship detention Financial losses Insurance premium Company image Bankruptcy Man Human Errors Physical Conditions Qualifications Machines Tools Equipments Materials & Furniture Methods & Procedures Management Leadership, commandment Marine environment Weather Incidents Fire Explosion Act of piracy Equipment failures Ship collision… and / or Accidents Personnel Injury Personnel illness UndesiredEvent From Causes to Consequences Ships in Service Training Material A-M CHAUVEL

10. CausesConsequencesUndesiredEvent Risk Analysis Incident / Accident Investigation Risk Assessment Risk Management Ships in Service Training Material A-M CHAUVEL Incident / Accident Investigation Today the training session covers

11. Course presentation Today the training session covers Ships in Service Training Material

12. Accident investigation is part of risk management. Incidents and near-misses should be investigated to find underlying causes and take preventive action. By investigating, companies show a responsible approach to safety management - also they benefit. There are also regulations and conformity procedures requiring investigations. Marine environment is hazardous - situations and scenarios jeopardizing safety must be identified and measures taken. Course presentation Ships in Service Training Material Course summary S. ISIK

13. Procedures need to be in place to investigate incidents, accident and near-misses. Companies need knowledge and experience for investigations - develop and apply methodologies effectively. Training on incident investigation is necessary for people involved in safety management. This course intended to provide training for conducting investigations. Ships in Service Training Material S. ISIK Course presentation Course summary

14. Introduction Ships in Service Training Material

15. New technology and management concepts introduced into our complex environment including safety and environmental issues. We are expected to address safety and environmental issues systematically with more responsibility and transparency. Incident/accident investigation is at the core of risk management. Ships in Service Training Material Introduction A-M CHAUVEL In a safety and pollution conscious world, way we operate is constantly changing.

16. Ships in Service Training Material We cannot work in a safe, risk free environment if we don’t understand existing dangers and take precautions to prevent them. Investigating uses first hand experience to learn/share and get closer to incident free environment. Finding facts during investigation is not enough - Aim is to find the root causes. S. ISIK Introduction

17. Ships in Service Training Material Finding causes of incidents is not simple - causes can be complex with many contributory factors. It is said that more than ten contributory factors coming together at the same time causes serious incidents. To improve safety, it’s not necessary to remove all of the contributory factors. Sometime one is enough. A-M CHAUVEL Introduction

18. Ships in Service Training Material it is easy to conclude that the cause is due to “human error” a term much debated, because all incidents are caused by human errors. Investigator should have the skill : - not to blame, and - be impartial to opinions. S. ISIK Introduction Find the root causes,

19. Incident/Accident Investigation Some Definitions Ships in Service Training Material

20. Sources of the Definitions Ships in Service Training Material AMSA = Australian Maritime Safety Agency HSE = Health and Safety Executive UK Government IMO Res A849(20) = International Maritime Organisation Resolution A849(20) OCIMF = Oil Companies International Marine Forum - Marine injury reporting guidelines a ship or ships. S. ISIK Source

21. An undesired event, which could have resulted in harm to a person and / or property damage, but was avoided by good luck. [HSE] Definitions Ships in Service Training Material S. ISIK An event or sequence of events which did not result in an injury but which, under slightly different conditions, could have done so. [OCIMF] Near Miss

22. Ships in Service Training Material An incident that could have caused: - The death - Serious injury or - Incapacity of a person but which did not have that outcome. [AMSA]. S. ISIK Definitions Dangerous occurrence

23. Definitions Ships in Service Training Material An undesired event that causes or has the potential to cause : - Harm to people - Damage to property - Loss to an operation. [AMSA] An unforeseen or unexpected event which may have the potential to become an accident but in which injury to personnel or damage to ship or to the environment does not materialised or remains minor. [IACS] S. ISIK Incident

24. Definitions Ships in Service Training Material An occurrence or event being caused by, or in connection with, the operations of a ship by which the ship or any person is imperilled, or as a result of which serious damage to the ship or structure or the environment might be caused. [IMO Res A849(20)] S. ISIK Marine incident

25. Definitions Ships in Service Training Material An undesired event which results in harm to a person and / or property damage. [HSE] An unintended event involving fatality, injury, ship loss or damage, other property loss, damage or environmental damage. [IACS] S. ISIK Accident

26. Definitions Ships in Service Training Material - Fracture, dislocation, amputation, loss of sight, penetration of eye including chemical or hot metal burn, electric shock or burn leading to unconsciousness. - 24 hr stay in hospital and / or requiring resuscitation, heat induced illness, asphyxia, loss of consciousness or illness requiring medical treatment from inhalation, ingestion or absorption of a chemical / biological agent or toxin. [HSE] S. ISIK Major accident (MAJ) Classification

27. Definitions Ships in Service Training Material An accident connected with work, which results in the death of an employee or self-employed person or a member of the public. [HSE] S. ISIK Fatal accident (FTL)

28. Definitions Ships in Service Training Material Means an event that has resulted in any of the following : - the death of, or serious injury to, a person, - the loss of a person from a ship, - the loss, presumed loss or abandonment of a ship or material damage to a ship, - the stranding or disabling of a ship, or the involvement of a ship in a collision; or material damage, - the damage to the environment brought about by the damage of a ship or ships, being caused by, or in connection with, the operations of a ship or ships. [IMO Res A849(20)] S. ISIK Marine casualty

29. Definitions Ships in Service Training Material Means a casualty which does not qualify as a very serious casualty and which involves : - A fire, explosion, grounding, contact, heavy weather damage, ice damage, hull cracking or suspected hull defect, etc…, resulting in : - Structural damage rendering the ship unseaworthy, such as penetration of the hull underwater, - Immobilization of main engines, - Extensive accommodation damage etc., or - Pollution (regardless of quantity), or - Breakdown necessitating towage or shore assistance [IMO Res A849(20)] S. ISIK Serious casualty

30. Definitions Ships in Service Training Material This is any sign or symptom of physical damage or impairment to any part of the body directly resulting from an incident, regardless of the length of time between the incident and the appearance of the injury. [OCIMF] S. ISIK Serious Injury Means an injury which is sustained by a person in a casualty resulting in incapacitation for more than 72 hours commencing within seven days from the date of injury. [IMO Res A849(20)] Work Injury

31. Definitions Ships in Service Training Material Means a casualty to a ship which involves : - The total loss of the ship. - Loss of life. - Severe pollution. [IMO Res A849(20)] S. ISIK Very serious casualty

32. Definitions Ships in Service Training Material Means a process held either in public or in camera conducted for the purpose of casualty prevention which includes: - Gathering and analysis of information, - Drawing of conclusions, including the identification of the circumstances and - Determination of causes and contributing factors and, when appropriate, - Making of safety recommendations. [IMO Res A849(20)] S. ISIK Investigation of Marine Casualty or Incident

33. Ships in Service Training Material Means action, omissions, events, existing or pre-existing conditions or a combination thereof, which led to the casualty or incident. [IMO Res A849(20)] S. ISIK Definitions Causes The outcome of an incident. There may be different possible consequences, e.g.: - Human fatalities (or injuries). - Environmental pollution. - Loss / damage to property. Consequences

34. Definitions Ships in Service Training Material A departure from acceptable or desirable practice on the part of the individual or group of individuals that can result in : - Unacceptable or - Undesirable risks. [IACS] S. ISIK Human Error

35. Ships in Service Training Material A-M CHAUVEL Category 0- Incident 1- Accident 2- Major Accident 3- Critical Accident 4- Disaster 5- Major Disaster Material Damages Less than 300 K€ Between 0,3 and 3 M€ Between 3 and 30 M€ Between 30 and 300 M€ Between 300 and 3 000 M€ More than 3 000 M€ Human Injuries No Injury 1 injure 1 to 9 deaths 10 to 99 deaths 100 to 999 deaths 1 000 deaths or more Definitions In French law: