Marine accident incident investigation model course3 11(q1 q2)

Additionally, to assist individual investigators in performing duties outside their normal assignments, the flag State should ensure ready access to expertise in the following areas, as

Model Course No: 3.11

Marine Accident and Incident

Investigation

'-Training Manual

4 Albert Embankment, London SE1 7SR

All rights reserved.

No part of this publication may, for sales purposes,

be produced, stored ina retrieval system or transmitted

in any form or by any means, electronic, electrostatic, magnetic tape, mechanical, photocopying or otherwise, without prior permission in writing from the International Maritime Organization.

CONTENTS

These notes have been compiled as a reference for this course and also as a workingdocument for use when!§ced with the need to investigate The thrust of the course is directedtowards achieving a system of investigation aimed at establishing the circumstances andcauses of a marine casualty, to learn and promulgate the safety lessons The course does notdeal with blame or liability and only briefly refers to more formal court or inquiry procedures.

The course is centred on the International Maritime Organization Assembly ResolutionA.849(20), the Code for the Investigation of Marine Casualties and Incidents andamendments to the Code as annexed to Resolution A.884(21) The course also will stress theneed for reporting to IMO under the provisions of MSC Circ 827/MEPC Circ 333

No two accidents are ever precisely the same However, the course sets out to show thatwhile the causal factors may be diverse, the underlying generic structure of any casualty oraccident, whether marine, road, rail or aviation, can be seen to have a common structure

Much of the course is centred on role playing and case studies Participants should use theirexperience and judgement to make the roles as realistic as possible; by so doing participantsshould complete the course with a clear concept of systemic investigations and their role inimproving the safety of life at sea and protecting the marine environment

1 Course Introduction

1.1 Introduction

Annexed to IMO Resolution A.847(20) are guidelines to provide flag States with a means to establish and maintain measures for the effective application and enforcement of IMO Conventions Part 7 of the annex refers to flag State investigations.

"7. FLAG STATE INVESTIGATIONS

7.1 In addition to providing qualified surveyors, the flag State should provide qualified

investigators Consistent with article 94.6 and articles 217.4,5 and 6 of UNCLOS and with the provisions of the relevant IMO conventions, investigations should be carried out following a marine casualty or pollution incident The flag State should ensure that individual investigators have a working knowledge and practical experience in those subject areas pertaining to their normal duties Additionally, to assist individual investigators in performing duties outside their normal assignments, the flag State should ensure ready access to expertise in the following areas, as necessary:

.1 navigation and the Collision Regulations 2 flag State regulations on certificates of competency 3 causes of marine pollution

.4 interview techniques 5 evidence gathering 6 evaluation of the effects of the human element

7.2 Any accident involving personal injury necessitating absence from duty of three days

or more and any deaths resulting from occupational accidents and casualties to ships

of the flag State should be investigated, and the results of such investigations made public Ship casualties should be investigated and reported on in accordance with UNCLOS, relevant IMO Conventions, and the Guidelines currently being developed by IMO Casualty investigations should be conducted by suitably qualified investigators, competent in matters relating to the casualty.The report of the investigation should be forwarded to IMO together with the flag State's observations, in accordance with the Guidelines referred to above."

It is important, therefore that flag and coastal State administrations have in place an effective and internationally acceptable system for investigating marine accidents.

1.2 The purpose of the course

The purpose of this course is to introduce you to the philosophy, processes and procedures required to support a marine casualty investigation in accordance with IMO Assembly Resolution A.849(20) and the Code for the Investigation of Marine Casualties and Incidents.

The Code seeks to introduce to the international shipping community uniform objectives and procedures for investigating casualties which occur in this most international of industries The international aviation industry has subscribed to such a code (Annex 13 of the International Civil Aviation Organization Convention) for some years and the systems approach into air accidents is credited with contributing to the safety of the civil aviation industry The IMO Code is aimed at a safety outcome to identify the circumstances under which a casualty occurred and to determine the causes of such an accident.

accident investigations and accident investigation methodology The course will be focused onthe IMO Code The course also provide administrators with an insight into what is required inconducting a casualty investigation, supporting the investigator in the field and what aninvestigation should achieve.

Investigations are an "official function of a flag or coastal State" When investigating in yourown country your own national laws will apply You will have to bear these laws in mind whendealing with certain parts of the course, this will apply particularly to Part 5

1.3 Course structure

The course is divided into eleven learning objectives or "parts", as outlined in the program Itwill be centred on group activities and lecture sessions

Recommended reading and references

Reason, J (1990) Human Error, Cambridge University Press, Cambridge (UK).ISBN 0521 314194

Reason, J (1997) Managing the Risks of Organizational Accidents, Ashgate,ISBN 1 84014 1050

Reason, J Corporate Culture and Safety NTSB Symposium on Corporate Culture andTransportation Safety, Washington, 1997

Moore-Ede, M., The Twenty-Four Hour Society, Random House Australia, 1993ISBN 0 09 182755 8

Perrow, C., Normal Accidents - Living with High-Risk Technologies, Basic Books, Inc New

York

Elizabeth F Loftus, Eyewitness Testimony, Harvard University Press, 1996.)

Rushbrook.R., Rushbrook's Fire Aboard, Third Edition, 1998, Brown, Son & FergusonISBN 0851746594

DeHaan J.D., Kirk's Fire Investigation, Fourth Edition, Prentice Hall Inc, 1997ISBN 0 8359 5056 5 (NOTE THERE MAY BE A 5th ED - GET THE LATEST)

O'Leary, M & Chappell, S Confidential incident reporting systems create a vital awareness

of problems ICAO Journal 51 :11-13, 1996

Ainsworth et aI, (1996) Proceedings of a Research Workshop on Fatigue in the MaritimeIndustry, Seafarers International Research Centre for Safety and Occupational Health,University of Wales, Cardiff, Executive Summary

Colquhoun, W P., Rutenfranz, J., Goethe, H., Neidhart, B., Condon, R., Plett, R & Knauth, P.(1988) Work at sea: a study of sleep, and of circadian rhythms in physiological functions, inwatch keepers on merchant vessels I.Watchkeeping on board ships: a methodological

approach International Archives of Occupational and Environmental Health, 60: 321-329 Siros, W.G., (1995), Alertness Assurance - The key to reducing Fatigue and Human Error in the Marine Industry, American Petroleum Institute/US Coast Guard

2 International Shipping - Shipping Casualties and

'-2.1 Marine accidents as seen by the public and the media

Shipping was once seen as the safest and most environmentally friendly way to transportgoods by sea In any analysis it is the only practical way for the vast bulk of the world's trade

Shipping accidents, particularly those that involve pollution, bring into question the safety ofshipping and the quality of ships and their crews Whether or not such questions are justified,

it is shipping accidents that provide an image of the industry, which attracts considerableattention

(Video "Scandal at sea" or equivalent Approx 30 minutes)

2.2 Shipping safety issues

What is risk? The risk is the probability of event multiplied by the exposure times theconsequences

",>-Is there such a thing as an acceptable accident rate?

The need is to set the risk as low as possible and at the same time make the operationpractical It is possible to design all manner of engineering solutions to minimise risk The idea

of "redundancy" is one that is widely used If one has three systems operating in parallel eachwith a possible failure rate of 1:100, the likelihood of all three failing at once is 1:1,000,000.Mechanical and electrical systems are increasingly reliable and with redundancy the chances

of a casualty through equipment failure is minimal

It is often stated that human error is the cause of about 80 per cent of accidents This coursewill examine this statement and introduce some basic consideration of human factors It willshow that all accidents bar "acts of God" have some human element in the chain of eventsleading to the accident

The aim of marine casualty investigations is to prevent similar casualties Open, systemic andfair investigations, which are not aimed at apportioning liability or blame, have proved effective

in the aviation industry Such an international approach in the marine world may have helpedprevented unacceptable losses at sea This course aims to introduce participants to a system

of investigation, which may help to prevent future casualties

Most casualties involve the smaller range of general cargo ships and fishing vessels The twotypes of ship that have caught the public's attention are bulk carriers and passenger ferries

Bulk carrier losses

The loss of these ships reflected a worldwide trend According to Lloyd's Register of Shipping,(J M Ferguson, Bulk Carriers - The Challenge, 14 May 1991) between 1980 and 1991, 64bulk carriers were lost under circumstances where structural failure may have been a factor

At the peak, 20 bulk carriers of over 15,000 gross tonnage were lost in a 20 month period,apparently as a result of some failure in their structure, between December 1990 and August

1991, with the loss of hundreds of seafarers

Bulk carriers make up about 15 per cent of the world fleet in numbers of ships over 1000deadweight tonnes The table below shows the number of bulk carriers (and OBOs) lostthrough having foundering or having been posted as missing compared to all vessels(excluding fishing vessels, tugs and dredgers) that have been reported as having foundered

or as missing The column of lives lost shows all lives lost on bulk carriers1.

The following table, from Lloyd's Casualty Returns and Lloyd's Annual year Books, shows thatthe safety of bulk carriers remains an important issue The following table is focused on bulkcarriers that sank or suffered known structural damage It does not include bulk carriers (orbulk carrier deaths) from fires, explosions etc

*Note: Lloyd's Casualty Returns changed the format in which they showed figures for loss of

life These figures are open to revision as reports are received

** Anna Spiratu sank after collision with loss of 26 lives, on 15 June 1996 ICL Vikraman

sank after collision with loss of 24 lives, on 26 Sept 1997

The loss of bulk carriers between 1987 and 1994 led to an initiative by the Secretary General

at MSC63, following which a six person correspondence group of competent personsaddressed the issues of bulk carrier safety This group reported to MSC, which drafted a newchapter to SOLAS 74 This Chapter was the subject of a Diplomatic conference in November

1997, which adopted the new chapter 12 to the SOlAS Convention on additional safetymeasures for bulk carriers

Passenger ferry losses

Ferries account for about 5.8 per cent of the total number of the world fleet of ships over 1000tonnes deadweight

Ferry accidents, particularly involving loss of life, are major incidents requiring the mostrigorous investigation Prior to 1989 a number of ferry casualties created considerableconcern These included:

Dona Paz involved in collision with the tanker Vector south-east of Manila on20/12/1990, the death toll has been put at 4,386, though the official figure is lower atabout 3148

Herald of Free Enterprise capsized and foundered after leaving Zeebrugge on 3/3/97

with the loss of 193 lives

Dona Marilyn capsized in a typhoon in the Philippines on 24/10/88 with the loss of as

many as 350 lives

1Source Lloyd's Casualty Return

INTERNATIONAL SHIPPING - SHIPPING CASUALTIES AND PUBLIC PERCEPTIONS

Since 1989 the losses have continued:

Salem Express on passage Jeddah-Suez struck a reef and sank on 14/12/91, 464deaths;

Jan Heweliusz - capsized in the Baltic, 14/1/93, 55 deaths;

Estonia - capsized in the Baltic 28/9/94, 852 deaths;

Cebu City - sank after a collision in Maila Bay on 2/12/94 with the loss of 140 lives; Gurita, stranded and sank on 19/1/96, Banda Archipelago (Indonesia) with loss of 338

lives;

Bukoba capsized on Lake Victoria in May 1996 with loss of 869 lives;

Princess of Orient- sank in tropical storm Vicki on 21/8/98, at least 150 deaths

Harta Rimba - sank in central Indonesian Archipelago on 6/2 99 with loss of approx.

300 lives

The loss of the Estonia and the ferry tragedies over the previous years prompted theSecretary General and the Chairman of the Maritime Safety Committee to seek approval ofthe 18th Assembly for the formation of a group of experts to consider the issues of ro-rosafety This group met on 8 occasions resulting in a Diplomatic Conference in 1995, whichapproved 30 amendments to SOLAS 74 dealing with ro-ro safety

2.3 Accidents as an iceberg

Action ratio study"

What can we learn from accident investigations and analysis? Which incidents should beinvestigated?

Quite obviously no marine authority has the resources to investigate all minor accidents andnear misses (sometimes referred to as "incidents") However, in an ideal world we would look

at even the most minor incident

Accidents can be seen as the part of an iceberg above the sea surface Beneath the surfacethere are a myriad of minor accidents and near misses which are largely unreported andwhether they are investigated or not may rely on the company safety culture and ethic

A study of industrial accidents undertaken by Frank E Bird, Jr and George L Germain (1969)2analysed 1,753,498 accidents reported by 297 companies from 21 industrial groups overcovering a period of 3 billion man hours

In comparing the severity of accidents they discovered that for every reported major injury(death, disability, lost time or medical treatment) there were 9.8 minor injuries requiring firstaid

2Bird F and Germain G., (1986) Practical Loss Control, Leadership Institute Publishing, Loganville, Georgia.

3 Investigations

3.1 Definitions

A marine casualty is an accident It is an unexpected or unlooked for event with unwelcomeoutcomes The definition is contained in the Code at paragraph 4

Casualty incident categories are normally grouped as follows:1

Foundering Includes ships which sink as a result of heavy weather, springing leaks,

breaking in two, etc., but not as a consequence of categories listedbelow

Missing After a reasonable period of time, no news having been received from

a ship and its fate is undetermined, the ship is posted as missing

Fire/Explosion Includes ships experiencing a fire and/or explosion where it is the first

event reported - it therefore follows that casualties where a fire and/orexplosion is the result of a some other incident category, such anincident is categorised under that incident

Collision The result of one ship being struck by another, regardless of being

whether under way, anchored or moored

Contact The result of a ship striking an external object - but not another ship or

the sea bottom This includes striking a drilling rigs/platforms

Grounding Includes a ship touching the sea bottom, sandbanks, shoals,

Wrecked/ sandbanks, seashore, etc., as well as being entangled on underwater

Stranded wrecks

Hull/machinery Failure of equipment or machinery, immobilisation of the main engine

Heavy weather Significant damage caused by heavy seas or the elements and ice

Ice damage damage

Other Any casualty that is not included above and may include war damage

(this being a deliberate act may not be classified as a casualty)

These classifications relate to casualties to ships and do not include accidents to crewmembers or others who may be involved in the operation of a ship, either at sea or in port.Death and injury to seafarers and others as a result of the operation of a ship are important,

if not the most important, part of an investigator's work However, a distinction may have to

be made between those deaths or injuries that are not directly connected with shipoperations Guidance in this matter is best taken from MSC/Circ.827/ MEPC/Circ.333 whichdefines a very serious casualty as "casualties to ships which involve total loss of the ship, loss

of life, or severe pollution" Hence the death (or serious injury or near miss) must also involvesome aspect of a ship's operation Heart attacks, or death or disability through a pre-existingmedical condition would not normally be covered by normal marine casualty or incidentinvestigation procedures

1Adapted from Lloyds World Casualty Statistics

3.2 Courts, tribunals and inquiries

Authorities may react to an accident in a number of ways At one end of the spectrum a criminal investigation may be mounted with a view to prosecution, at the other end a pure

"safety investigation", with no blame attached, may be undertaken Both extremes are legitimate and are a necessary part of the armoury to promote safer operation of any enterprise.

There is no reason why two such investigations should not be carried out in parallel.

An offence suggests a deliberate intent to act contrary to law, though it can also include the neglect of a person to act competently The public interest in punishing a person that may have contributed to an accident (or casualty) has to be weighed against the public interest of understanding why an accident occurred and in helping to prevent a similar accident happening again (See following Lloyd's List leader of 11 Feb 1998 [3.2.5.])

There is no reason why two such investigations should not be carried out in parallel, but they should be separate.

3.2.2 Coroners

Under some legal systems a Coroner has the responsibility of establishing the cause of death When investigating a fatality, or where a fatality is involved, an investigator may become involved with the Coronial system The various responsibilities in the case of a marine casualty involving death are a matter of national law In some countries with the coronial system, under certain conditions (e.g Australia) there may be dual jurisdiction It is advisable to make early contact with the Coroner's office to work out the various interests and

to offer expert assistance.

3.2.3 Civil proceedings

Civil courts hear and pass judgement on claims for damages or other loss The casualty investigation is often seen as a source of useful information It is a matter for municipal (national law) as to what is or is not admissible as evidence.

Some reports may be considered "hearsay" Some jurisdictions require evidence to be sworn Others may require the investigation files to be made available It is also possible that an investigator may be called as a witness.

Of great importance is the relationship between the investigation team, and other parties to the investigation (e.g the ship owner, equipment company, master, officers) and a party's legal advisers It is not uncommon for a party to try and channel everything through the legal adviser, and for the legal adviser to dispute the investigator's right to certain information and control any information provided Usually the primary concern of the legal adviser is the use that such information can be put to in civil proceedings.

A safety investigation can be a rich source of information.

In 1948 Mr Justice Streeton said:

"I have come to the conclusion that these inquiries are, and inevitably will be, misused

by the parties to them, excepting the Director of Navigation, for the purpose of

establishing evidence for use in civil litigation between the parties That misuse is, if I may be permitted aparadox, alegitimate misuse, but it is none the less amisuse."2

3.2.4 Formal safety investigations

Formal investigations are normally conducted before a judge or tribunal independent of themarine administration The maritime authority is just another party presenting evidence to theinquiry

Marine casualty investigators have an important part to play in the formal investigationprocess The investigator may be required to prepare a report setting out the administration'sposition and conclusions This will involve producing evidence in a form acceptable to theinquiry

During the inquiry the investigator may be required to produce a brief of questions that must

be put to the witnesses In the hearing he/she may be required to listen to the answers andensure that the questions have been answered to the satisfaction of the administration Anyissues arising from a witness's answers may have to be followed up

The investigator may' be called as a witness to recount what he/she actually saw andobserved Unless directed an investigator should not normally recount hearsay evidence oroffer opinions Such a witness should stick to facts unless specifically directed otherwise bythe inquiry

When the evidence is complete the investigator may be required to draft a final submission

on behalf of the administration Such a submission should be backed with references toevidence before the inquiry

3.2.5 Viewpoint

By Michael Grey

When there is failure - who knows about it?3

ONE of the most harrowing documents I have read for many years is the official report into

the loss of the Estonia, which was finally made public just before Christmas, more than three

years after the event

It contains much in it that will appal, from the terrifying incident itself, to the inability of wellequipped ships on the spot to rescue people from the cold waters, and the nightmare whichmust have been experienced by the divers as the pushed their way into the collapsedwreckage of the ferry's internals

I know there is much "in the report that remains contentious, and the subject of furtherlitigation, but one specific and recurring problem impressed itself upon me, reinforcing a longheld belief that something, which the industry itself has the power to fix, needs to be urgentlydone

I refer to the fact that by the time of this disaster, there had been a considerable number ofincidents involving failure or part-failure of bow doors with ships at sea

2 Streeton, J.re "Koonda" & "George H Emircocos" and re "Iron Monach" & "Empire Strength", CMI 1943.

3 Lloyd's List, Wednesday 11 February 1998; this leader is reproduced by kind permission of Lloyd's List.

but it is surely reasonable to suppose that there have been others over the years, sinceadministrations and classification societies judged that a drive through ship with a large bowopening was a safe option.

The Estonia report admits that the list is by no means complete, as it contains only Finnish

and Swedish vessels

Some of these incidents, and they stretch back to the early 1970s, were very serious andpotentially lethal, although it appears that prompt action by those in charge of the shipsslowing or stopping, turning the vessels out of the weather and returning immediately to thesafety of port prevented water getting onto the cardecks

Additionally the availability of a watertight door inside the visor or clamshell doors providedthe necessary level of insulation and saved the day

But the point is, and the question must be asked, just how widely knowledge about thesethese accidents was promulgated by those who had knowledge of them?

The Finnish and Swedish authorities would have been in possession of the full facts, and it isreasonable to suppose that those operating ships under these flags would have been madeaware of the incidents

A number of the major classification societies were also clearly informed about accidentswhich had taken place aboard ships they had responsibility for Presumably the individualowners, after an accident, made very sure that they closely inspected the fastenings andhinges of bow doors in other vessels of their fleets

But who else learned abouJ such accidents throughout the world, bearing in mind that through ships are a more or less universal ferry type of today?

drive-Were naval architects working on designs for big ferries ordered by Japanese operators madeaware of the problems that had been experienced?

Were owners of ex-Baltic boats working in the Eastern Mediterranean or Far East ever told

about the problems that were experienced by the operators of the Finlandia or Viking Saga,

or the fright that the watchkeeper of the Wellamo received when he saw the bow visor lifting

as he ran down from Helsinki to Stockholm in a storm one night in 1975?

There were drive through ships designed in North America and the United Kingdom, Italy andFrance - did any of their designers ever learn about the incident in which heavy seas tore off

the clamshell doors of the Finnhansa in a storm off the Finnish coast in 1977?

Did the administrations which were busily approving plans for bigger and more sophisticatedferries with enormous passenger loads ever learn about these and other incidents?

Were the Japanese or Canadian or British or French government surveyors ever made aware

of these operational problems? And indeed, was there any proper mechanism available forthe transmission of accident information between one ferry owner and his competitor downthe road, or owners of similar ships throughout the world?

Did the International Maritime Organisation ever become engaged in the receipt, study, orpromulgation of information about such incidents?

The answer to all these questions, I'm afraid, is probably a resounding no, because themechanisms for the transmission of such important operational information was not generallyavailable

Indeed, there is some evidence that the seriousness of such incidents, and the possibleconsequences for these ships if water had got onto their cardecks was not properlycontemplated In the event, the officers aboard the ships reacted promptly and properly, theships went back to port, were repaired to everyone's satisfaction and returned to service.The incident had effectively ended, and what lessons that were drawn from it were probablyconfined to a very small number of people Perhaps, in fact, the potential seriousness of theincidents were not fully comprehended, perhaps it was merely assumed that the secondarysafety appliances would continue to be adequate, as they had been in these accidents.This inability of the maritime industry to construct and maintain a system for the prompt andinternational promulgation of important safety information has worried a number of thoughtful

people over the years, but there is still very little that is done about it.

The classification societies have probably gone rather farther than most, in establishingformal systems for alerting each other to elements prescribed by their rules which have beenshown to give trouble, but there is very little else

There is certainly nothing even approaching the systems in the aviation world which, if a boltfails in the tailplane of a 737, alerts every operator of similar aircraft to this failure in a trice

The fatal bow door damage the Estonia, for whatever reason, is merely the worst possible

example of this maritime industry system failure, which extends into every area of shipping

It is made infinitely worse by the fragmention of the industry into so many different sectors,and the emergence of the flag of convenience and corresponding weakening of the'traditional' flags

There are some focs do their level best and provide an excellent maritime administration, butothers don't bother

The International Maritime Organisation, some have suggested, could be an effective forumfor an international system of incident or accident alerting Indeed, there is an obligation foradministrations which subscribe to IMO conventions, to hold their accident inquiries and toinform the organisation of their discoveries, for the greater beneft of world shipping

Most don't bother, and of those that do send IMO reports, these are collected, but nothing isdone with them, for there is no budget to provide for such a system that would let relevantpeople know of the findings

There is a growing number of people who are suggesting that shipping is becoming regulated and that IMO ought to layoff for a few years Accidents are declining in number and

over-marine safety is improving But this particular lesson from the Estonia, like the scandal of the

bulk carrier sinkings before it, shows that there is one great gap in the system that needs to

3.3 A Brief History of Casualty Investigation

The United Kingdom

The late eighteenth century and throughout the nineteenth century was a time of massmigration and expanding trade links Travel and transport by sea was the only way to movepeople and goods between continents With land transport reliant on horse drawn vehicles,the coastal passenger trade was a major means of transporting people within a country

During this time, in the United Kingdom, shipping was largely unregulated The loss of life atsea on both domestic and international transport, together with the loss of cargo caused greatpublic concern in the UK In 1836 the UK Government to set up a select committee of theHouse of Commons to inquire into the causes of shipwrecks

The Committee recommended that amongst other measures, a system of "Courts of Inquiry"should be set up with the specific task of:

• investigating the causes of individual shipwrecks

• censuring "commanders" and ship owners

• suspending licenses

• rewarding those that displayed particular skill, courage and humanity

• publicising the outcomes of such inquiries

11

publication of the evidence and the findings was not only to warn masters and owners, but to

" stimulate and suggest the exercise of preventive measures for the avoidance of future casualties."

In 1846 Parliament passed the Steam Navigation Act This act initially applied only to British steam vessels, but later the jurisdiction to was extended to British sailing vessels It required them to carry boats and detailed minimum welfare conditions for the crew Section 104 required that serious accidents must be reported to the Board of Trade and made provision for the appointment of suitably skilled and qualified inspectors to inquire into and report on such marine casualties.

The Act came into operation on 1 January 1847 On 16 January 1847, the steamship Sirius

was wrecked and a Royal Naval officer Captain Henry Denham was appointed to investigate.

No firm procedures were set out in the act and Captain Denham seems to have made up procedures as he went along The interviews of individuals were held "in camera" Captain Denham undertook some 12 investigations in the first two or three years of accident investigation As a result of each investigation he made recommendations to the authorities

to address causal factors By 1850 he submitted, separate from any specific casualty, a memorandum headed "Amendments to the Steam Navigation Act 9 & 10 Vict., c.100, as suggested by the Official Investigations of steam vessel accidents, of Captain Denham, RN, FRS, , "a list of the p'Oints which official inspections of steam vessel accidents had developed, and whereon the Board might deem it advisable to promote further regulations for the safety of life and property at sea."4

Captain Denham, a RN Hydrographer, completed some 12 investigations over the next two years He made some 50 safety recommendations many of which were adopted into legislation over the following years Late in 1851, Captain Denham was appointed to command the survey sloop Herald and he sailed for Australia and the Pacific where he undertook extensive survey work He retired from the Royal Navy as an Admiral.

The earliest official investigations, therefore, emphasised the principle that the main aim of an investigation was to stop accidents happening from similar causes In evidence to a select Committee of Parliament in 1860 it was stated:

" it is necessary to remember what are the absolute requisites for these inquiries In the first place they must be summary, local and inexpensive If they are not so they will

be oppressive to the parties, they will be impracticable to the Government and they will

be ineffectual Thus further (and it is very important to mention this) the object of the inquiry is not so much to punish anyone who may be at fault, as to prevent wrecks

in the future, whether by punishment of and warning against negligence, or remedying anything that is wrong in the way of navigation "5

Responding to criticisms that the investigation system developed by Denham and others meant that the Board of Trade was both "judge and jury", the inquiry role was given to Stipendiary Magistrates and Justices of the Peace under the new Merchant Shipping Act of

1854 Inquiries became more formal and largely followed court procedures The specialist technical safety investigator was replaced, by a more judicial process However the basic emphasis on learning the safety lessons remained.

4Murton, W Wreck Inquiries, Stevens & Sons, London, 1884.

5 Farrer, Sir Thomas, Permanent Secretary to the Board of Trade, Report to a Select Committee of the United Kingdom Parliament, 1860

The Merchant Shipping Act of 1876 introduced a new, two tier system of inquiry Thisintroduced the Preliminary Inquiry, followed by a Formal Investigation before a judge, advised

by specialist "assessors" The Preliminary investigation was to establish whether or not aformal investigation was warranted The Merchant Shipping Acts were binding on BritishDominions and Colonies and were adopted by these countries when they became sovereignstates This system endured in many jurisdictions to the 1970s and beyond

By 1929, the shipping courts occupied a unique position in the British legal system:

'They are administrative courts of a special character The Courts were created for the purpose of assisting the Board of Trade in their duty of preserving a reasonable standard of safety of life at sea, and of maintaining the private rights of individuals in cases where they appear to be in conflict with the public interest asinterpreted by the Board of Trade For these reasons it was thought to be necessary to create special shipping courts, which would combine, so far as is possible, the merits of an administrative court in the ordinary sense with those of a court of justice.''6

Although the procedures were altered and a system of Preliminary investigations and Formalinquires was adopted, the idea of a technically competent investigator remains in place.Because of the UK's overseas colonies and dominions, the British system was used

extensively around the world The aim of the investigation remains as stated in about 1860: lilt

is not somuch to punish anyone who may be at fault, as to prevent wrecks in the future ".

Judicial inquiries carr}' be expensive and various parties use them to gain information forfuture civil action, rather than concentrating on the safety issues

In 1948 Mr Justice Streeton stated in handing down two judgements:

"I have come to the conclusion that these inquiries are, and inevitably will be, misused

by the parties to them, excepting the Director of Navigation, for the purpose of establishing evidence for use in civil litigation between the parties That misuse is, if I may be permitted aparadox, a legitimate misuse, but it is none the less a misuse.'7

A number of States, while maintaining the options of Formal Investigations, have reverted tothe '1echnical investigation"

It is with this in mind that the International Code for the Investigation of Marine Casualties andIncidents was drafted

3.4 Concept of culpability

The problem of a criminal action is that the prosecution has the sole purpose of proving acase against the party or parties accused of the crime and will focus on the narrow issues ofblameworthy action Unfortunately the causes of accidents are more complex and numerousthat one or two acts of commission or omission

IIAccidents appear to be the result of highly complex coincidences which could rarely

be foreseen by the people involved The unpredictability is caused by the large number

of causes and the spread of information over the participants Accidents do not occur because people gamble and lose, they occur because people do not believe that the accident that is about to occur is at all possible." (Wageneer & Groeneweg, 1988 P42).

6McMillan, A.R.G., Shipping Inquiries and Courts, Stevens and Sons, 1929

7 Streeton, J.re "Koonda" & "George H Emircocos" and re "Iron Monach" &"Empire Strength", CMI1943.

approach is required to determine the circumstances and causes of a casualty, so that thecauses can be addressed - internationally - and measures introduced to prevent furthercasualties Casualty investigations under the IMO code are essentially to determine thesafety issues and identify the unsafe conditions that contributed to the accident.Blame and liability are not relevant to IMO.

Any safety information system, for a marine casualty investigation under the Code, as part ofsuch a system, depends upon receiving accurate information This requires the co-operation

of anybody involved who can give accurate, honest evidence of what occurred

The IMO Code aims to achieve:

• Qualified indemnity against disciplinary proceedings

• Confidentiality or anonymity

• Separation of the investigation process from disciplinary or criminal procedures

• Rapid, transparent, impartial and accurate reporting

• A simple reporting format, which is available and distributed widely

In dealing with the confidential reporting of air accidents O'Leary and Chappell stated:8

"For any incident reporting programme to be effective in uncovering failures which contribute to an incident, it is paramount to earn the trust of the reporters This is even more important when there is a candid disclosure of the reporter's own errors Without such trust, the reporter will be selective and will probably gloss over pivotal human factors information In the worst case - that in which potential reporters have no trust

in the safety organization - there may be no report at all."

Such a system is ideal and suitable for an "in-house" reporting system The Code aims tocome as close as possible to these ideals, while recognising that casualty investigations arecarried out by, or on behalf of, a State administration

Reason {1997} discussed the issue of culpability and the investigation of accidents.9

'~n effective reporting culture depends, in turn, on how the organization handles blame and punishment A 'no-blame' culture is neither feasible nor desirable. A small proportion of human unsafe acts are egregious (e.g substance abuse, reckless non- compliance, sabotage, etc.) and warrant sanctions, severe ones in some cases. A

blanket amnesty on all unsafe acts would lack credibility in the eyes of the workforce More importantly, it would be seen to oppose natural justice What is needed is ajust culture, an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information - but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour."

An important feature of the figure is what Neil Johnston has called the substitution test Thisinvolves asking the individual's peers the following question: Given the circumstances thatprevailed at the time, could you be sure that you would not have committed the same or asimilar type of unsafe act? If the answer is 'no', then blame is almost certainly inappropriate.The best people can make the worst mistakes

8 O'Leary, M & Chappell, S Confidential incident reporting systems create a vital awareness of problems.

ICAO Journal 51 :11-13, 1996

9 Reason, J.Corporate Culture and Safety NTSB Symposium on Corporate Culture and Transportation

Safety, Washington, 1997

3.5 Objective of an investigation

(Video: Piper Alpha (ICI) 45 minutes - Group activity - In five minutes write down what advantages a prosecution would have had and what advantages a safety investigation offered.)

3.6 Hindsight

Investigators usually have the advantage over the investigated and are blessed with perfect hindsight It is important that this hindsight is used with professionalism, realism and constructively Investigators are not judges and should avoid being judgemental and should ensure that they understand the situation in which the individuals were placed It is worth bearing in mind two quotes from Professor James Reason's book Human Error.

"For those of us who pick over the bones of other people's disasters, it often seems incredible that these warnings and human failures, seemingly soobvious in retrospect should have gone unnoticed at the time Being blessed with both uninvolvement and hindsight, it is a great temptation for retrospective observers to slip into a censorious frame of mind and to wonder at how these people could have been so blind, stupid, arrogant or reckless."

"First, most people involved in serious accidents are neither stupid nor reckless, though they may well have been blind to the consequences of their actions Secondly,

we must be aware of falling prey to the fundamental attribution error (i.e., blaming people and ignoring situational errors."10

iMcMillan, A.R.G., Shipping Inquiries and Courts, Stevens and Sons, 1929

10 Reason, J., Human Error, pg.216, Cambridge University Press, Cambridge (UK), 1990.

4 International Conventions, Requirements etc.

Article 87 of the United Nations Law of the Sea Convention (UNCLOS) provides that the high seas (the waters beyond the 12 mile territorial sea) are open to all States Freedom of the high seas is exercised under the conditions laid down by the Convention and by other rules

of International law, of any State may be traversed by all ships and fishing vessels The various freedoms of the high seas shall be exercised by all States with due regard for the interest of other States in their exercise of the freedom of the high seas, and also with due regard for the rights under the Convention with respect to activities in the Area.

Under Article 17 ships of all States, whether coastal or land-locked, enjoy the right of innocent passage through the territorial sea Passage is innocent so long as it is not prejudicial to the peace, good order or security of the coastal State.

IMO was created in 1948.

of sea, described as the territorial sea.

2 This sovereignty extends to the air space over the territorial sea as well as to Its bed and subsoil.

3 The sovereignty over the territorial sea is exercised subject to this Convention and to other rules of international law.

Article 3 Breadth of the territorial sea

Every State has the right to establish the breadth of its territorial sea up to a limit not exceeding 12 nautical miles, measured from baselines determined in accordance with this Convention.

Article 4 Outer limit of the territorial sea

The outer limit of the territorial sea is the line every point of which is at a distance from the nearest point of the baseline equal to the breadth of the territorial sea.

Article 17 Right of innocent passage

Subject to this Convention, ships of all States, whether coastal or land-locked, enjoy the right

of innocent passage through the territorial sea.

1 The coastal State may adopt laws and regulations, in conformity with the provisions of this Convention and other rules of international law, relating to innocent passage through the territorial sea, in respect of all or any of the following:

(a) the safety of navigation and the regulation of maritime traffic;

(b) the protection of navigational aids and facilities and other facilities or installations; (c) the protection of cables and pipelines;

(d) the conservation of the living resources of the sea;

(e) the prevention of infringement of the fisheries laws and regulations of the coastal State;

(f) the preservation of the environment of the coastal State and the prevention, reduction and control of pollution thereof;

(g) marine scientific research and hydrographic surveys;

(h) the prevention of infringement of the customs, fiscal, immigration or sanitary laws and regulations of the coastal State.

2 Such laws and regulations shall not apply to the design, construction, manning or equipment of foreign ships unless they are giving effect to generally accepted international rules or standards.

3 The coastal State shall give due publicity to all such laws and regulations.

4 Foreign ships exercising the right of innocent passage through the territorial sea shall comply with all such laws and regulations and all generally accepted international regulations relating to the prevention of collisions at sea.

Article 24 Duties of the coastal State

1 The coastal State shall not hamper the innocent passage of foreign ships through the territorial sea except in accordance with this Convention In particular, in the application of this Convention or of any laws or regulations adopted in conformity with this Convention, the coastal State shall not: (a) impose requirements on foreign ships which have the practical effect of denying or impairing the right of innocent passage; or (b) discriminate in form or in fact against the ships of any State or against ships carrying cargoes to, from or on behalf of any State.

2 The coastal State shall give appropriate publicity to any danger to navigation, of which

it has knowledge, within its territorial sea.

Article 27 Criminal jurisdiction on board a foreign ship

1 The criminal jurisdiction of the coastal State should not be exercised on board a foreign ship passing through the territorial sea to arrest any person or to conduct any investigation in connection with any crime committed on board the ship during its passage, save only in the following cases:

(a) if the consequences of the crime extend to the coastal State;

(b) if the crime is of a kind to disturb the peace of the country or the good order of the territorial sea;

(c) if the assistance of the local authorities has been requested by the master of the ship

or by a diplomatic agent or consular officer of the flag State; or (d) if such measures are necessary for the suppression of illicit traffic in narcotic drugs or psychotropic substances.

2 The above provisions do not affect the right of the coastal State to take any steps authorized by its laws for the purpose of an arrest or investigation on board a foreign ship passing through the territorial sea after leaving internal waters.

3 In the cases provided for in paragraphs 1 and 2, the coastal State shall, if the master

so requests, notify a diplomatic agent or consular officer of the flag State before taking any

18

steps, and shall facilitate contact between such agent or officer and the ship's crew In cases

of emergency this notification may be communicated while the measures are being taken.

4 In considering whether or in what manner an arrest should be made, the local authorities shall have due regard to the interests of navigation.

5 Except as provided in Part XII or with respect to violations of laws and regulations adopted in accordance with Part V, the coastal State may not take any steps on board a foreign ship passing through the territorial sea to arrest any person or to conduct any investigation in connection with any crime committed before the ship entered the territorial sea, if the ship, proceeding from a foreign port, is only passing through the territorial sea without entering internal waters.

Article 28 Civil jurisdiction in relation to foreign ships

1 The coastal State should not stop or divert a foreign ship passing through the territorial sea for the purpose of exercising civil jurisdiction in relation to a person on board the ship.

2 The coastal State may not levy execution against or arrest the ship for the purpose of any civil proceedings, save only in respect of obligations or liabilities assumed or incurred by the ship itself in the course or for the purpose of its voyage through the waters of the coastal State.

3 Paragraph 2 is without prejudice to the right of the coastal State, in accordance with its laws, to levy execution against or to arrest, for the purpose of any civil proceedings, a foreign ship lying in the territorial sea, or passing through the territorial sea after leaving internal waters.'

Article 94 Duties of the flag State

1 Every State shall effectively exercise its jurisdiction and control in administrative, technical and social matters over ships flying its flag.

2 In particular every State shall:

(a) maintain a register of ships containing the names and particulars of ships flying its flag, except those which are excluded from generally accepted international regulations on account of their small size; and (b) assume jurisdiction under its internal law over each ship flying its flag and its master, officers and crew in respect of administrative, technical and social matters concerning the ship.

3 Every State shall take such measures for ships flying its flag as are necessary to ensure safety at sea with regard, inter alia, to:

(a) the construction, equipment and seaworthiness of ships;

(b) the manning of ships, labour conditions and the training of crews, taking into account the applicable international instruments;

(c) the use of signals, the maintenance of communications and the prevention of collisions.

4 Such measures shall include those necessary to ensure:

(a) that each ship, before registration and thereafter at appropriate intervals, is surveyed

by a qualified surveyor of ships, and has on board such charts, nautical publications and navigational equipment and instruments as are appropriate for the safe navigation of the ship; (b) that each ship is in the charge of a master and officers who possess appropriate qualifications, in particular in seamanship, navigation, communications and marine engineering, and that the crew is appropriate in qualification and numbers for the type, size, machinery and equipment of the ship;

(c) that the master, officers and, to the extent appropriate, the crew are fully conversant with and required to observe the applicable international regulations concerning the safety of life at sea, the prevention of collisions, the prevention, reduction and control of marine pollution, and the maintenance of communications by radio.

conform to generally accepted international regulations, procedures and practices and to take any steps which may be necessary to secure their observance.

6 A State which has clear grounds to believe that proper jurisdiction and control with respect to a ship have not been exercised may report the facts to the flag State Upon receiving such a report, the flag State shall investigate the matter and, if appropriate, take any action necessary to remedy the situation.

7 Each State shall cause an inquiry to be held by or before a suitably qualified person or persons into every marine casualty or incident of navigation on the high seas involving a ship flying its flag and causing loss of life or serious injury to nationals of another State or serious damage to ships or installations of another State

or to the marine environment.The flag State and the other State shall co-operate in the conduct of any inquiry held by that other State into any such marine casualty or incident of navigation.

Article 97 Penal jurisdiction in matters of collision or any other incident of navigation

1 In the event of a collision or any other incident of navigation concerning a ship on the high seas, involving the penal or disciplinary responsibility of the master or of any other person in the service of the ship, no penal or disciplinary proceedings may be instituted against such person except b~fore the judicial or administrative authorities either of the flag State or of the State of which such person is a national.

2 In disciplinary matters, the State which has issued a master's certificate or a certificate

of competence or licence shall alone be competent, after due legal process, to pronounce the withdrawal of such certificates, even if the holder is not a national of the State which issued them.

3 No arrest or detention of the ship, even as a measure of investigation, shall be ordered

by any authorities other than those of the flag State.

Article 98 Duty to render assistance

1 Every State shall require the master of a ship flying its flag, in so far as he can do so without serious danger to the ship, the crew or the passengers:

(a) to render assistance to any person found at sea in danger of being lost;

(b) to proceed with all possible speed to the rescue of persons in distress, if informed of their need of assistance, in so far as such action may reasonably be expected of him;

(c) after a collision, to render assistance to the other ship, its crew and its passengers and, where possible, to inform the other ship of the name of his own ship, its port of registry and the nearest port at which it will call.

2 Every coastal State shall promote the establishment, operation and maintenance of an adequate and effective search and rescue service regarding safety on and over the sea and, where circumstances so require, by way of mutual regional arrangements co-operate with neighbouring States for this purpose.

2 In the event of any doubt whether any categories of persons are to be regarded as seafarers for the purpose of this Convention, the question shall be determined by the competent authority in each country after consultation with the shipowners' and seafarers' organizations concerned.

3 For the purpose of this Convention, the term 'occupational accidents' covers accidents

to seafarers arising out of or in the course of their employment.

Article 2

1 The competent authority in each maritime country shall take the necessary measures

to ensure that occupational accidents are adequately reported and investigated, and comprehensive statistics of such accidents kept and analysed.

2 All occupational accidents shall be reported and statistics shall not be limited to fatalities or to accidents involving the ship.

3 The statistics shall record the numbers, nature, causes and effects of occupational accidents, with a clear indication of the department on board ship-for instance, deck, engine

or catering - and of the area - for instance, at sea or in port - where the accident occurred.

4 The competent authority shall undertake an investigation into the causes and circumstances of occupational accidents resulting in loss of life or serious personal injury, and such other accidents as may be specified in national laws or regulations.

Article 3

In order to provide a 'Sound basis for the prevention of accidents which are due to particular hazards of maritime employment, research shall be undertaken into general trends and into such hazards as are brought out by statistics.

3 In particular, these provisions shall cover the following matters:

(a) general and basic provisions

(b) structural features of the ship

(c) machinery

(d) special safety measures on and below deck

(e) loading and unloading equipment

(f) fire prevention and fire-fighting

(g) anchors, chains and lines

(h) dangerous cargo and ballast

(i) personal protective equipment for seafarers

referred to in Article 4, by means of adequate inspection or otherwise

2. Appropriate measures shall be taken to ensure compliance with these provisions.

3 All necessary steps shall be taken to ensure that inspection and enforcementauthorities are familiar with maritime employment and its practices

4 In order to facilitate application, copies or summaries of the provisions shall be brought

to the attention of seafarers, for instance by display in a prominent position on board ship

Article 7

Provision shall be made for the appointment, from amongst the crew of the ship, of a suitableperson or suitable persons or of a suitable committee responsible, under the Master, foraccident prevention

3 In particular, national or local joint accident prevention committees or ad hoc workingparties, on which both shipowners' and seafarers' organizations are represented, shall beestablished

2. All appropriate and practicable measures shall also be taken to bring to the attention

of seafarers information concerning particular hazards, for instance by means of officialnotices containing relevant instructions

Article 10

Members, with the assistance as appropriate of intergovernmental and other internationalorganizations, shall endeavour, in co-operation with each other, to achieve the greatestpossible measure of uniformity of other action for the prevention of occupational accidents.RATIFICATIONS

INTERNATIONAL CONVENTIONS, REQUIREMENTS ETC.

sea-2 National laws or regulations shall determine when ships are to be regarded as going ships for the purpose of this Convention.

sea-3 This Convention applies to sea-going tugs.

4 This Convention does not apply to:

(a) ships primarily propelled by sail, whether or not they are fitted with auxiliary engines; (b) ships engaged in fishing or in whaling or in similar pursuits;

(c) small vessels and vessels such as oil rigs and drilling platforms when not engaged in navigation, the decision as to which vessels are covered by this subparagraph to be taken by the competent authority in each country in consultation with the most representative organisations of shipowners and seafarers.

5 Nothing in this Convention shall be deemed to extend the scope of the Conventions referred to in the Appendix to this Convention or of the provisions contained therein.

Article 2

Each Member which ratifies this Convention undertakes:

(a) to have laws or regulations laying down, for ships registered in its territory:

(i) safety standards, including standards of competency, hours of work and manning, so

as to ensure the safety of life on board ship;

(ii) appropriate social security measures; and

(iii) shipboard conditions of employment and shipboard living arrangements, in so far as these, in the opinion of the Member, are not covered by collective agreements or laid down

by competent courts in a manner equally binding on the shipowners and seafarers concerned;

and to satisfy itself that the provisions of such laws and regulations are substantially equivalent to the Conventions or Articles of Conventions referred to in the Appendix to this Convention, in so far as the Member is not otherwise bound to give effect to the Conventions

(ii) social security measures prescribed by national laws or regulations;

(iii) shipboard conditions of employment and shipboard living arrangements prescribed by national laws or regulations, or laid down by competent courts in a manner equally binding

on the shipowners and seafarers concerned;

(c) to satisfy itself that measures for the effective control of other shipboard conditions of employment and living arrangements, where it has no effective jurisdiction, are agreed between shipowners or their organisations and seafarers' organisations constituted in accordance with the substantive provisions of the Freedom of Association and Protection of the Right to Organise Convention, 1948, and the Right to Organise and Collective Bargaining Convention, 1949;

(d) to ensure that:

(i) adequate procedures - subject to over-all supervision by the competent authority, after tripartite consultation amongst that authority and the representative organisations of shipowners and seafarers where appropriate - exist for the engagement of seafarers on ships registered in its territory and for the investigation of complaints arising in that connection;

(ii) adequate procedures - subject to over-all supervision by the competent authority, after tripartite consultation amongst that authority and the representative organisations of shipowners and seafarers where appropriate - exist for the investigation of any complaint made in connection with and, if possible, at the time of the engagement in its territory of seafarers of its own nationality on ships registered in a foreign country, and that such complaint as well as any complaint made in connection with and, if possible, at the time of the engagement in its territory of foreign seafarers on ships registered in a foreign country, is promptly reported by its competent authority to the competent authority of the country in which the ship is registered, with a copy to the Director-General of the International Labour Office;

(e) to ensure that seafarers employed on ships registered in its territory are properly qualified or trained for the duties for which they are engaged, due regard being had to the Vocational Training (Seafarers) Recommendation, 1970;

(f) to verify by inspection or other appropriate means that ships registered in its territory comply with applicable international labour Conventions in force which it has ratified, with the laws and regulations required by subparagraph (a) of this Article and, as may be appropriate under national law, with applicable collective agreements;

(g) to hold an official inquiry into any serious marine casualty involving ships registered in its territory, particularly those involving injury and/or loss of life, the final report of such inquiry normally to be made public.

Article 3

Any Member which has ratified this Convention shall, in so far as practicable, advise its nationals on the possible problems of signing on a ship registered in a State which has not ratified the Convention, until it is satisfied that standards equivalent to those fixed by this Convention are being applied Measures taken by the ratifying State to this effect shall not be

in contradiction with the principle of free movement of workers stipulated by the treaties to which the two States concerned may be parties.

Article 4

1 If a Member which nas ratified this Convention and in whose port a ship calls in the normal course of its business or for operational reasons receives a complaint or obtains evidence that the ship does not conform to the standards of this Convention, after it has come into force, it may prepare a report addressed to the government of the country in which the ship is registered, with a copy to the Director-General of the International Labour Office, and may take measures necessary to rectify any conditions on board which are clearly hazardous

to safety or health.

2 In taking such measures, the Member shall forthwith notify the nearest maritime, consular or diplomatic representative of the flag State and shall, if possible, have such representative present It shall not unreasonably detain or delay the ship.

3 For the purpose of this Article, 'complaint' means information submitted by a member

of the crew, a professional body, an association, a trade union or, generally, any person with

an interest in the safety of the ship, including an interest in safety or health hazards to its crew.

Article 5

1 This Convention is open to the ratification of Members which:

(a) are parties to the International Convention for the Safety of Life at Sea, 1960, or the International Convention for the Safety of Life at Sea, 1974, or any Convention subsequently revising these Conventions; and

(b) are parties to the International Convention on Load Lines, 1966, or any Convention subsequently revising that Convention; and

(c) are parties to, or have implemented the provisions of, the Regulations for Preventing

INTERNATIONAL CONVENTIONS, REQUIREMENTS ETC.

Collisions at Sea of 1960, or the Convention on the International Regulations for Preventing Collisions at Sea, 1972, or any Convention subsequently revising these international instruments.

2 This Convention is further open to the ratification of any Member which, on ratification, undertakes to fulfil the requirements to which ratification is made subject by paragraph 1 of this Article and which are not yet satisfied.

3 The formal ratifications of this Convention shall be communicated to the General of the International Labour Office for registration.

Director-APPENDIX

Minimum Age Convention, 1973 (No 138), or

Minimum Age (Sea) Convention (Revised), 1936 (No 58), or

Minimum Age (Sea) Convention, 1920 (No.7);

Shipowners' Liability (Sick and injured Seamen) Convention, 1936 (No 55), or

Sickness Insurance (Sea) Convention, 1936 (No 56), or

Medical Care and Sickness Benefits Convention, 1969 (No 130);

Medical Examination (Seafarers) Convention, 1946 (No 73);

Prevention of Accidents (Seafarers) Convention, 1970 (No 134) (Articles 4 and 7);

Accommodation of Crews Convention (Revised), 1949 (No 92);

Food and Catering (Ships' Crews.) Convention, 1946 (No, 68) (Article 5);

Officers' Competency Certificates Convention, 1936 (No 53) (Articles 3 and 4),*

Seamen's Articles of Agreement Convention, 1926 (No 22);

Repatriation of Seamen Convention, 1926 (No 23);

Freedom of Association and Protection of the Right to Organise Convention, 1948 (No 87); Right to Organise and Collective Bargaining Convention, 1949 (No 98).

* In cases where the established licensing system or certification structure of a State would be prejudiced by problems arising from strict adherence to the relevant standards of the Officers' Competency Certificates Convention, 1936, the principle of substantial equivalence shall be applied so that there will be no conflict with that State's established arrangements for certification.

Recommendation concerning the Prevention of Occupational Accidents to Seafarers

RECOMMENDATION: R142

Place: Geneva

Session of the Conference: 55

Date of adoption = 30:10:1970

The General Conference of the International labour Organisation,

Having been convened at Geneva by the Governing Body of the International labour Office, and having met in its Fifty-fifth Session on 14 October 1970, and

Considering that, although much is being done in a number of countries to reduce occupational accidents to seafarers, there is room for further study of such accidents and for further measures for their prevention, and that international standards embodying a relevant programme of action for the maritime sector are accordingly desirable, and

Having decided upon the adoption of certain proposals with regard to accident prevention on board ship at sea and in port, which is the fifth item on the agenda of the session, and

Having determined that these proposals shall take the form of a Recommendation supplementing the Prevention of Accidents (Seafarers) Convention, 1970, and

Noting that the following standards have been framed with the co-operation of the Governmental Maritime Consultative Organization, and that it is proposed to seek its continuing co-operation in promoting and securing the application of these standards,

Inter-adopts this thirtieth day of October of the year one thousand nine hundred and seventy, the following Recommendation, which may be cited as the Prevention of Accidents (Seafarers) Recommendation, 1970:

1 For the purpose of this Recommendation:

(a) the term seafarer covers all persons who are employed in any capacity on board a ship, other than a ship of war, ordinarily engaged in maritime navigation;

(b) the term occupational accidents covers accidents to seafarers arising out of or in the course of their employment.

2 In giving effect to paragraph 3 of Article 2 of the Prevention of Accidents (Seafarers) Convention, 1970, Members should have due regard to any international system of recording accidents to seafarers which may have been established by the International labour Organisation.

3 Subjects to be investigated in pursuance of Article 3 of the Prevention of Accidents (Seafarers) Convention, 1970, might include:

(a) working environment, such as working surfaces, layout of machinery and means of access and lighting, and methods of work;

(b) incidence of accidents in different age groups;

(c) special physiological or psychological problems created by the shipboard environment;

(d) problems arising from physical stress on board ship, in particular as consequence of increased workload;

(e) problems arising from and effects of technical developments and their influence on the composition of crews;

(f) problems arising from any human failures such as carelessness.

4 In formulating the accident prevention provisions called for by Article 4 of the Prevention of Accidents (Seafarers) Convention, 1970, Members should have due regard to any Code of Practice concerning the safety and health of seafarers which may have been published by the International Labour Office.

5 In giving effect to Article 5 of the Prevention of Accidents (Seafarers) Convention,

1970, account should be taken of Articles 7 and 11 of the Guarding of Machinery Convention,

1963 - and the corresponding provisions of the Guarding of Machinery Recommendation,

1963 - under which the obligation to ensure compliance with the requirement that machinery

in use is properly guarded, and its use without appropriate guards prevented, rests on the employer, while there is an obligation on the worker not to use machinery without the guards being in position nor to make inoperative the guards provided.

6.(1) The functions of the committees and other bodies referred to in paragraph 3 of Article

8 of the Prevention of Accidents (Seafarers) Convention, 1970, might include:

(a) the preparation of accident prevention provisions, rules and manuals;

(b) the organisation of accident prevention training and programmes;

(c) the organisation of accident prevention publicity, including films, posters, notices and brochures;

(d) the distribution of accident prevention literature and information so that it reaches seafarers on board ship.

(2) Relevant provisions or recommendations adopted by the appropriate national authorities or organisations or responsible international maritime organisations should be taken into account by those preparing texts of accident prevention measures and/or recommended practices.

7 The syllabuses of the instruction referred to in Article 9 of the Prevention of Accidents (Seafarers) Convention, 1970, should be reviewed periodically and brought up to date in the light of development in types and sizes of ships and in their equipment, as well as changes

in crewing practices, nationality, language and the organisation of work on board ship.

8 (1) There should be continuous accident prevention publicity.

(2) Such publicity might take the following forms:

(a) instructional films, film strips and shorts, for use in vocational training centres for seafarers and where possible in film programmes screened on board ship;

(b) display of safety posters on board ship;

(c) inclusion of articles on hazards of maritime employment and accident prevention measures in periodicals read by seafarers;

seafarers in accident prevention and safe working practices.

(3) The publicity should take into account that there are often seafarers of different nationalities, languages and habits on board ship.

9 (1) In giving effect to Article 10 of the Accident Prevention (Seafarers) Convention, 1970, Members should have due regard to relevant Model Codes of Safety Regulations or Codes

of Practice published by the International Labour Office and the appropriate standards of international organisations for standardisation.

(2) Members should further have regard to the need for international co-operation in the continuous promotion of action for the prevention of occupational accidents; such co- operation might take the form of:

(a) bilateral or multilateral arrangements for uniformity in accident prevention standards and safeguards;

(b) exchange of information on particular hazards affecting seafarers and on means of preventing accidents;

(c) assistance in testing of equipment and inspection according to the national regulations

of the country of registration of the ship;

(d) collaboration in the preparation and dissemination of accident prevention provisions, rules or manuals;

(e) collaboration in the production and use of training aids;

(f) joint facilities for or mutual assistance in the training of seafarers in accident prevention and safe working practices.

Cross references 1970 - Guarding of Machinery Recommendation, 1963

4.4.1 International Convention for the Safety of Life at Sea, 1974

as amended by the Protocol of 1978

Chapter I

Part C

Casualties

Regulation 21

(a) Each Administration undertakes to conduct an investigation of any casualty occurring

to any of its ships subject to the provisions of the present Convention when it judges that such

an investigation may assist in determining what changes in the present regulations may be desirable.*

(b) Each Contracting Government undertakes to supply the Organization with pertinent information concerning the findings of such investigations No reports or recommendations of the Organization based upon such information shall disclose the identity or nationality of the ships concerned or in any manner fix or imply responsibility upon any ship or person.

*Refer to the following resolutions adopted by the Organization:

Resolution A.173(ES.lV): Participation in official inquiries into marine casualties.

Resolution A.203(VII): Recommendation on the conclusion of agreements and arrangements between States on the question of access and employment of foreign seaborne salvage equipment in territorial waters.

Resolution A.322(IX): The conduct of investigations into casualties.

Resolution A.440(XI) : Exchange of information for investigations into marine casualties.

Resolution A.442(XI): Personnel and material resource needs of Administrations for the investigation

of casualties and contraventions of conventions.

Resolution A.637(16) : Co-operation in maritime casualty investigations.

Refer also to:

MSC/Circ.70/Rev.l: Questionnaire on die maritime distress system.

MSC/Circ.224: Submission of damage cards and intact stability casualty records.

MSC/Circ.388: Fire casualty records.

MSC/Circ.433: Reports on investigations into serious casualties.

MSC/Circ.539/Add.2: Reports on casualty statistics concerning fishing vessels and fishermen at sea MSC/Circ.359: Guidelines to ensure the reporting to the Organization of incidents involving dangerous goods and marine pollutants in packaged form on board ships and in port areas.

MSC/Circ.621: Guidelines for the investigation of accidents where fatigue may have been a

contributing factor.

4.4.2 International Convention on Load Lines, 1966

Article 23

(c) Each Administration undertakes to conduct an investigation of any casualty occurring

to any of its ships subject to the provisions of the present Convention when it judges that such

an investigation may assist in determining what changes in the present regulations may be desirable.

(d) Each Contracting Government undertakes to supply the Organization with pertinent information concerning the findings of such investigations No reports or recommendations of the Organization based upon such information shall disclose the identity or nationality of the ships concerned or in any manner fix or imply responsibility upon any ship or person.

4.4.3 International Convention for the Prevention of Pollution from Ships 1973, as

amended by the Protocol of 1978 (MAR POL 73n8)

Article 8

Reports on Incidents involving harmful Substances

1 A report of an incident shall be made without delay to the fullest extent possible in accordance with the provisions of Protocol I to the present Convention.

2 Each party to the Convention shall:

(a) make all arrangements necessary for an appropriate officer or agency to receive and process all reports on incidents; and

(b) notify the Organization with complete details of such arrangements for circulation to other Parties and Member States of the Organization.

3 Whenever a Party receives a report under the provisions of the present Article, that Party shall relay the report without delay to:

(a) the Administration of the ship involved; and

(b) any other State which may be affected.

4 Each party to the Convention undertakes to issue instructions to its maritime inspection vessels and aircraft and to other appropriate services, to report to its authorities any incident referred to in Protocol I to the present Convention.That Party shall, if it considers

it appropriate, report accordingly to the Organization and to any other party concerned.

Casualties to Ships

1 Each Administration undertakes to conduct an investigation of any casualty occurring

to any of its ships subject to the provisions of the Regulations if such casualty has produced

a major deleterious effect upon the marine environment.

2 Each party to the Convention undertakes to supply the Organization with information concerning the finding of such investigation, when it judges that such information may assist

in determining what changes in the present Convention might be desirable.

4.4.4 International Convention on Standards of Training, Certification and

Watchkeeping for Seafarers, 1978 - as amended in 1995

Regulation 1/5

National provisions

1 Each party shall establish processes and procedures for the impartial investigation of any reported incompetency, act or omission, that may pose a direct threat to safety of life or property at sea or to the marine environment, by the holders of certificates or endorsements issued by that Party in connection with their performance of duties related to their certificates and for the withdrawal, susp~nsion and cancellation of such certificates for such cause and for the prevention of fraud.

2 Each Party shall prescribe penalties or disciplinary measures for cases in which the provisions of its national legislation giving effect to the Convention are not complied with in respect of ships entitled to fly its flag or of seafarers duly certified by that Party.

3 In particular, such penalties or disciplinary measures shall be prescribed and enforced

in cases in which:

.1 a company or master has engaged a person not holding a certificate as

required by the Convention;

.2 a master has allowed any function or service in any capacity required by these

regulations to be performed by a person holding an appropriate certificate, to

be performed by a person not holding the required certificate, a valid dispensation or having the documentary proof required by regulation 1/10,paragraph 5; or

.3 a person has obtained by fraud or forged documents an engagement to perform

any function or serve in any capacity required by these regulations to be performed or filled by a person holding a certificate or dispensation.

4 A Party, within whose jurisdiction there is located any company which, or any person who, is believed on clear grounds to have been responsible for, or to have knowledge of, any apparent non-compliance with the Convention specified in paragraph 3, shall extend all co- operation possible to any Party which advises it of its intention to initiate proceedings under its jurisdiction.

4.4.5 International Convention for the Safety of Fishing Vessels, 1977

(TORRE MOLINOS CONVENTION)

1 Each Party shall arrange for an investigation of any casualty occurring to any of itsvessels subject to the provisions of the present Convention when it judges that such aninvestigation may assist in determining what changes in the present regulations may bedesirable

2 Each Party shall supply the Organization with pertinent information concerning thefindings of such investigations for circulation to all parties No reports or recommendations ofthe Organization based upon such information shall disclose the identity or nationality of theships concerned or in any manner fix or imply responsibility upon any ship or person

4.4.6 The Convention relating to Intervention on the High Seas in Cases of Oil

Pollution Casualties 1969, as amended by the Protocol of 1973

-(The Intervention Convention)

On 18 March 1967, the tanker Torrey Canyon ran aground near the Scilly Isles - outside UK

territorial waters - with a cargo of 119,000 tons of oil on board Many of the cargo tanks weredamaged as a result of the grounding, and by 20 March some 30,000 tons of oil had escapedinto the sea Subsequent strong winds and high seas broke the back of the vessel, so that by

27 March a further 30,0.00 tons had been released with a likelihood of even more escapinglater Therefore, in order to avoid serious pollution of the Cornish coast, the UK Governmentordered the wreck bombed so as to burn the remaining oil

The actions of the UK in bombing the Torrey Canyon were contrary to international law at the

time, and described by some as piracy The incident did, however, lead to a general review ofthe problems of pollution of the sea in international law

As a result, the Convention relating to Intervention on the High Seas in Cases of Oil PollutionCasualties was adopted by a Diplomatic Conference (convened by IMO) in November 1969for the purpose of clarifying the rights of the coastal state The intervention in the Torrey Canyon incident was subsequently justified by the International Law Commission as an act

of necessity It is this doctrine that forms the basis of the Convention The doctrine meanseffectively that it is lawful to do what would otherwise be unlawful if there is a compellingnecessity to act to save life or to protect the environment

The Convention allows parties to take such measures on the high seas as may be considerednecessary to prevent, mitigate or eliminate grave and imminent danger to their coastline orrelated interests from pollution or threat of pollution of the sea by oil

Related interests, as defined, include fishing activities, tourism and the well-being of livingmarine resources and of wildlife For the Convention to apply, these interests must be directlyaffected or threatened Hence there is a power to intervene on purely environmental grounds,

in contrast to the position regarding civil liability at common law The Convention is not limited

to tankers nor only to pollution by oil: it applies to any sea-going vessel of any typewhatsoever and any floating craft It does not apply to an installation or device engaged in theexploration and exploitation of the resources of the seabed Warships and government-ownedships on non-commercial service are also excluded

The coastal state is empowered to take action only after due consultations with appropriateinterests, including the flag state(s) of the ships(s) involved, the owners of the ship(s) orcargoes in question and where circumstances permit, independent experts appointed for this

is liable to pay compensation for any damage caused by such measures Provision is made for the settlement of disputes arising in connection with the application of the Convention The provisions of the Convention were extended by a protocol to the Convention, extending its provisions to pollution by chemical cargoes.

4.5 IMO Resolutions and circulars

4.5.1 Resolution A.847(20) Guidelines to Assist Flag States,

Annex para 7

7 FLAG STATE INVESTIGATIONS

7.1 In addition to providing qualified surveyors, the flag State should provide qualified investigators Consistent with article 94.6 and articles 217.4,5 and 6 of UNCLOS and with the provisions of the relevant IMO conventions, investigations should be carried out following a marine casualty or pollution incident The flag State should ensure that individual investigators have a working knowledge and practical experience in those subject areas pertaining to their normal duties Additionally, to assist individual investigators in performing duties outside their normal assignments, the flag State should ensure ready access to expertise in the following area S , as necessary:

.1 navigation and the Collision Regulations

.2 flag State regulations on certificates of competency

.3 causes of marine pollution

.4 interview techniques

.5 evidence gathering

.6 evaluation of the effects of the human element.

7.2 Any accident involving personal injury necessitating absence from duty of three days

or more and any deaths resulting from occupational accidents and casualties to ships of the flag State should be investigated, and the results of such investigations made public Ship casualties should be investigated and reported on in accordance with UNCLOS, relevant IMO Conventions, and the Guidelines currently being developed by IM04 Casualty investigations should be conducted by suitably qualified investigators, competent in matters relating to the casualty The report of the investigation should be forwarded to IMO together with the flag State's observations, in accordance with the Guidelines referred to above.

4 Refer to the Code for the Investigation of Marine Casualties and Incidents, adopted by the Organization by resolution A.849(20).

4.5.2 IMO Circular

MSC/Circ.827

MEPC/Circ.333

9 December 1997

REPORTS ON MARINE CASUALTIES AND INCIDENTS

Harmonized reporting procedures - Reports required under

SOlAS regulation V21 and MARPOl 73nS articles Sand 12

1 The Maritime Safety Committee, at its sixty-eighth session (28 May to 6 June 1997) and the Marine Environment Protection Committee, at its fortieth session (18 to 25 September 1997) approved an MSC/MEPC circular on Reports on marine casualties and incidents - Harmonized reporting procedures, amalgamating and harmonizing the procedures for reporting casualties to the Organization contained in existing MSC and MEPC circulars; and agreed there was a need to develop guidelines for the application of the reporting procedures (especially with regard to a uniform application of the coding systems thereof)

2 Under SOlAS regulation 1/21 and MARPOl 73/78 articles 8 and 12, each Administration undertakes to conduct an investigation into any casualty occurring to ships under its flag subject 10 those conventions and to supply the Organization with pertinent information concerning the findings of such investigations.

3 The reporting formats contained in the annexes to this circular replace the reporting forms contained in MSC/Circ.224 on Damage Cards and Intact Stability Casualty Records, MSC/Circ.388 on Fire Casualty Records, MSC/Circ.433 on Reports on Investigations into Serious Casualties, MSC/Circ.559 on Incidents Involving Dangerous Goods or Marine Pollutants in Packaged Form, MSC/Circ.621 on Fatigue and COM/Circ.70/Rev.1 on the Maritime Distress System The reporting format on Incidental Spillages of Harmful Substances of 50 Tonnes or More has been added, as such reports are considered necessary when investigating a casualty or an incident (MARPOl 73/78, articles 8 and 12); however, this does not replace the one-line entry report required by the annual mandatory report under MARPOL 73/78, article 11 (MEPC/Circ.318, Part 1).

4 For the purpose of reporting information to the Organization, vessel casualties are classified as ''very serious casualties", "serious casualties", "less serious casualties" and

"marine incidents" Administrations are requested to submit data for all "very serious casualties" and "serious casualties"*.

Where there are important lessons to be learned from "serious casualties", "less serious casualties" and "marine incidents", full investigation reports should be submitted along with the additional information indicated in annex 3.

*"Very serious casualties" are casualties to ships which involve total loss of the ship, loss of life, or severe pollution, the definition of which, as agreed by the Marine Environment Protection Committee at its thirty-seventh session (MEPC 37/22, paragraph 5.8), is as follows:

"Severe pollution" is a case of pollution which, as evaluated by the coastal State(s) affected or the flag State, as appropriate, produces a major deleterious effect upon the environment, or which would have produced such an effect without preventive action.

"Serious casualties" are casualties to ships which do not qualify as "very seriouscasualties" and which involve:

- a fire, explosion, collision, 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, extensiveaccommodation damage, etc.; or

- pollution (regardless of quantity); and/or

- a breakdown necessitating towage or shore assistance

"Less serious casualties" are casualties to ships which do not qualify as ''very seriouscasualties" or "serious casualties" and for the purpose of recording useful informationalso include "marine incidents"

5. Administrations are urged to submit data as indicated below.

Information to be submitted per casualty class

Annexes Tobe provided Tobe provided May be May be

2 and 3 at the end at the end provided if provided if

of the attached of the of the there are there are report format, investigation investigation important important

annexes

investigation at the end provided if provided if provided if report of the there are there are there are

learned learned learned

Very serious casualty

• preliminary information as indicated in Annex 1*

• information as indicated in Annexes 2 and 3, as well as other relevant annexes

• a full investigation report in all cases

Serious casualty

• preliminary information as indicated in Annex 1*

• information as indicated in Annexes 2 and 3, as well as other relevant annexes

• a full investigation report only in cases of important lessons to be learnt regarding IMO regulations

(* To be submitted within six months of the casualty date unless complete information

is submitted within this time limit.)

Less serious casualty and marine incident

• Information as indicated in Annexes 1, 2 and 3, as well as other relevant annexes, only in cases of important lessons to be learnt regarding IMO regulations

• a full investigation report only in cases of important lessons to be learnt regarding IMO regulations.

Information to be submitted for casualties/incidents as indicated below.

Information from casualties involving dangerous

goods on marine pollutants in packaged form on

board ships and in port areas - Annex 4

Damage cards and intact stability records - Annex 5

Fatigue as a contributory cause to maritime

accidents - Fatigue factors data compilation sheet - Annex 8

Incidental spillage of liquids of 50 tonnes or more - Annex 9

List of Annexes

ANNEX 1: SHIP IDENTIFICATION AND PARTICULARS

Indicates the information to be submitted in all casualty reports.

ANNEX 2: DATAFOR VERY SERIOUS AND SERIOUS CASUALTIES

Indicates information to be supplied on "very serious" and "serious" casualties.

ANNEX 3: SUPPLEMENTARY INFORMATION ON VERY SERIOUS

CASUALTIES AND SERIOUS CASUALTIES Additional information required for "very serious casualties" and

"serious" casualties.

GOODS OR MARINE POLLUTANTS IN PACKAGED FORM ON BOARD SHIPS AND IN PORT AREAS

This form may be applicable for marine casualties as defined as well as marine incidents.

ANNEX 5: DAMAGE CARDS AND INTACT STABILITY CASUALTY RECORDS

This form may apply to "very serious" and "serious" casualties.

ANNEX 6: FIRE CASUALTY RECORD

This form may apply to "very serious" and "serious" casualties.

ANNEX 7: QUESTIONNAIRE RELATED TO THE MARITIME DISTRESS

SYSTEM This form may apply to "very serious" and "serious" casualties.

ANNEX 8: FATIGUEAS A CONTRIBUTORY CAUSE TO MARITIME ACCIDENTS

_ FATIGUE FACTORS DATACOMPILATION SHEET This form will apply where fatigue is deemed to be a contributory factor

in the casualty.

ANNEX 9: INCIDENTAL SPILLAGE OF HARMFUL SUBSTANCES OF 50

TONNES OR MORE This form relates to incidents involving harmful substances The report

is considered necessary when investigating a casualty or an incident (MARPOL 73/78, articles 8 and 12), however this does not replace the one-line entry report required by the annual mandatory report under MARPOL 73/78, article 11 (MEPC/Circ.318, Part 1).

ANNEX 1

IMO MARINE CASUALTY AND INCIDENT REPORT

SHIP IDENTIFICATION AND PARTICULARS

Administrations are urged to supply the ship identification information listed in this annex for all marine casualty reports submitted to the Organization.

.4 Other Liquids (non-flammable) Tanker

.5 Bulk Dry (general, ore) Carrier

.6 Bulk Dry/Oil Carrier

.7 Self-Discharging Bulk Dry Carrier

.8 Other Bulk Dry (cement, woodchips, urea and other specialized) Carriers 9 General Cargo Ship