incident/accident investigation safety today definition ships in service training material 2009

Incident/Accident Investigation

Safety todayDefinition

Ships in Service Training Material

2009

EventsNon

Events

Ships in Service Training Material A-M CHAUVEL

Ships in Service Training Material A-M CHAUVEL

EventsNon

Events

Ships in Service Training Material A-M CHAUVEL

Events

Unhappiness

Happiness

Indifference

Ships in Service Training Material A-M CHAUVEL

Events

Distress

Stress

Eustress

Ships in Service Training Material A-M CHAUVEL

Events

Unexpected

Predictable

HazardsDangers

In any System Risks Exist

PotentialBreaches in the

System

OperativeProtectiveMeasures

Ships in Service Training Material A-M CHAUVEL

UnwantedEvent

InoperativeProtectiveMeasures

HazardsDanger

An Unwanted Event may occur

Ships in Service Training Material A-M CHAUVEL

Breaches in theSystem

UnwantedEvent

CausesCauses ConsequencesConsequences

SocialLoss of livesLoss of jobsEnvironmentalAir pollutionWater & Land pollutionEconomicLoss of the shipCargo damagesShip damagedShip detentionFinancial lossesInsurance premiumCompany imageBankruptcy

ManHuman ErrorsPhysical ConditionsQualificationsMachinesTools EquipmentsMaterials & FurnitureMethods & ProceduresManagementLeadership, commandmentMarine environmentWeather

IncidentsFire ExplosionAct of piracyEquipment failuresShip collision…

and / or

AccidentsPersonnel InjuryPersonnel illness

UndesiredUndesiredEventEvent

From Causes to Consequences

Ships in Service Training Material A-M CHAUVEL

CausesCauses ConsequencesConsequencesUndesiredUndesiredEventEvent

Risk Analysis

Incident / AccidentInvestigation

Risk Assessment

Risk Management

Ships in Service Training Material A-M CHAUVEL

Incident / AccidentInvestigation

Today the training session covers

Introduction

Ships in Service Training Material

New technology and management concepts introduced into our complex environment including safety and environmental issues.

We are expected to address safety and environmental issues systematically with more responsibility and transparency. Incident/accident investigation is at the core of risk management.

Ships in Service Training Material

Introduction

A-M CHAUVEL

In a safety and pollution conscious world,way we operate is constantly changing.

Ships in Service Training Material

We cannot work in a safe, risk free environment if we don’t understand existing dangers and take precautions to prevent them.

Investigating uses first hand experience to learn/share and get closer to incident free environment. Finding facts during investigation is not enough - Aim is to find the root causes.

S. ISIK

Introduction

Ships in Service Training Material

Finding causes of incidents is not simple - causes can be complex with many contributory factors.

It is said that more than ten contributory factors coming together at the same time causes serious incidents.

To improve safety, it’s not necessary to remove all of the contributory factors. Sometime one is enough.

A-M CHAUVEL

Introduction

Ships in Service Training Material

it is easy to conclude that the cause is due to “human error” a term much debated, because all incidents are caused by human errors.

Investigator should have the skill : - not to blame, and - be impartial to opinions.

S. ISIK

IntroductionFind the root causes,

Incident/Accident Investigation

Some Definitions

Ships in Service Training Material

Sources of the Definitions

Ships in Service Training Material

AMSA = Australian Maritime Safety Agency

HSE = Health and Safety Executive UK Government

IMO Res A849(20) = International Maritime Organisation Resolution A849(20)

OCIMF = Oil Companies International Marine Forum - Marine injury reporting guidelines a ship or ships.

S. ISIK

Source

An undesired event, which could have resulted in harm to a person and / or property damage, but was avoided by good luck. [HSE]

Definitions

Ships in Service Training Material S. ISIK

An event or sequence of events which did not result in an injury but which, under slightly different conditions, could have done so. [OCIMF]

Near Miss

Ships in Service Training Material

An incident that could have caused:

- The death - Serious injury or - Incapacity of a person but which did not have that outcome. [AMSA].

S. ISIK

DefinitionsDangerous occurrence

Definitions

Ships in Service Training Material

An undesired event that causes or has the potential to cause :

- Harm to people- Damage to property- Loss to an operation. [AMSA]

An unforeseen or unexpected event which may have the potential to become an accident but in which injury to personnel or damage to ship or to the environment does not materialised or remains minor. [IACS]

S. ISIK

Incident

Definitions

Ships in Service Training Material

An occurrence or event being caused by, or in connection with, the operations of a ship by which the ship or any person is imperilled, or as a result of which serious damage to the ship or structure or the environment might be caused. [IMO Res A849(20)]

S. ISIK

Marine incident

Definitions

Ships in Service Training Material

An undesired event which results in harm to a person and / or property damage. [HSE]

An unintended event involving fatality, injury, ship loss or damage, other property loss, damage or environmental damage. [IACS]

S. ISIK

Accident

Definitions

Ships in Service Training Material

- Fracture, dislocation, amputation, loss of sight, penetration of eye including chemical or hot metal burn, electric shock or burn leading to unconsciousness.

- 24 hr stay in hospital and / or requiring resuscitation, heat induced illness, asphyxia, loss of consciousness or illness requiring medical treatment from inhalation, ingestion or absorption of a chemical / biological agent or toxin. [HSE]

S. ISIK

Major accident (MAJ) Classification

Definitions

Ships in Service Training Material

An accident connected with work, which results in the death of an employee or self-employed person or a member of the public. [HSE]

S. ISIK

Fatal accident (FTL)

Definitions

Ships in Service Training Material

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

S. ISIK

Marine casualty

Definitions

Ships in Service Training Material

Means a casualty which does not qualify as a very serious casualty and which involves :

- A fire, explosion, grounding, contact, heavy weather damage, ice damage, hull cracking or suspected hull defect, etc…, resulting in :

- Structural damage rendering the ship unseaworthy, such as penetration of the hull underwater, - Immobilization of main engines,- Extensive accommodation damage etc., or- Pollution (regardless of quantity), or - Breakdown necessitating towage or shore assistance [IMO Res A849(20)]

S. ISIK

Serious casualty

Definitions

Ships in Service Training Material

This is any sign or symptom of physical damage or impairment to any part of the body directly resulting from an incident, regardless of the length of time between the incident and the appearance of the injury. [OCIMF]

S. ISIK

Serious Injury

Means an injury which is sustained by a person in a casualty resulting in incapacitation for more than 72 hours commencing within seven days from the date of injury. [IMO Res A849(20)]

Work Injury

Definitions

Ships in Service Training Material

Means a casualty to a ship which involves :

- The total loss of the ship. - Loss of life. - Severe pollution. [IMO Res A849(20)]

S. ISIK

Very serious casualty

Definitions

Ships in Service Training Material

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

S. ISIK

Investigation of Marine Casualty or Incident

Ships in Service Training Material A-M CHAUVEL

Category

0- Incident

1- Accident2- Major Accident3- Critical Accident

4- Disaster5- Major Disaster

MaterialDamages

Less than 300 K€

Between 0,3 and 3 M€Between 3 and 30 M€Between 30 and 300 M€

Between 300 and 3 000 M€ More than 3 000 M€

HumanInjuries

No Injury

1 injure 1 to 9 deaths 10 to 99 deaths

100 to 999 deaths1 000 deaths or more

DefinitionsIn French law: