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Investigating accidents gives insight to avoiding them in the future

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Unfortunately, the beginning of 2016 has brought an unusual number of yachts lost. Accidents happen, but it is important to determine what happened. Furthermore, we must determine if a repeat accident can be prevented.

As we all know, yachts operate in a highly dynamic environment; frequently the people onboard follow a set routine of work disrupted only by arrival at, working in, and sailing from port. This is an existence that involves living in the place of work for prolonged periods of time. It creates a unique form of working life and it almost certainly increases the risk of human error.

Historically, the international maritime community has approached safety from a predominantly technical perspective. The conventional wisdom has been to apply engineering and technological solutions to promote safety and to minimize the consequences of marine casualties and incidents.

Accordingly, safety standards have primarily addressed ship design and equipment requirements. Despite these technical innovations, significant marine casualties and incidents have continued to occur.

Analyses of marine casualties and incidents that have occurred over the past 30 years have prompted the international maritime community and the various safety regimes concerned to evolve from an approach which focuses on technical requirements for ship design and equipment to one that seeks to recognize and more fully address the role of human factors in maritime safety within the entire industry.

These general analyses have indicated that given the involvement of the human in all aspects of marine endeavors, including design, construction, management, operations, and maintenance, almost all marine casualties and incidents involve human factors. The development of the International Safety Management (ISM) Code is a prime example of this shift in thinking.

One way our community has sought to address the contribution of the human factor to marine casualties and incidents has been to emphasize the proper training and certification of crews.

The development of the Standards of Training, Certification and Watchkeeping (STCW) Code was an initiative to establish a minimum international standard. It has become increasingly clear, however, that training is only one aspect of the human factor.

There are other factors, which contribute to marine casualties, and incidents, which must be understood, investigated and addressed. These factors include communication, competence, culture, experience, fatigue, health, situational awareness, stress, and working conditions.

It has been recognized that there is a critical need for guidance for accident investigators. It will help them to identify specific human factors, which have contributed to marine casualties and incidents. There is also a need to provide practical information on techniques and procedures for the systematic collection and analysis of information on human factors during investigations.

In response to this need, the International Maritime Organization (IMO) developed a series of guidelines to provide an international framework from which to standardize such investigations. They include a list of topics, which should be considered by investigators, and procedures for recording and reporting the results.

There are six general topics to be covered by an investigator. They are People Factors, Ship Factors, Working and Living Conditions, Organization on Board, Shoreside Management and External Influences and Environment.

People factors are seen as the most critical of information areas. Investigators will address areas of ability, skills, and knowledge (outcome of training and experience); personality (mental condition, emotional state); physical condition (medical fitness, drugs and alcohol, fatigue); activities prior to accident/occurrence; assigned duties at time of accident/occurrence; actual behavior at time of accident/occurrence; and attitude.

The organization onboard will investigate the division of tasks and responsibilities; composition of the crew (nationality/competence); manning level; workload/complexity of tasks; working hours/rest hours; procedures and standing orders; communication (internal and external); on-board management and supervision; organization of on-board training and drills; teamwork, including resource management; and planning (voyages, maintenance, etc.)

Another area of concern for investigators is the working and living conditions on board. This includes the level of automation; ergonomic design of working, living and recreation areas and equipment; adequacy of living conditions; opportunities for recreation; adequacy of food; and level of vessel motion, vibrations, heat, and noise.

Ship factors that have an impact on an investigation include the yacht’s design, state of maintenance, equipment (availability, reliability), and trading certificates.

If the yacht is managed from a shoreside office, did any of the following areas have an affect on the accident: policy on recruitment, safety policy and philosophy (culture, attitude and trust), management commitment to safety, scheduling of leave periods, general management policy, voyage scheduling, contractual and/or industrial arrangements and agreements, assignment of duties, and ship-shore communication.

Other external influences and environment that may have affected the incident will be addressed as well. These include weather and sea conditions, port and transit conditions (Vessel Traffic Separation (VTS), pilots, etc), traffic density, ice conditions, organizations representing owners and crew, regulations, and surveys and inspections (international, national, port, classification societies, etc.)

Once facts are collected, they need to be analyzed to help establish the sequence of events in the occurrence, and to draw conclusions about safety deficiencies uncovered by the investigation.

Analysis is a disciplined activity that employs logic and reasoning to build a bridge between the factual information and the conclusions.

The ultimate goal of a marine safety investigation is to advance safety and protection of the environment. In the context of this IMO resolution, identifying safety deficiencies through a systematic investigation of marine casualties and incidents, and then recommending or effecting change in the maritime system to correct these deficiencies achieves this goal.

Capt. Jake DesVergers currently serves as Chief Surveyor for the International Yacht Bureau (IYB), a recognized organization that provides flag-state inspection services to private and commercial yachts on behalf of several flag-state administrations. A deck officer graduate of the US Merchant Marine Academy at Kings Point, he previously sailed as Master on merchant ships, acted as Designated Person for a shipping company, and served as regional manager for an international classification society. Contact him at 954-596-2728 or www.yachtbureau.org

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2 thoughts on “Investigating accidents gives insight to avoiding them in the future

  1. Capt. Robert Wiltz

    Another factor, which must be realized AND absorbed, is interpersonal respect. This quality-of-life standard can significantly increase a positive response in emergency situations. A seasoned Captain understands this, and a crew worth their jobs will learn it fast. Respect adds to communication, will, drive, and physical energy. Interpersonal respect and proper arbitration of petty disagreement, coupled with an open and unbiased intolerance for dramatic behavior has gone a long way with the crews I have chosen to serve with and/or command. The bridge must, first and foremost, create a pleasant environment for crew. That is the position of a true leader.

  2. Duncan Warner

    Excellent article, post mortem investigation after the accident and implementing changes to prevent further accidents is incredibly important. The recent sentencing of Cpt Fossi brings back the reality that we are accountable, this in turn fosters a strong culture of safety on the yacht, from the coxswain of the dingy to myself on the bridge.

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