5 Accident Investigation Process Rev

World Maritime University
Seminar on 1
Maritime Casualty
Investigations
Accident Investigation Process

• Data analysis
• Time line
• Event and causal factor charts
• Analytical follow-up 2
Barrier analysis

• Developing a timeline

• What is a timeline?
• How to put together the evidence in order to
enable the analysis
• Sequence of events (narrative) 4

• How to generate a timeline?

• Issues to be considered
The vessel, sometimes to go back as far as the
ship design and construction stages
5
Manning issues, including crew conditions
before the accident
Company policies and procedures
Local conditions.

• How to generate a timeline?

• Team work
Add bits of information together piece by piece
Identify areas of further investigation 6
o Information gaps
o Lacking evidence
o Conflicting information
o Missing pieces in the information chain

• Principles of establishing a timeline

• Each event should describe an occurrence or
happening (tank lid ruptured) and not a
condition (tank lid had leak in it)
7
• Each event description should be a short
sentence (ship altered course to port)
• Events should be precisely described (mate
turned valve clockwise) not (mate shut tank)
• Each event should be a single discreet
occurrence (ship grounded)

• Principles of establishing a timeline

• Each event should be quantified where
possible (Tank lost 3,000 tonnes of oil)
• Each event block should contain date and time 8
if possible
• Each event should follow sequentially from the
event and conditions preceding it.

• Drawing a timeline
04:00 06:00 06:14 06:15 9
Visible flames
Non critical engine room Several fire alarm Smoke spreading
on engine room
alarm on the bridge signals around in the ship
closed-circuit TV
Master
Master Master Master C/O, C/E, 1st engineer
Chief Officer Master main engine pitch
on the bridge to checked fire alarm asked watchkeeping 2nd mate, 3rd mate
on watch noticed alarm control to ‘0’ ,
relieve C/O for shower panel IR for investigation to the bridge
general alarm
2nd engineer
2nd engineer
noticed alarm and
arrived in the
left for the engine
engine room
room

• Drawing a timeline
Time Event Bridge Engine room Helicopter Deck
04:00 Chief Officer

on watch
Master 10
06:00 on the bridge to
relieve C/O for shower
Non critical engine room

06:14 alarm on the bridge
Master 2nd engineer

noticed alarm noticed alarm and
left for the engine
room
Master
Several fire alarm
checked fire alarm
signals
panel
Visible flames Master

on engine room asked watchkeeping
closed-circuit TV IR for investigation

• Case study
• Part 4 – Timeline
11

• Time line
• First step
• Is a tool to coordinate the investigation
• Answers questions as to who, where and what 12
• Does not answer the questions why and how

• Identifying causes
• Sequence of events is not enough
• Starting point
• Further investigation into the preconditions for 13
significant events leading to the accident

• How can a timeline be used to

identify causes?
• Organize the accident data
• Guide the investigation
14
• Validate and confirm the true accident
sequence
• Identify and validate factual findings, probable
causes and contributing factors
• Simplify the organization of the investigation
report
• Illustrate the accident sequence in the
investigation report

Accidents Involve
• A sequence of EVENTS
The Sequence has a beginning and an end
• Events are affected by CONDITIONS that exist 15
at the time
• The EVENTS and CONDITIONS result in
unintentional harm
Courtesy by NTSB

• Events and causes

• Each event has at least one cause
• Often a combination of causes (sometimes in
a total parallel story) 16
• Example: Herald of Free Enterprise

EVENTS Accident
17
Courtesy by NTSB

Events and Causal Factors Analysis

• Organizes the accident data
• Develops the investigation
• Validates the accident sequence 18
• Validates logic of findings, causes, &

contributing factors
• Helps organize the accident report
Courtesy by NTSB

Causal factors
CONDITIONS
EVENTS 19
Courtesy by NTSB

Criteria for Event Descriptions

• Events describe an occurrence, not a condition
• Events should be described with ONE subject
and ONE active verb 20
• An event should be precisely described
• Events should describe only one discrete
occurrence.
Courtesy by NTSB

Criteria for Events Description

(con’t)
• Events should be quantified when possible
• Events should be based on valid evidence 21
• Events should range from the beginning to the

end of an accident sequence.
• Each event should be derived from the event
preceding it.
Courtesy by NTSB

Event No.1 Event No.2 Event No.3 Condition

22
Start-up Tank Tank

Compressor at
Switch Pressure
Runs 300 psi
Activates Increases
Courtesy by NTSB

Understanding Conditions
• Conditions express a state of being
• Conditions result from events
• Conditions are a shortcut in E&CF charting 23
• Note: Events leading to them may not be

depicted.
Start-up Tank Tank

Compressor at
Switch Pressure
Runs 300 psi
Activates Increases
Courtesy by NTSB

Causal Factors Relationship
Management
Always ask
why an 24
unwanted Supervision
condition was
allowed to exist Specific
condition
Event Event Event Accident
Courtesy by NTSB

Events & Causal Factors Diagram
1. All events are enclosed in rectangles

25
2. All conditions are enclosed in ovals
3. All events are connected to the

preceding and succeeding event
by arrows.
Courtesy by NTSB


(Cont.)
4. All conditions are connected to other
conditions and/or events by dashed 26
arrows.
5. Presumptive events or conditions are

shown by dashed rectangles or ovals.
Courtesy by NTSB


(Continued)
6. “Primary” sequences of events are depicted
in a straight horizontal line with the relative
27
time sequence from left to right.
1 2 3
7. Secondary event sequences, contributing

factors, and systemic factors are depicted
above or below the primary sequencing
line.
Courtesy by NTSB

• Events and causal factor charts

Guidelines
Are active (e.g. crane strikes building)

28
Should be stated using one noun and one active verb
Should be quantified as much as possible and where

Events applicable (e. g.,the worker fell 8 meters rather than
the worker fell off the platform)
Should indicate the date and time of the event, when
they are known
Should be derived from the event or events and
conditions immediately preceding it.

Events and Causal Factor Charts

Guidelines
Are passive (e.g. fog in the area) 29
Describe states or circumstances rather than

occurrences or events
Con-
As practical, should be quantified
ditions
Should indicate date and time if practical/applicable
Are associated with the corresponding event.

• Events and Causal Factor Charts
Guidelines
30
Primary
Encompasses the main events of the accident and
Events
those that form the main line of the chart.
Sequence
Secondary Encompasses the events that are secondary or

Events contributing events and those that form the
Sequence secondary line of the chart.

• Symbols used in event and causal

factor charts
Presumed Condition 31
Condition
Presumed Event Event Accident


Condition
Condition 32
Secondary event sequence
Secondary Secondary
event event
Primary event sequence
Primary Primary Primary Primary

Accident
event event event event

33

MECHANIC MECHANIC MECHANIC MECHANIC 34

LOOSENS JACKS CAR REMOVES REMOVES
LUG NUTS LUG NUTS FLAT TIRE
1310 1312 1313 1314
7/27/00 7/27/00 7/27/00 7/27/00
Courtesy by NTSB

CONDITION
35
CONDITION CONDITION CONDITION
PRIMARY PRIMARY PRIMARY PRIMARY

ACCIDENT
EVENT EVENT EVENT EVENT
Courtesy by NTSB

CONDITION
CONDITION
PRIMARY EVENT PRIMARY EVENT

PRIMARY EVENT
SHIP 1 SHIP 1
SHIP 1 36
COLLISION
PRIMARY EVENT PRIMARY EVENT

PRIMARY EVENT
SHIP 2 SHIP 2 SHIP 2
CONDITION
CONDITION
Courtesy by NTSB

SECONDARY SECONDARY
EVENT EVENT CONDITION 37
PRIMARY PRIMARY PRIMARY PRIMARY

EVENT EVENT EVENT EVENT ACCIDENT
Courtesy by NTSB

Causal Factors Analysis

• Begin early
• Use guidelines
• Key on accident 38
• Proceed logically
• Use easily updated format (“yellow stickies”)
Courtesy by NTSB

39
Courtesy by NTSB

40
Courtesy by NTSB

Causal Factors Analysis

(Continued)
• Use time line
• Use multiple lines 41
• Make appropriate length

• Correlate analyses
• Place legends on charts
Courtesy by NTSB

EXAMPLE
• The Epic Saga of the Boy and the Truck
42
Courtesy by NTSB

• Scenario
• Ajax Construction Company was awarded a contract to
build a condominium on a hill overlooking the city.
Prior to initiation of the project, a comprehensive safety
program was developed covering all aspects of the 43
project. Construction activities began on Monday,
October 4, 1995, and proceeded without incident
through Friday, October 8, 1995, at which time the
project was shut down for the weekend. At that time,
several company vehicles, including a 2-1/2-ton dump
truck, were parked at the construction site. On
Saturday, October 9, 1995, a nine-year-old boy, who
lives four blocks from the construction site, climbed the
hill and began exploring the project site.
Courtesy by NTSB

• Upon finding the large dump truck unlocked, he climbed
into the cab and began playing with the vehicle
controls. He apparently released the emergency brake
and the truck began to roll down the hill. The truck
rapidly picked up speed. The boy was afraid to jump
out and did not know how to apply the brakes. The 44
truck crashed into a parked auto at the bottom of the
hill. The truck remained upright, but the boy suffered
serious cuts and lacerations and a broken leg. The
resultant investigation revealed that, although the
safety program specified that unattended vehicles
would be locked and the wheels chocked, there was no
verification that these rules had been communicated to
the drivers.
Courtesy by NTSB

Events
45
Ajax
Ajax shuts 9-yr old
Initiates Driver parks
down for boy climbs
Hilltop truck on hill
weekend hill
Project
Courtesy by NTSB

Truck rolls
down hill
46
Boy Boy
Boy enters
manipulates releases
truck cab
vehicle brake brake
Boy stays
in truck
Courtesy by NTSB

47
Truck Boy suffers

crashes into serious
parked auto injury
Courtesy by NTSB

Conditions
Ajax
Ajax shuts 9-yr old
Initiates Driver parks 48
down for boy climbs
Hilltop truck on hill
weekend hill
Project
Supervision
NOTE: LTA = Less Than Adequate
?
of boy LTA
Courtesy by NTSB

Wheels not
?
Truck not ?
chocked
locked
Truck rolls
down hill
49
Boy Boy
Boy enters
truck cab
vehicle brake brake
Boy stays
in truck
Afraid to
Courtesy by NTSB ?
jump

Rules not
communicated Company rules
to drivers World Maritime University
req’d trucks be locked
& chocked
?
Truck not
locked Wheels not
?
chocked Truck rolls
down hill 50
Boy Boy
Boy enters
truck cab
vehicle brake brake
Boy stays
in truck
Afraid to
Courtesy by NTSB jump

Truck Boy suffers

crashes into serious
51
parked auto injury
Boy could
not control Did not
truck know
how
Courtesy by NTSB

• Case study
• Part 5 – Event and causal factor chart
52

• What to do with event and causal

factor charts?
53
B
A Safety
R Critical
Danger /
R Operation /
Hazard
I System
E
R

• How do we know our barriers are

functioning
BARRIERS
54
D
R
S
E
K
D
I
G
L
P B E
L
V I U D
Ship E
T L O
D Accident
S O Y F
T S A
C
I
R
R
E
W
W
A
Y

• Barrier analysis
55

• Step 1
Identify the hazard and the target. Record them at
the top of the worksheet.
• Step 2
Identify each barrier. Record them in column one. 56
• Step 3
Identify how the barrier performed (What was the
barrier’s purpose? Was the barrier in place or not in
place? Did the barrier fail? Was the barrier used if it
was in place?) Record the findings in column two.
• Step 4
Identify and consider probable causes of the barrier
failure. Record the findings in column three.
• Step 5
Evaluate the consequences of the failure in this
accident. Record your conclusions in column four.

• Worksheet
Hazard: Target:
57
•What were the •How did each •Why did the •How did the
barriers? barrier perform? barrier fail? barrier affect the
accident?

Hazard: Lack of oxygen in cargo

Target: Tank washing AB
tank
58
•What were the •How did each •Why did the •How did the
barriers? barrier perform? barrier fail? barrier affect
the accident?
No tank entering Breathing AB man was new AB man entered

was allowed apparatus was on ship and the tank without
without proper not used unaware of this proper protection
Breathing requirement and suffocated.
apparatus

• Advantages
Easy to use
Efficient 59
• Disadvantages
Basic tool
Not for complex systems
Further evaluation has to be done with other
tools

• TRIPOD
Inspect & Control
General Failure
Types (GFT) 60
Identify &
Confirm Minimise
GFT
Defences
Hazards
Accidents,
Incidents,
Unsafe acts
Losses
Learn from Inspect & improve Train & motivate

• TRIPOD
• Control the controllable
• Focus on latent rather than active conditions
• Accidents are reduced if the environment 61
offers suitable working conditions
• Individuals can still fail

• TRIPOD
• 11 Basic Risk Factors
No. Basic Risk Abbr. Definition
Factor
1 Design DE Ergonomically poor design of tools or equipment 62
(user-unfriendly)
2 Tools and TE Poor quality, condition, suitability or availability of
Equipment materials, tools, equipment and components
3 Maintenance MM No or inadequate performance of maintenance tasks
Management and repairs
4 Housekeeping HK No or insufficient attention given to keeping the
work floor clean or tidied up
5 Error enforcing EC Unsuitable physical performance of maintenance
Conditions tasks and repairs
6 Procedures PR Insufficient quality or availability of procedures,
guidelines, instructions and manuals (specifications,
“paperwork”, use in practice)

• TRIPOD
No. Basic Risk Abbr. Definition
Factor
7 Training TR No or insufficient competence among employees
(not sufficiently suited/inadequately trained)
8 Communication CO No or ineffective communication between the
63
various sites, departments or employees of a
company or with the official bodies
9 Incompatible IG The situation in which employees must choose
Goals between optimal working methods according to the
established rules on one hand, and the pursuit of
production, financial, political, social or individual
goals on the other
10 Organisation OR Shortcomings in the organisation’s structure,
organisation’s philosophy, organizational processes
or management strategies, resulting in inadequate
or ineffective management of the company
11 Defences DF No or insufficient protection of people, material and
(Barriers) environment against the consequences of the
operational disturbances

• TRIPOD
Latent Failure Active
Precondition
(BRF) Failure
64
HAZARD
Barrier EVENT
TARGET

• TRIPOD
• Event:
An event is the release of/exposure to a hazard
directed against a target (e.g. AB damages his
foot with a heavy tool). 65
• Hazard:
A hazard is a substance, energy, condition,
other source directed against a target with a
potential to harm or threaten it (e.g. a heavy
tool that has to be lifted by an AB).
• Target:
A target is something that can be
harmed/threatened by a hazard/an event (e.g.
an AB supposed to move the heavy tool).

• Case study
• Part 6 – Barrier analysis
66

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World Maritime University

Accident Investigation Process

World Maritime University

World Maritime University

World Maritime University

World Maritime University

• How to generate a timeline?

World Maritime University

• How to generate a timeline?

World Maritime University

• Principles of establishing a timeline

World Maritime University

• Principles of establishing a timeline

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04:00 06:00 06:14 06:15 9

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04:00 Chief Officer

Non critical engine room

Master 2nd engineer

Visible flames Master

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• Does not answer the questions why and how

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• How can a timeline be used to

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• Events and causes

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Events and Causal Factors Analysis

• Validates logic of findings, causes, &

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Criteria for Event Descriptions

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Criteria for Events Description

• Events should range from the beginning to the

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Event No.1 Event No.2 Event No.3 Condition

Start-up Tank Tank

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• Note: Events leading to them may not be

Start-up Tank Tank

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Causal Factors Relationship

Event Event Event Accident

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Events & Causal Factors Diagram

1. All events are enclosed in rectangles

3. All events are connected to the

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Events & Causal Factors Diagram

5. Presumptive events or conditions are

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Events & Causal Factors Diagram

7. Secondary event sequences, contributing

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• Events and causal factor charts