Beruflich Dokumente
Kultur Dokumente
1
Introduction and Background to Accident Investigation
Learning Outcomes:
Discuss the international background to marine accident investigation, its stakeholders and the influence of current legislation and
regulations
Identify relevant marine accident legislation and regulations
Evaluate the difference between an investigation for
safety purposes and enforcement action leading to
prosecution
2
The Common Causes of Marine Accidents
Learning Outcomes
What is an accident?
Accident causes
Technical (e.g mechanical, lack of maintenance)
Operational (e.g navigation, cargo stowage)
Human factors
Stress
Fatigue
3
First Principles of Marine Accident Investigation
Learning Outcomes
4
Practical Preparation for the Investigation
Learning Outcomes
5
Investigation Protocol
Learning Outcomes
Describe how to set up an investigation ensuring data collection and relationships with stakeholders are not compromised
Evaluate the benefits of using checklists for data and evidence collection
Establishing collection of data protocol with stakeholders and availability of information and personnel – use of checklists
Establishing the culture surrounding the accident
Visit the site of the accident and other locations
Setting the scene for the investigation – initial meetings with selected stakeholders
Ensure a clear understanding of the investigation process
Making clear the investigators approach/powers and competencies
Security of the scene, including media management policy
Learning Outcomes
Conduct a risk assessment (including a dynamic risk assessment), identifying all key risk factors
Discuss how to ensure the investigation is handled sensitively with regards to victims and families
Identify the tools, priorities and hazards involved in carrying out a safety investigation
7
Data Collection
Learning Outcomes
8
Analysis of Data
Learning Outcomes
Definitions
Defence, event, unsafe act, unsafe condition, underlying conditions
Establishing the sequence of events and sequence of events diagram
Significant events and underlying factors
Root cause analysis
Kletz’s view: effort expended versus actual
importance
Organisational and management (O&M) factors
Investigating for O&M factors
Filters in respect of O&M factors
O&M Factors and the four Ps: philosophy, policy, procedures and practices
Questions to ask when considering O&M factors
Early issues and the need for early communication of safety issues
Drafting a safety communication
Risk assessments in safety investigation analysis
The risk equation
Risk matrix and ALARP (as low as reasonably practicable)
The risk paradigm
Drawing conclusions
Types of incident analysis: fire, navigation, cargo and occupational/personnel accidents, structural failures, stability and
+44 (0)20 7017 4483 www.lloydsmaritimeacademy.com/minv safetyandenvironment@knect365.com
maintenance issues
9
The Investigation Report
Learning Outcomes
10
Post-Publication of a Marine Accident Report
Learning Outcomes
Describe how to set up a press conference and deal directly with the media
Define the court process as it applies to marine accidents
Discuss the implications of public inquiries
Write a ‘lessons learned’ report
Follow-up
Monitoring action plans
Public and media attention
Hosting press conferences
Court proceedings for investigators
Court process
Expert witness evidence
Public inquiries and implications
Compiling lessons learned reports
11
A Mock Marine Accident Investigation and Report
Learning Outcomes
Integrate learning from across the course to a topical case study situation
Produce a detailed and well-structured report
Given an example accident you will be required to carry out your own investigation concluding with a marine accident investigation report.
You will be expected to do an analysis of all the evidence, conduct a root cause analysis and draw a sequence of events diagram as well as
draw conclusions and make recommendations.
This course and many others are available for corporate client delivery. To find out more about our capability, the benefits of Corporate In-
Company Training, or to obtain a quote, call +44 (0)20 7017 4455 or email ct@informa.com [ct@informa.com].
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