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- ISM LINKS / ACCIDENT AND NEAR MISS REPORTING

ACCIDENT AND NEAR MISS REPORTING - Information available on this page

  Introduction
American Bureau of Shipping – ABS
Australian Transport Safety Bureau – ATSB
Canada - The Transportation Safety Board of Canada – TSB
Confidential Hazardous Incident Reporting Programme - CHIRP
Countryman & McDaniel
The European Maritime Safety Agency – EMSA
Failure in Safety-Critical Systems: A Handbook of Accident and Incident Reporting
Finland – Accident Investigation Board
France - The Bureau d'enquêtes sur les événements de mer
Hong Kong - The Marine Department of the Hong Kong Special Administrative Region (SAR)
International Maritime Organisation – IMO
The International Transportation Safety Association – ITSA
Marine Accident Investigation Branch - MAIB
Marine Accident Investigators’ International Forum – MAIF
The Nautical Institute – MARS
The Netherlands – The Dutch Transport Safety Board - DTSB
New Zealand – Transport Accident Investigation Commission – TAIC
Sweden – The Swedish Accident Investigation Board – SHK
The United Kingdom – Statutory Instruments
The United States National Transportation Safety Board – NTSB
 

Accident and Near Miss Reporting
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Clearly the old saying 'prevention is better than cure' is a truism with which few would disagree. However, if an accident does happen then it is important that we do not lose the opportunity to study the circumstances carefully and learn whatever lessons we can and make sure such mistakes are not repeated.

Section 9 of the ISM Code sets out requirements for 'Reports and analysis of non-conformities, accidents and hazardous occurrences' it states:

  • 9.1 The safety management system should include procedures ensuring that non-conformities, accidents and hazardous situations are reported to the Company, investigated and analysed with the objective of improving safety and pollution prevention.
  • 9.2 The Company should establish procedures for the implementation of corrective action.

We do not need to wait for accidents to happen to realise that something is going wrong. Hazardous occurrences, near misses and non-conformities are all learning opportunities - by reporting and analysing these incidents we can understand what is starting to go wrong and we can introduce corrective action before the accident actually occurs.

Listed below is a wide range of organisations who either provide reports of maritime accidents and incidents or otherwise provide guidance and instructions on investigating, reporting and / or analysing accidents and incidents.

I would be most grateful to receive advice of other appropriate organisations who should be included in this list. Please send your suggestions to me at philanderson@consultism.co.uk
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American Bureau of Shipping - ABS - website address: www.eagle.org
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The American Bureau of Shipping (ABS) has produced a very detailed set of guidance notes on ‘The Investigation of Marine Incidents’. A summary of their approach to ‘Root Cause Analysis’ can be accessed through the following link:

http://www.eagle.org/news/pubs/bulletins/info/Root%20Cause%20Analysis.pdf

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Australian Transport Safety Bureau - ATSB - website address: www.atsb.gov.au
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The Australian Transport Safety Bureau (ATSB) is an operationally independent body within the Australian Government Department of Transport and Regional Services and is Australia 's prime agency for transport safety investigations.

A large number of marine casualty investigation reports are posted on the ATSB website and can be accessed through the following link:

http://www.atsb.gov.au/publications/investigation_reports/index.aspx?mode=mar

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Canada - The Transportation Safety Board of Canada - TSB - website address: www.tsb.gc.ca
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The Transportation Safety Board of Canada (TSB) is an independent agency created to advance transportation safety through the investigation of occurrences in the marine, pipeline, rail and air modes of transportation.

A range of marine casualty reports and related information is posted on their website which can be accessed through the following link:

http://www.tsb.gc.ca/en/marine/index.asp?section=1

The TSB has also implemented SECURITAS, a confidential program through which you can report potentially unsafe acts or conditions relating to the Canadian transportation system that would not normally be reported through other channels. Details are posted on their website and can be accessed through the following link:

http://www.tsb.gc.ca/en/securitas/index.asp

The TSB also produce REFLEXIONS which is a safety digest providing feedback to the transportation community on safety lessons learned, based on the circumstances of occurrences and the results of TSB investigations. Free subscription is available and back copies can be accessed through the following link:

http://www.tsb.gc.ca/en/publications/reflexions/marine/index.asp

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Confidential Hazardous Incident Reporting Programme - CHIRP - website address: www.chirp.co.uk
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The aim of the UK Confidential Hazardous Incident Reporting Programme, known by the acronym CHIRP, is to contribute to the enhancement of safety in the UK commercial and general aviation and maritime industries, by providing a totally independent confidential (not anonymous) reporting system for all individuals employed in or associated with these industries.

Its objects are to carry out research on the causes of incidents and accidents involving aviation and maritime modes of transportation through a confidential reporting system for the collection of Human Factors safety related issues, to analyse data and identify trends, and to advise interested bodies on Human Factors issues relevant to air and maritime transport safety with the aim of the preservation of human life.

CHIRP publishes very useful and interesting 'Feedback' reports on a quarterly basis disseminating some of the interesting 'lessons learnt'. These Feedback reports can be accessed through the following link:

http://www.chirp.co.uk/main/Maritime.htm?http://www.chirp.co.uk/main/downloads/Maritimefeedback.htm

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Countryman & McDaniel - Law Offices - Los Angeles International Airport - The Gallery of Transport Loss - Photos & Lessons of Disasters - A courtesy reference
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The website contains an excellent collection of illustrated accounts of maritime, as well as other transport related, disasters - with some fascinating photographs. Well worth a visit! The website can be accessed through the following link:

http://www.cargolaw.com/gallery.html

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The European Maritime Safety Agency - EMSA - website address: www.emsa.eu.int
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One of the key functions of the European Maritime Safety Agency - EMSA is to provide guidelines for the investigation of marine accidents and collecting relevant data concerning the causes, consequences and contributory factors. An interesting article on this topic is posted on the EMSA website and can be accessed through the following link:

http://www.emsa.eu.int/end185d007d003d002.html

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Failure in Safety - Critical Systems: A Handbook of Accident and Incident Reporting
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A very detailed and authoritative book on accident and incident reporting by Prof. Chris Johnson of Glasgow University can be downloaded free of charge from http://www.dcs.gla.ac.uk/~johnson/book - which is a most valuable reference source. The full reference is: C.W. Johnson, Failure in Safety-Critical Systems: A Handbook of Accident and Incident Reporting, University of Glasgow Press, Glasgow, Scotland, October 2003. ISBN 0-85261-784-4

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Finland - Accident Investigation Board - website address: www.onnettomuustutkinta.fi/2579.htm
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In Finland the Accident Investigation Board investigates all major accidents regardless of their nature as well as all aviation, maritime and rail accidents and their incidents.

The purpose of the investigation of accidents is to improve safety and prevent future accidents. The flow of events during the accident, its causes and results as well as the rescue operation are dealt with in the investigation. A report is prepared on the results of the investigation. The report also presents the recommendations, which are based on the conclusions of the investigation. All reports are written in Finnish with English summaries. An English version is prepared from important reports. The English language summaries of the accident reports can be accessed through the following link:

http://www.onnettomuustutkinta.fi/2606.htm

Video clips of the Estonia can be accessed through the following link:

http://www.onnettomuustutkinta.fi/5974.htm

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France - The Bureau d'enquêtes sur les événements de mer ( French Marine Accident Investigation Office ) - BEAmer - website address: www.beamer-france.org/english/index.htm
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The Bureau d'enquêtes sur les événements de mer ( French Marine Accident Investigation Office ) was created in December, 1997.

It is working independently of any governmental agencies responsible for safety at sea (standards and regulation, whether for merchant navy or fishing / leisure boats ).

Its action exercises in accordance with follow-on regulations:

  • In the international field with " Resolution A849/20 : Code for the investigation of marine casualties and incidents " adopted on November 27 th , 1997 by the International Maritime Organization ;
  • In the European field with " 1999/35/CE Directive " ;
  • In the national field with " 3 rd of January, 2002 Act on technical inquiries after sea event ", décret of 26 of January 2004 on technical inquiries after sea event.

A number of detailed accident reports have been posted on their website and can be accessed through the following link:

http://www.beamer-france.org/english/inquieries/inquieries.htm

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Hong Kong - The Marine Department of the Hong Kong Special Administrative Region (SAR). - website address: www.mardep.gov.hk
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The principal functions of the Marine Department are to ensure safe operation of the port and all Hong Kong waters as well as to operate the Hong Kong Shipping Register and safeguard the quality of the Hong Kong registered ships.

A good collection of marine accident reports and statistics is posted on the Marine Department website and can be accessed through the following link:

http://www.mardep.gov.hk/en/publication/ereport.html

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International Maritime Organisation - IMO - website address: www.imo.org
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The International Maritime Organisation ( IMO ) has developed a number of important Resolutions and guidelines on accident investigation and related topics. The text of the main documents can be accessed through the following links:

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The International Transportation Safety Association - ITSA - website address: www.itsasafety.org
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The International Transportation Safety Association (ITSA) is based in the Netherlands and describes its Mission as:

ITSA was founded on the notions that:

  • independent non-judicial investigations of transportation accidents contribute significantly to the safety of the travelling public and the environment
  • there is a need for an international organization, that brings together accident investigation agencies in all modes of transportation
  • it would be beneficial to learn from the experiences of other countries and share safety information

The mission of ITSA is: "To improve transport safety in each member country by learning from the experiences of others"

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Marine Accident Investigation Branch - MAIB - website address: www.maib.gov.uk/home/index.cfm
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The Marine Accident Investigation Branch (MAIB) examines and investigates all types of marine accidents to or on board UK ships worldwide, and other ships in UK territorial waters. The sole objective of MAIB accident investigations is to determine the circumstances and causes of the accident with a view to preserve life and avoid accidents in the future, not to apportion blame or liability.

MAIB reports and analysis can be accessed through the following link:

http://www.maib.gov.uk/publications/index.cfm

MAIB 'Accident Reporting and Investigation Guidance Notes'

MAIB 'Accident Reporting Form'

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Marine Accident Investigators' International Forum - MAIF - website address: www.maif.net
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The Marine Accident Investigators' International Forum (MAIF) describe their objectives as:

  • To foster, develop and sustain a co-operative relationship among national marine investigators for the purpose of improving and sharing of knowledge in an international forum.
  • To improve maritime safety and the prevention of pollution through the dissemination of information gained in the investigative process.
  • To encourage through co-operation the development, recognition, implementation and improvement of related international instruments, where appropriate.

On their website they post a very detailed 'Investigators Manual' as well as a 'Draft Guide for conducting Marine Fire Investigations' - both of which can be accessed through the following link:

http://www.maiif.net/manuals.htm

They also post 'Guidelines - To assist Investigators in the implementation of the Code' - which can be accessed through the following link:

http://www.maiif.net/guidelines.htm

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The Nautical Institute - MARS - website address: www.nautinst.org
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The Marine Accident Reporting Scheme (MARS) is a confidential reporting system run by The Nautical Institute to allow full reporting of Accidents (and Near Misses) without fear of litigation. MARS reports are held in a database which may be searched in different ways through a Nautical Institute website page which can be accessed through the following link:

http://www.nautinst.org/MARS/index.htm

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The Netherlands - The Dutch Transport Safety Board - DTSB - website address: www.safetyboard.nl
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The Dutch Transport Safety Board - (DTSB)

  • is a statutorily established autonomous agency, responsible for the independent and integral investigation of the causes and possible consequences of disasters, serious accidents and incidents in a broad range of sectors;
  • conducts investigation of crisis management and disaster control;
  • identifies the learning points resulting from the investigation;
  • issues recommendations aimed at improving public safety to responsible organizations;
  • monitors the implementation of recommendations, accidents and incidents.

The DTSB website is available in both the Dutch and the English languages. However, the incident reports are only available in the Dutch language. These can be accessed through the following link:

http://www.onderzoeksraad.nl/onderzoek.htm

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New Zealand - Transport Accident Investigation Commission - TAIC - website address: www.taic.org.nz
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The principal purpose of the New Zealand Transport Accident Investigation Commission (TAIC) is to determine the circumstances and causes of accidents and incidents with a view to avoiding similar occurrences in future, rather than to ascribe blame to any person. (s4 of the TAIC Act)

A number of marine accidents and incidents are posted on their website which can be accessed through the following link:

http://www2.taic.org.nz/InvList.aspx?Mode=Marine

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Sweden - The Swedish Accident Investigation Board - SHK - website address: www.havkom.se
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SHK - The Swedish Accident Investigation Board - is a state authority tasked to investigate accidents and incidents for the purpose of improving safety.

An accident investigation should result in answers to the following three questions:
What happened?
Why did it happen?
How can a similar event be avoided?

The main incident which is posted on the website is the final report on the tragic sinking of the Ro Ro Ferry Estonia on the 28 th September 1994 . This can be accessed through the following link:

http://www.havkom.se/index-eng.html

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The United Kingdom - Statutory Instruments
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UK Statutory Instrument 2005 No. 881 - The Merchant Shipping (Accident Reporting and Investigation) Regulations 2005. This can be accessed through the following link:

http://www.mcga.gov.uk/c4mca/si_2005_no_881.pdf

ALSO SEE The Marine Accident Investigation Bureau (MAIB) above

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The United States National Transportation Safety Board - NTSB - website address: www.ntsb.gov
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The United States National Transportation Safety Board (NTSB) investigates major marine accidents on navigable waters of the United States , involving U.S. merchant vessels in international waters, and collisions involving U.S. public and nonpublic vessels. In addition, it investigates selected marine accidents that involve public transportation or those of a recurring nature.

A number of interesting accident reports are posted on the NTSB website and can be accessed through the following link:

http://www.ntsb.gov/Surface/marine/marine.htm

The NTSB also post their 'Accident / Incident Investigation Procedures' on their website and these can be accessed through the following link:

http://www.access.gpo.gov/nara/cfr/waisidx/49cfr831.html

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