ABThe International Marine Contractors Association Guidance on The Investigation and Reporting of Incidents www.imca-int.com IMCA SEL 016 January 2007 International MarineContractors Associationwww.imca-int.comAB AB The InternationalMarineContractorsAssociation (IMCA)istheinternationaltradeassociation representingoffshore,marineandunderwater engineering companies. IMCApromotesimprovementsinquality,health,safety, environmentalandtechnicalstandardsthroughthepublication ofinformationnotes,codesofpracticeandbyother appropriate means. Membersareself-regulatingthroughtheadoptionofIMCA guidelinesasappropriate.Theycommittoactasresponsible members by following relevant guidelines and being willing to be audited against compliance with them by their clients. There are two core activities that relate to all members: Competence & Training Safety, Environment & Legislation TheAssociationisorganisedthroughfourdistinctdivisions, eachcoveringaspecificareaofmembersinterests:Diving, Marine, Offshore Survey, Remote Systems & ROV. Therearealsofiveregionalsectionswhichfacilitateworkon issuesaffectingmembersintheirlocalgeographicarea Asia-Pacific, Central & North America, Europe & Africa, Middle East & India and South America. IMCA SEL 016 This guidance has been prepared for IMCA under the direction of its Safety, Environment & Legislation Core Committee. www.imca-int.com/sel The information contained herein is given for guidance only and endeavours toreflect best industry practice.For the avoidance of doubt no legal liability shallattach to any guidance and/or recommendation and/or statement herein contained. The Investigation and Reporting of Incidents IMCA SEL 016 January 2007 Part 1 An Overview Preface............................................................................................................................ 1 1Introduction ........................................................................................................... 3 1.1Scope ......................................................................................................................................................................... 3 1.2Reasons for Investigations .................................................................................................................................... 3 1.3Identifying Causes ................................................................................................................................................... 3 1.4Requirements of Procedures............................................................................................................................... 3 1.5Preventative Measures .......................................................................................................................................... 4 2General Principles of Investigation ...................................................................... 5 2.1Basic Necessities ..................................................................................................................................................... 5 2.2Ownership of Evidence ......................................................................................................................................... 5 2.3Securing Evidence and Establishing Relevant Procedures Categorising Incidents .............................. 5 2.4Inclusion of All Relevant Evidence ..................................................................................................................... 6 3What Procedures Should There Be? ................................................................... 7 3.1Types of Procedure ............................................................................................................................................... 7 3.2Who Should Be Involved and What Are Their Responsibilities? .............................................................. 8 3.3Who Looks After Documentary Evidence?Document Control .............................................................. 8 4An Incident Occurs What Should Happen? ................................................... 10 4.1Make Safe and Secure ......................................................................................................................................... 10 4.2Prepare for Investigation ................................................................................................................................... 10 4.3Investigation Kit ................................................................................................................................................... 10 4.4Investigation Requirements ............................................................................................................................... 10 Part 2 Investigation and Reporting 5Interviewing Personnel ....................................................................................... 13 5.1Interview Overview ............................................................................................................................................ 13 5.2Factors That Can Affect a Witness ................................................................................................................ 13 5.3Example Interview Questions .......................................................................................................................... 15 5.4Drafting the Witness Report............................................................................................................................ 16 6Site Investigation ................................................................................................. 18 6.1Securing Evidence ................................................................................................................................................ 18 7Initial Analysis ...................................................................................................... 21 7.1Storyboard ............................................................................................................................................................ 21 7.2Final Examination of the Storyboard .............................................................................................................. 21 7.3Prepare Report .................................................................................................................................................... 22 7.4Report .................................................................................................................................................................... 22 8Subsequent Analysis ............................................................................................ 23 9Other Considerations.......................................................................................... 24 9.1Litigation Concerns ............................................................................................................................................. 24 9.2Insurance Issues ................................................................................................................................................... 26 10IMCA Incident Reporting .................................................................................... 27 10.1IMCA Safety Flashes ........................................................................................................................................... 27 10.2IMCA Safety Statistics ........................................................................................................................................ 27 10.3DP Incidents .......................................................................................................................................................... 27 10.4Lifting Incidents .................................................................................................................................................... 27 10.5Security Incidents ................................................................................................................................................ 27 11Appendices ........................................................................................................... 28 Appendices 1Sample Investigation Levels ............................................................................... 29 2Typical Flowchart Symbols ................................................................................. 31 3Sample Company Incident Reporting Form .................................................... 33 4Sample Incident Management Review Report Format ................................... 39 5Sample Company Investigation Report Format .............................................. 41 6Sample Incident Flowchart ................................................................................. 45 7Sample Near-Miss Reporting Form ................................................................... 47 8Sample Format for Infringement of Safety Zone Report Procedure .......... 49 9Sample Definitions of Incident Terminology .................................................... 51 Lagging Safety Statistics ................................................................................................................................................... 51 Leading Safety Statistics .................................................................................................................................................. 52 10Sample Company Incident Classification Scheme ........................................... 53 11Sample Insurance Reporting Procedure ........................................................... 57 12Example Introduction for a Privileged Document ........................................... 59 IMCA SEL 0161 Preface The IMCA Safety Environment& Legislation (SEL) Core Committee, having consideredthat there was a need for industry guidance regarding the identification of the root cause of incidents, called for members to provide samples of their incident investigation procedures.From the information provided, the following guidance has beendeveloped,partlytoreflectcurrentpracticeforsettingupincidentinvestigationandreporting procedures,butprimarilytoexaminehowthesemaybeimprovedtohelpidentifythetruerootcausesof incidents. For example, an obvious reason for a lifting incident may appear to be a failure of equipment, but the reasons foritsfailureneedtobeidentified.Therecouldhavebeenamomentinthelead-uptotheincident,which could be a long time in the past, where the subject risk could have been removed; and it would be instructive to define why it was not.It is obviously necessary to identify all causal factors in order to aid the prevention of further incidents. Only by completing a thorough investigation will there be a possibility of determining the true root cause of an incident.This guidance seeks to assist that process by setting out the procedures that will help.It can be used bycompaniesconstructingtheirownproceduralinstructionsorbythoseactuallychargedwiththetaskof investigating and reporting an incident. Anyoneintheworkforcecouldbenefitfromguidanceonincidentreporting.Evenifsomeoneisnotthe person actually compiling the report, he or she will understand the process better if they can refer to guidance that explains why they need to provide evidenceand why the scope of the information they need to provide might be far wider than that which might immediately be apparent.Thus, although the guidance is intended to helpacompanyconsiderthecontentoftheirinvestigationprocedures,itisalsowordedtoassistthose carrying out an investigation. The guidance compiled below thus seeks to address the parameters required for an in depth investigation, but it will be clear that it might not be possible to completesome elements in every instance.Sometimes only a shortreportmayindeedbeallthatisnecessary,butthiswilldependuponthesituationandcompany requirements. IMCA SEL 0163 Part 1 An Overview 1Introduction 1.1Scope Thescopeofthisdocumentistogiveguidanceonthestructureofcompanyproceduresforthe investigation of incidents. Theguidanceshouldalsobeofusetothosechargedwiththeactualinvestigationandreportingof incidents. Theobjectiveoftheproceduresandforthoseconductingtheinvestigationshouldbetodetermine thetrueroot cause(s) sothatappropriatepreventativemeasures can beput in place.Theguidance describesoutlinemethodsforconductinganinvestigationintoanyincident,whetherthatincident involves injury to persons, damage to equipment or to the environment, or the potential to do so. 1.2Reasons for Investigations An investigation and reporting procedure should be focused on the determination of all causes of an incident, especially with defining the root causes; and on making recommendations for the prevention of any recurrence and to gain information on incidents generally, such as detection of trends of types of incident. It should also alert the company to any legal, official or commercial issues that might need to be dealt with.Thus, a secondary aim should be to provide a report which will include the evidence necessary to give a member enough factual information to seek advice on what consequences there might be in terms of litigation.Litigation is sometimes dealt with separately, but as this subjectcan be intricately connectedtotheinvestigationoftheincident,ashortsectionisincludedinthisdocumentwhich addresses these issues (see section 9.1). 1.3Identifying Causes A proper investigation of the incident should help the reporter establish its root causes or, if not, help to obtain as much information as might be relevant, so that any subsequent investigation can be based onasufficiencyoffacts.Itisimportanttotryandobtainasmuchmaterialaspossiblewhilethe knowledge of the incident is still fresh and while evidence is still available. If successful, the resultant data should give the workforce and its management a clear insight into what happened and provide reliable data on which to base preventative measures. 1.4Requirements of Procedures Theincidentinvestigationprocedureshouldgiveaclearoutlineoftherequirementsforan investigating team when carrying out an investigation into any type of incident. Thisguidancecanbeusedinthecaseofallincidentswheretherehasbeenoneormoreofthe following: fatality; personal injury; illness which requires medical evacuation or repatriation; damage to vessel, cargo, equipment or third party property; pollution incident either from own vessel or as a result of a collision; or there has been the potential for any such occurrence. 4IMCA SEL 016 This guidance does not detail specifically structured, systematic methods of analysis of incident causes.Therearesuchanalyticalsystems,developedbyclassificationsocietiesandothers,showing,for example, particular ways of using flowcharts and displaying relevant information along causal paths. 1.5Preventative Measures A prime reason for thorough investigation is to identify appropriate preventative measures and these need careful consideration.Sometimes the implementation of several preventative measures can have anegativeeffect,inthatsomemeasuresmayactuallyincreasethenumberofaspectsthatcango wrong, creating a different causal path and possibly another accident. If a previously unknown risk is discovered in an investigation, care has to be taken in the way in which mitigation of it is factored into any operational process.A simplistic example could be taken from a lifting operation, where an accident occurred in which it was noted that one of the causal factors was that too few people were involved on deck.Twice the amount of people being employed on the same task might not betheanswer,not least becausemoreof them could beinharmswaywhen the lift starts to move. The guidance outlines the basic structure of incident reporting, showing currentaccepted practice of how to do so. Theguidancedoes not deal with procedures for ensuring there-establishment of safety at thework siteimmediatelyaftertheincident,assuchissuescouldbecoveredseparately,forexamplein companyemergencyandsafetyprocedures.Thesewouldbeexpectedtoalsoincludethecareof injured personnel and the process required for the continuation of operations.Such guidance would set machinery in motion toensure that injured personnel are properly cared for, that theproject in hand is delayed as little as possible and that any other personnel issues are dealt with. In this document, the term company is intended to refer to the entity owning or operating a vessel or work site where there has been an incident requiring investigation. IMCA SEL 0165 2General Principles of Investigation The following general principles can be applied to all incident investigations.These principles can be modified to suit the seriousness, or potential seriousness, of the incident. 2.1Basic Necessities Categorise the incident (see 3.1) and decide on the level of investigation required; Identify procedures to use, such as storyboard (see 7.1) and the equipment and facilities required (see 4.3); Collect all available information and verify the events leading up to the incident (see 5, 6 and 7); Interviewallpotentialwitnessesassoonaspossiblenotjustactualeyewitnessestothe incident, but anyone who can provide relevant information, to obtain the necessary facts relating to the cause of the incident (see 5); Secure and ensure safe keeping of evidence (see 6); Draft a report which clearly sets out all the relevant facts (see 7); Formulateconclusionsbasedontheinformationandproposerecommendationstopreventa recurrence (see 7); Complete an incident report in full (see 7.4) and make recommendations to close out. Companiesusuallydevelopproceduresthatarerelevanttothelevelofincident.Forguidanceon evaluating incident levels, see section 3.1 and Appendix 1).These procedures should encompass the general principles outlined above. An outline of the activities following an incident is illustrated in the flow chart below. 2.2Ownership of Evidence Whenseriousincidentsoccur,investigatorsfromgovernmentalauthoritiesoftenattend.Whilstno onboardorinternalinvestigationsshouldinterferewithordisruptanyofficialinvestigationsbeing carried out by an authorised government body, or those genuinely instructed by them, care should be taken that any information is only passed to identifiable official parties with legal authority to demand such information. Any requests for information should preferably be referred to the company legal advisers. 2.3Securing Evidence and Establishing Relevant Procedures Categorising Incidents Inparticular,evidencemustnotbedisturbedorremovedfromanaccidentsiteifanofficial investigationistobecarriedout.Companyprocedureswillneedtoidentifywhensuchan investigation would be carried out and what steps need to be taken.This will be aided by an ability to categorise incidents, which is addressed in section 3.1 below. In the case of that which is categorised by the company asa serious injury or fatality, the site should notbedisturbeduntilpermissionisgivenbythecompanysrelevanthealthandsafetydepartment, which should be liaising with the appropriate authorities. Non-disturbance does not of course prevent the removal of casualties for first aid, or action taken for safety purposes, or any prevention of further deterioration of the situation. Itisessentialhowevertosecureevidenceandensurethatitwillnotbedamagedoraffectedby subsequent interference as indicated in section 6.1. Companiesmayalsoneedtocategoriseincidentsforthepurposesofcompilingaccidentstatistics.This aspect is addressed in section 3.1. 6IMCA SEL 016 Example flow chart indicating actions following an incident as described by this guidance: Company actionAddresspersonnel issuesAdvise IMCA forinitial safety flashAdvise:- Authorities- Insurers- LawyersAdvise work site/vessel of relevantprocedure Investigation procedureGather witnessreportsGather photographsand sketchesGather physicalevidenceGatherdocumentaryevidenceStoryboardAssess evidence andreport causes Company actionAdvise IMCA forfollow-up to initialsafety flashAdvise:- Authorities- Insurers- Lawyers Action on site/vessel Make safeAdvise localauthoritiesas requiredReport to company Attend personnelIncidentCategorise incidentand instigateinvestigationprocedureAct on findings/recommendationsas appropriate 2.4Inclusion of All Relevant Evidence It should be borne in mind from the outset that the root causes of an incident need to be found and addressed.Thesystematicanalysisofthedataacquiredshouldresultindefiningtherootcause(s); whichwillbemoreeasilyidentifiedifallpossibleevidenceisconsidered.Thiscouldinclude,for example relevant near miss or hazardous incident reports from any time in the past. IMCA SEL 0167 3What Procedures Should There Be? 3.1Types of Procedure Company procedures are needed for various situations. 3.1.1Categorising Incidents Whendevelopingacompanyprocedure,theremightbeaneedtocategoriseincidents,so that certain types of incident are treated differently.For example, DP failure, heavy lifting or engineroomincidentscouldallrequiredifferentspecialistinvestigatorstoattend.The seriousnessoftheincidentwillalsobeafactor.Amajorincidentinvolvingfatalityor serious injury, or considerable financial loss, is likely to require the most urgent attention and is certain to involve regulators and the close attention of lawyers. Categories are generally kept to a small number; up to four is common and reasonably wide ranging.A typical matrix is set out in Appendix 1, from which it can be seen that the example company used four levels of investigation requirements. Apart from broad categorisation of incidents, it is also useful to identify types of incident with regardtoreportingstatistics.Companieswillbereportingaccidentstatisticstosatisfy differentreportingregimes.IMCAundertakesannualcollectionofitsmembersstatistics againstdefinitions set outinan annual information note,an example of which isincludedat Appendix9.ThisisgenerallycompatiblewithotherindustryregimessuchasthatofOGP (the International Association of Oil and Gas Producers), but which differs from, for example, OSHA(theUSOccupationalSafetyandHealthAdministration).Anexamplecompany format is given in Appendix 10. See section 10 and relevant appendices for description of typical company reporting formats. 3.1.2Statutory Reporting Procedures Companyproceduresshouldalsoindicatetheactionsrequiredinrespectofstatutory reporting in the areas in which the vessel or work site is operating.These are not included in this guidance as they will vary between coastal and flag states and may change periodically. 3.1.3Near-Miss Reporting Procedure A vital part of investigating the safety of any ongoing operation is to understand where near-misses are occurring.Companies should have a procedure which encourages the submission ofnear-missreporting.Suchreportsshouldbeinvitedfromallpersonnelanditis worthwhile including a method of submitting anonymous reports, which should be simple and brief,toencouragecompletion.Ifrecordsofnear-missesofalltypesarekept,preferably filedincategories,theycanbeaccessedtoseeif thereis acommonlinkpointingtowarda root cause.It will also be useful in examination of incident trends. 3.1.4Safety Zone Infringements Reporting Procedure Theconceptofinfringingthesafetyzoneofanoperationassumesvaryingsignificance dependent upon the operation, the global location and company and/or client requirements. Whereavesselisoperatingasaninstallationforexample,thevesseloperatororowner companymightwishtorecordinfringementsbyothervesselsandwillneedtoprovidea procedure and format for doing so. Aformatforasafetyzoneinfringementreportformusedbyonecompanyisdescribedin Appendix 8. Story Board Assess Evidence and Report Causes COMPANY IMCA follow up of safety flash 8IMCA SEL 016 3.1.5Misuse of Drugs or Alcohol Guidanceforcompanyproceduresforthetreatmentofincidentsconcerningthemisuseof drugs or alcohol, which will involve testing, is covered separately in IMCA SEL 008 Guidance on Drug and Alcohol Policies: The Collection of Samples and IMCA SEL 011 Guidance on Drug andAlcoholPolicies:BreathTesting.Notetheimportanceofthedocumenttrailforthe protection of evidence in those guidelines. 3.2Who Should Be Involved and What Are Their Responsibilities? TheresponsibilitieslistedagainsteachofthefourlevelsintheexampleinAppendix1areauseful guide.Titlesforpersonnel willvaryfromcompanytocompany,buttheprocedures canspecifythe appropriaterankorlevelofpersonsforthedifferentlevelsofincident,orindicateaspecific department with personnel intended to deal with all types of incident. Itiscommonforprocedurestohighlightthatallpersonnelhavearesponsibilityforreportingall incidents and that the reports should be completed in a particular format. Then,toensurethattheappropriatepersonnelareinvolvedinthatreporting,therewouldbea procedure for the deployment of personnel according to the type or level of incident.A matrix such as that indicatedinAppendix1would givea clearindication of thedifferent levelsof incident andit would be relatively simple to identify the requisite personnel for each level. It may be, for example, that a low-level incident can be dealt with by the vessel crew, with the master and vessel safety officer likely to be responsible.It is probable, however, that they would be engaged withanyincidentonboardandwillprobablyneedtocarryoutaninitialinvestigation,securethe evidenceandpreparetoassistanysubsequentinvestigationteam.SeeAppendix11forasample flowchartprovidedbyacompanywhichcouldguidethoseonboardorataworksitethroughan adopted procedure. See section 10 for reporting formats. 3.3Who Looks After Documentary Evidence?Document Control 3.3.1Focal Point Itisworthwhileestablishingafocalpointinthecompanyforalldocumentationanddata arisingfromanincidentorclaim,sothatthereisasourceatwhichalldocumentationand data can be found and there is knowledge of where the original documents are securely held and easily traced. 3.3.2Document File Reference Itisusefultohaveanestablishedmethodofcodingitemsofevidencesothattheyclearly relatetoaparticularincident.Ifaparticularstyleofcodingisfollowedforallcompany incident investigations then filing is made easier and more efficient.Thus Enterprise (26 June 06)(JPG29June06)couldindicateevidenceobtainedfromavesselcalledEnterprise relative to an incident on a certain date, who collected it and when. Further,thedocumentsshouldbefiledandreferencedinsuchawaythatindividual documents from specific incidents can be easily traced even years after the event. 3.3.3Care in Preservation Those in charge of documentation and data should be aware of what is required to keep it in good condition.For example, electronic media can be affected by damp, heat, magnetic fields (perhaps from nearby cable runs); and some documents can be pressure sensitive, or similarly damaged by damp, heat or strong light. Even if it seems that theinvestigation aspects are overand legal issues dealt with, it will still benecessarytoretaindocumentswithinthecompanyincasefurtherlegalactionsariseor IMCA SEL 0169 they are required for the adjusters or insurers use.They may also be of use for reference in future investigations and/or in other legal cases. 3.3.4Security Documentationanddatashouldnotonlybekeptsafely,butthoseinchargeofitshould understanditsimportancenot just for thecompanys own need in relation toitsvaluein helpingtopreventfurtherincidentsbut,forexample,inrelationtothecontentsof sub-sections under 9.1; and only allow release of it to personnel authorised by the company. 10IMCA SEL 016 4An Incident Occurs What Should Happen?In cases of serious injury or a serious incident the following actions are important.Company procedures can identify what actions are required for each type or level of incident. 4.1Make Safe and Secure Wherepracticable,conditionsattheaccidentsceneneedtobemadesafetopreventfurther incidents, as would be set out in company safety procedures.The site should be secured and remain undisturbed until the investigators have completed their work. 4.2Prepare for Investigation Obtainauthorisationfromthecompanyorbyreferencetoon-board/on-siteproceduresto commence the relevant level of investigation and reporting procedure (see Appendix 1). It should bemade clearto all possible witnesses to theincident (or whohave knowledgeof related information)thattheyshouldnotmakeanystatementstoanybodyexceptthedesignatedcompany officials or lawyers or consultants known to be instructed by the company. 4.3 Investigation Kit If possible, a specific room should be set up as the investigation centre.Ideally, this should, if possible, be separate from the room in which a witness is interviewed (see section 5.1). Whateveraccommodationisprovided,theequipmentsuggestedtobeavailabletotheinvestigating team is as follows: at least one desk with chairs; sufficient appropriate stationery; at least one whiteboard with markers; a bulkhead area for creating a storyboard (see section 7.1); computer facilities; oil/chemical sample bottles; measuring tape; digital camera; quality 35mm camera with flash; video camera; Dictaphone or tape recorder. Guidancefor company procedures for thetreatment of incidents concerning themisuseof drugs or alcohol,includingguidanceontheaccommodationrequiredfortestingandtherecommendedinvestigationkit,iscoveredseparatelyinIMCASEL008GuidanceonDrugandAlcoholPolicies:The Collection of Samples and IMCA SEL 011 Guidance on Drug and Alcohol Policies: Breath Testing. 4.4Investigation Requirements A detailed examination should be carried out at the incident site.If there is a specific company officer responsible for the vessel or work site, such as an area supervisor, then this person should assist. Notetheworksite,thepersonnel andequipment (if any)involved and thegeneralsequenceof events. Any information relating to physical conditions of the plant, equipment and the workplace should be noted and logged.IMCA SEL 01611 All casualties and potential witnesses should be identified and interviewed in a systematic manner.Careshouldbetakeninrespectofanyinjuredpersonnelandmedicaladvicetakenastothe advisabilityofinterviewingthemwhenthereisanydoubt.However,interviewsshouldbe conductedassoonaspracticalinorderthattheincidentdetailsarerecordedaccurately.See section 5 for interview of personnel. See section 3.1.5 where misuse of drugs or alcohol is suspected. Take photographs of the incident site, see section 6. Take note of, or consign to a safe place, any broken parts and log them see section 6.1.2. Examineandphotocopythepaperworkrelatingtotheincident,forexample,charts,work permits, logs and written procedures see section 6.1.1. Evaluate the accuracy of the data and interviews. Re-check any conflicting evidence. Re-interviewpersonnelifrequiredorshouldanynewinformationbediscoveredasaresultof these investigations. IMCA SEL 01613 Part 2 Investigation and Reporting 5Interviewing Personnel 5.1Interview Overview The term witness report is used to differentiate from statement, which is the term used in section 9.1 Litigation Concerns. Theplaceusedforinterviewsshouldideallybearoominanareafreefrominterruptionand retaining sufficient privacy. The situation should be made as relaxed and informal as possible. Thereasonfor the interview should be madeclear, which should be toascertain all of the facts thatleduptotheincidentandtopreventfurtherdangerorincidents;andnottoapportion blame. Avoid more than a two-to-one ratio and offer to let the interviewee be accompanied if necessary. If there are twointerviewers, one should take the lead whilst the other takes notes, only asking questions when necessary to clarify a point.Avoid interruptions if at all possible. Wherewitnessesaresufferingphysicalorpossiblementalinjuryasympatheticapproachshould beadoptedandonlyessentialquestionsaskedwhereverpossible.Medicaladviceshouldbe soughtifthereisanydoubtastotheadvisabilityofinjuredorotherwisetraumatisedpersons being interviewed. Ifpossible,let interviewers beofat leasta compatible level totheinterviewee, with compatible skills and expertise.This generally will be more productive, especially on technical matters. Never tape record any interview without the full consent ofthe interviewee.(A Dictaphone or tape recorder at the incident site can be useful, especially when describing the site and incident.) Donottrytocoercewitnessreportsormakeleadingorsuggestivecomments.Letthe interviewees tell it in their own way.Encouragement such as what did you do next? should be used, not Why didn't you do?. Avoid questions with yes/no answers and encourage a full description of events.A good principle toadoptistostartquestionswithwhat,when,where,howorwho.Avoidasking whyquestions,asthiswillputtheintervieweeonthedefensive(seeexampleinterview questions in section 5.3). Witnesseswillrespondtobeinginterviewedinavarietyofdifferentways.Bepreparedtobe adaptable, patient and consider how cultural issues might affect the process. Beingawareofthewaysinwhichanwitnessmightrespondwillhelpinterviewerstoobtaina better quality of evidence, which will assist in defining the true root causes of an incident. 5.2Factors That Can Affect a Witness Wheneveranaccidentoccurs,apartfromphysicalinjury,thoseinvolvedareaffectedbyarangeof emotionsthathaveabearingontheevidencetheygive.Shockshouldneverbediscounted;itcan affect people in different ways and at different lengths of time after the incident. They might also feel angry at a mistake that was made by themselves, or by someone else.They might feelguiltyorprofessionallyembarrassed.Theymightseemaggressivetowardtheinterviewerfora mix of the above reasons.They might even enjoy being in the limelight of an interview. Complicationscanarisewhenanumberofwitnessesconferafteranincident.Hopefully,the interviewer is on hand as soon as practicallypossible, as this might avoid the problem. Each witness will haveseen theincident from adifferent perspectiveand each hasaviewas towhat went wrong and why.Witnesses, in discussion with others, start to absorb suggestions, consciously or not, which 14IMCA SEL 016 can affect their own recollection of the incident.As they talk to each other, it is almost inevitable that their own perception of what occurred is tainted by anothers view, which can lead to uncertainty of what they thought they had seen.This can happen very easily and quite innocently. Conversely, a witness who has not talked to anyone about the incident might have an incorrect view of what occurred, merely because of a lack of understanding of what happened and their recollection is affected by trying to make sense of what they thought they saw. These elements can sometimes show themselves by careful examination of the information provided. 5.2.1Location Interviewers should ask, for example, where the witness was standing at the moment of the incident. Then, the interviewer should stand in that place and seek to understand what the witness should haveseen.Take intoaccount wherethelight was coming from at thetime.Would the sun have been in the witnesss eyes; was it at night, what does that area look like under decklights?A reality checkof the information provided can sometimesbesimple to arrange. 5.2.2Timing The timing of an account is often surprisingly in error.There are two elements to this.One witnessmightestimatethewholeeventtakinglessthanaminute;whereasanothermight swear that it lasted three or four minutes.As a rule of thumb, it sometimes seems that those nearest and most affected by an incident perceive the time to go slower than those distanced from it. This is possibly related to the adrenalin rush that witnesses might have been subject to when anincidentisinprogress,whichwillbelikelytobehighestinthosemostaffectedbythe incident. Perhaps this makes them concentrate more on what is happening and the amount ofinformationtheyconsequentlyabsorbcreatestheimpressionthatalotmoretimewas needed for it all to happen. Thesecondelement,inrelationtotiming,isthesourceofthetimewhentheincident occurred.On a ships bridge or in an engine control room it is usually straightforward; most actionsarerecordedbythetimeonthewheelhouseorcontrolroomclockorfrom automatictimerecordingdevices,whichshouldresultinthesametime.Elsewhereonthe ship or work site it is not always straightforward.A lot of people do not wear a wrist watch whentheyareworking,and/ortheclockortimerecordingdevicethattheyarerelyingon might not be synchronised with the bridge time. 5.2.3Culture Differentcharactersandpeoplefromdissimilarculturesreactindiversewaystodangeror otherpossiblytraumaticresultsofanincidentand/orhavedifferentwaysofdescribingit afterwards and this needs to be taken into account by the interviewer. 5.2.4Individual Recollection When people witness an event, they quickly form a mental image, which need not necessarily becorrect.Thisimageissubsequentlydifficulttoerase.Askanynumberof peopleinthe same room to report a simple incident and they will each come up with stunning variations.Times,coloursofclothes,equipmentheld,weather,whatwassaid,allcanvary.They subsequently find it hard to accept that they were wrong. Those actually involved in the incident can be equally incorrect.If witnesses were confronted withavideoplaybackofwhattheywereactuallydoing,especiallywhentheywereunder pressure, it could surprise them. They might have an absolute and unshakable view of what occurred,buttheirrecollectionmighthavebeenaffectedbysomeorallofthefactors described above. IMCA SEL 01615 5.2.5Status and Personal Characteristics Anotherfactoristheperceptionofbothwitnessandinterviewerinrelationtotheir respectivestatus.Ifthewitnessdecidesthatheorshehasahigherstatusthanthe interviewer,thentheymighttrytousethattotheiradvantageandmakeitdifficultforthe interviewer to ask some important questions. This is particularly an area where the character of both witness and interviewer could play a significant part.If the witness has the more dominant character, the interviewer might need tobeespeciallyastuteinthewayinwhichthequestions areasked.Conversely,ifitisthe interviewer who has the stronger character, then care should be taken that the witness is not intimidated.Usually,whenhonestpeoplearebeinginterviewed,themorerelaxedthe witness, the better the information obtained. Sometimes, there is an advantage if the interviewer comes from a department in the company that deals specifically with incident investigation, or a lawyer from in or outside the company, as then the status element might not be so clearly defined. 5.2.6Summary In summary, the following are some of the issues that can have an influence on a witness: shock; anger; guilt; professional embarrassment; discussion with other witnesses; misunderstanding of what occurred; timing; culture and characters; relative status and characters of witness and interviewer; relaxed witness, better information. 5.3Example Interview Questions To assist interviewers with their task, it is sometimes helpful for them to have a checklist of possible generic questions. It is most beneficial if those questions are set out in a logical order, which helps both the interviewer and the interviewee to bring out the necessary information. These generic questions are examples. What would be a brief overview of your usual job description on this vessel? What qualifications/competence/experience do you have relevant to that? What other vessels (work sites) have you served (worked) on? What is your total time to date on this vessel (work site)? What time did you come on duty for the work period in which the incident occurred? When was the last time you were on duty prior to this period? What rest period had there been between the two shifts/watches? When was your last meal break prior to the incident?At what time did you start the period of work in which the incident occurred? Whenyoucommencedworkonthiswatch/shift/period,whattasksdidyouanticipateworking on? 16IMCA SEL 016 What operation was being carried out? Was there a handover briefing from someone else and if so what was said? What were the lighting/daylight/visibility conditions? What were the weather conditions? What were sea, swell and current conditions? How much was the vessel moving in roll/pitch? What had been the sea and weather conditions over the previous 24 hours? Was there any change in weather/sea/tide/daylight conditions up until the incident? Was there a specific briefing concerning the activities in which the incident occurred? What do you actually recall of what was said at that briefing? Do you have any written notes? What were your specific duties in relation to the incident? What specific instructions were you given? Who was in charge? Were work permits required for the relevant task and were they in place? Regarding equipment use: -What equipment was in use? -Was this equipment subject to class requirements? -Was the certification and condition of this equipment checked? -Had there been any previous problems with this equipment? -Had the equipment been subject to any repair or overhaul and if so when and who by? -Had any of the equipment been in storage? -Details of storage -When was the equipment last used? -Were you operating the equipment and if so when did you last use the equipment? Were you told to wear protective clothing? Were you wearing the protective clothing you were told to wear? Where were you located at the relevant times of the incident? Who else could you see? Where were they? What were they doing? Describe your activities, including relevant timings, until and shortly after the subject incident. Describe exactly and only what you saw or experienced in relation to the incident. Include recollections of all relevant conversation/orders/remarks. What written records (include scrap paper notes) or electronic data exist that you have provided any input to? When and why did you first realise that something was going wrong? If you were not specifically involved in the incident describe as much of the above as you can and how you happened to be in the location you were in. 5.4Drafting the Witness Report Once the interviewer has sufficient material to draft a witness report, he or she should take the time to complete this.It is not usually satisfactory to try and write the witness report in its final format the same time as the information is taken from the witness.It is best to take copious notes and try to geteverythinginapproximatelogicalorder.Veryoften,informationwillcometolightduringthe IMCA SEL 01617 interviewthatwasunknownornotfocusedonatthebeginningoftheinterview.Ifthereportis written as the information is received it will usually be badly constructed with a fractured story line. Wherepossible, referencetosupporting evidencesuch as data retrieved from other sources should be referred to in the report. Oncethewitnessreporthasbeendrafted,withalltherelevantdetailssetoutinalogicaland sequentialmanner,itshouldbegiventothewitnesswhoshouldbegiventimetoreaditproperly.It isoftenhelpfultogothroughitwiththewitness toensurethatallfactsarecorrectandtomake sure there are no omissions or misunderstandings. Thewitnessreportshouldbesignedanddatedbythewitnessandcountersignedanddatedbythe personwhocarriedouttheinterview.Itshouldbemadeclearthatitisnotobligatoryforthe interviewee to do so.If there is an unwillingness to sign, an appropriate explanatory note should be made on the report. Companiessometimesrequireasummaryofthekeyissuesand,ifthisisrequired,itshouldbea clearly separate, headed addition, preferably on a separate sheet.With a witness report that has been prepared on any kind of word processor, a different typeface might assist.To summarise the points to be considered concerning the interview: Take care in selecting an appropriate interview location; Establish a calm, informal and relaxed situation; Obtainallrelevantdetailsrelatingtoexperience,qualifications,competenceandother background; Examine facts provided carefully; Set them in logical order; Refer to evidence from other sources, such as electronic data; Do not be afraid to keep asking questions; Write witness report for approval of witness; Obtain dated signature when witness satisfied with witness report content. 18IMCA SEL 016 6Site Investigation Apartfrominterviewingwitnesses,itisusuallyworthwhilemakingasketchoftheareainwhichtheincident occurred and taking measurements of significant points.Copies of vessel plans can be very helpful in preparing these. If it is a lifting incident, factors such as the operating radius of the crane, the line of sight of the crane driver and other personnel might be initial information required for input onto a sketch of the deck area. Deploymentofanyrigging,attachmentringbolts,heightsandsizesofobstructionsinthewayofthelift, directionofwind,tide,lightsourcesandanyotherrelevantdetailscanbeadded.Photographsareofgreat assistance but they do not always provide the necessary scale; and a sketch with measurements can. Photographscanprovideveryusefulillustrationsinsupportofanincidentreport,especiallyforthose recipients not familiar with the work site or vessel.If there is doubt about whether photographs are required, thecompanyprocedureshoulddefinesomeonetobecontacted,perhapssomeoneinthecompanylegal department.See section 6.1.3 regarding photographic evidence. If it is not practical or possible to retain the incident site as it was at the time of the incident then, as a broad guide, photographs showing theincident site,anydamageincurred anddemonstratingwherepersonnel were sited will be helpful. Companieswillusuallyhaveproceduresinplacethatforbidtakingphotographsofbodies,bodyparts,and injured personnel or focusing on bloodstains. Video cameras can also provide excellent information, especially in comparing sight lines of witnesses and giving anideaofvesselmotionandtheambientsoundsatthesite,suchasthenoiseofenginesorwinchmotors running. Whilst on site, try and obtain an understanding of what the situation was at the time of the incident. Note, for example,wherethelightsourcesareatdifferenttimesofdayorondifferentvesselheadings;howdifferent environmentalconditionswouldaffectthearea;whatthenoiselevelis;howcommunicationsareconducted; whether thereareobstructionstomovementaboutthedeck,oranythingelsethatmightberelevanttothe incident. In summary: Sketches can be very useful; Take appropriate measurements where necessary; Use vessel plans; Take relevant photographs/video records; Carefullyassessthecharacteristicsofthesitewithrespecttotheoperation(s) under wayatthetimeof the incident. 6.1Securing Evidence Inadditiontothereportsfromindividuals,therewillbeanumberofsourcesofdata,writtenor electronic,thatcouldbevitalinestablishingtherootcausesofanincident.Vesselshavedifferent sources of electronic data available, whether from the bridge, engine room, crane, and dive control or where any equipment is used that includes some form of data retrieval. Refertosuchrelevantevidenceinwitnessreportswhereappropriatetohelpidentifyitintheon-going investigation and in any subsequent litigation.6.1.1Written Evidence Therearewrittenevidentialsources,suchasdeckandenginelogbooks,charts,stability books, work permits, written proceduresand a wealth of vessel data that might be relevant to the incident.It is not always possible to take such data from the vessel and care should be IMCA SEL 01619 takentoobtainclearphotocopies,whichshouldbesignedasbeingtruecopiesbyan appropriate person on board, preferably the master. Notethatoneoftheexampleinterviewquestionsinsection5.3wasDoyouhaveany writtennotes?Suchnotescouldjustbescribbledonscrapsofpaper,buttheycouldbe important and useful to the investigation.They should be obtained and treated in the same way as all other retrieved evidence. Whereverpaperworkisretrieved,itshouldbecarefullyhandledsothatitdoesnotget marked in any way.It should be filed and kept where it will not get marked or damaged. Avoidmarkingdocumentalevidenceforfilingpurposesorwithinvestigatorsnotes.If necessary, it could be signed and dated for verification in a harmless area of the document, where it does not obliterate anything else.Put it in a specific file, which can itself be marked for filing, and add separate sheets of paper with any necessary explanatory notes.(Refer to section3.3.2forfilereferencing.)Beawarethatsomemachineprint-outscanbeon pressure-sensitive paper and data can be easily obliterated by careless handling. 6.1.2Physical Evidence Physical evidence, such as broken pieces of rigging or sections of machinery, can also be vital to an enquiry and care must be taken to preserve them and keep them secure. These might range, for example, from small chunks of a broken shackle toa propeller tail shaft or crane boom.Iftheyarekeptsomewherewheretheycanbeexposedtocorrosionorother damage, they might losesome forensic value. Photographs of the items could be extremely helpful especially to show their condition, in case corrosion or further damage is inflicted at a later time. Takesamplesofbrokenpartswherepossibleandlogthem.Ifnecessary,dispatchbroken partstothecompanyshealth,safetyandenvironmentdepartmentorothercompany nominatedindependentspecialistforanalysis.Ensureallpartsandoriginaldocumentssent away are recorded and logged by the vessels master, safety officer or site safety officer or his nominee. Wherepartsaresentaway,perhapsbecausetheyaretoolargetostoreonthevesselor work site, care should be taken that they are stored somewhere where they are available to acompanyinvestigationteamatalaterdate,butotherwisesecure.Theyshouldalsobe protected from interference and from damage, from corrosion for example. Ifnavigationalissuesareinvolved,theoriginalchartmustbekept,unmarked,followingthe incident.If the records are kept on ECDIS, company procedures should ensure that data is retainedappropriately.Thevesselsvoyagedatarecorder(VDR)mayneedtobeaccessed andproceduresshouldallowforthiseventuality.Navigationalincidentsrequirespecialist investigation and are not dealt with in detail in this guidance. 6.1.3Photographic Evidence Takephotographsofthespecificobjects,relatingthemtosomethinginthepicturethat indicatesthescaleandsizeoftheobjectwherepossible.Usethetimeanddateimaging facilityonthecamera.Useadigitalcamerasfacilitytoseewhetherthephotographis sufficiently clear and useful. Thecamerashould havea facility toshow the dateand time of thepicture taken.A digital camera is useful as theimages can bedownloaded and sent electronically.A flash facility is nearly always needed and better quality cameras generally give more useful results.The time and date thatall photographs are taken should be recorded.This record may then be used as evidence at subsequent enquiries or to assist with interviews. Printed photographic records of the incident should be endorsed by two signatures in order thattheycanactasanagreedrecordofthesiteatthetime.Non-digitalimagescanbe helpfulifthereisaneedtodemonstratethatdigitalimageshavenotbeeneditedfromthe original. 20IMCA SEL 016 Acquirecopiesofanyotherphotographic(cameraorvideo)evidenceoftheincidentitself.Give photographs a distinguishing mark on their reverse side and mark the media disc or tape appropriately for filing reference and for identification in statements where appropriate. Video cameras can provide excellentevidencegathering material.They often providemore informationthanmightbeexpected.Also,videofootagetakenbytheinterviewerorthe interviewing teamcan provideuseful reminders about the incident and itsenvironment that can prove to be a valuable aid some years after the event. 6.1.4Recorded Media Evidence A significant and increasing quantity of recorded media evidence is available from equipment onboard vessels or at work sites.Whereas simple printouts of engine telegraph movements andcourse recorderswereall that was once available, this has largely been improvedupon with, for example, voyage data recorders. Theequipmentcarriedonboardvesselsfittedwithdynamicpositioningsystemsprovides further access to electronic data records.That carried on seismic survey vessels and pipe or cable layers could carry significantly more. Heavylifting systems andcranes could havea number of different electronic datacollection points. Anysystemthatrecordsdatathataffectsthevessel,suchasitsnavigationorstability,ora system that records data on any equipment relevant to the incident should be examined for evidence. Communication records should be checked.TheremightberecordsofVHFandotherconversationscapturedonVDR,dependingon what options have been activated in the particular vessels system. Records of divers communications will usually be kept for 24 hours after a dive, before being erased. Careful liaison is required with those onboard or at the work site to ensure that all possible mechanical or electronic data is extracted and secured by the interviewer. Careshouldbetakenthatdataretainedonvarioustypesofmediaisnotharmedby inappropriate storage or by electronic interference. Obtainverificationoftheidentityofsupportingevidencebydescriptioninawitnessreport and/or by signatures and date in a harmless area upon it. Allevidenceshouldbehandledandkeptwithcare,asmostelementsofitcouldhavean extensivelifeaheadofthem.Theywillbeusedintheincidentinvestigation;thencouldbe used again in any legal action, which could goon for some years(seesection3.3.3).There may also be insurance claims see section 9.2 and relevant appendices. Summary of points for supporting evidence: Obtain (or note secure location of) all relevant evidence; Obtain verification of its identity; Preserve with care; Keep somewhere secure; Ensure items are file coded, or kept in a file appropriately coded; Obtain consultants assistance where required; Take photographic/video evidence; Collect copies of photographs/videos taken at the time of the incident; Collect data from all relevant recording equipment; Obtain verification of the datas identity. IMCA SEL 01621 7Initial Analysis The purpose of an analysis will always be to define what happened, when, where and how it happened and most importantly why it happened. Thoseinvestigatingincidentsgenerallydeveloptheirownmethodsofanalysingtheinformationobtained.The following is intended to act as an aidboth for formatting a company procedure and for those involved in an investigation. 7.1Storyboard Itisveryhelpfulifthereisaroomavailablethatcanbeusedasanincidentroom,assuggestedin section4above. Flipcharts orchinagraph boardscan beutilised todraft storyboard detail of all the relevant items learned.The space or equipment should ideally encourage the development of a long timelineillustration,workingbackfromtheincidentforalongenoughperiodtoincludeallthe background information. Thetimelinecouldincludeanythingrelevanttotheincident,suchasforexampleequipment certificationandinspectiondates,datesthatpersonneljoinedthevessel,timeswhendifferent personnelcameonduty,changesintide,weatherandseastate,whereandunderwhatconditions equipment had been in storage, when it was last used and so on. There could be a specific area or flip chart page devoted to the activitiesimmediately prior to and at thetimeoftheincident.Thiscouldincludeasketchshowingsuchthingsasthelocationsof equipment and personnel and show sight lines of individual witnesses, wind strengths and direction and sources of light. If printed photographs are available these can be attached, together with any notes and sketches, along the timeline. Displayingtheinformationinthiswaycanbeofparticularhelpiftheinvestigatingteamconstitutes morethanonepersonandtheyallinputeverythingtheyknowrelativetotheincident.Itis sometimes surprising that what is thought to be general knowledge by one member of the team turns out to be a revelation to another. Some companies set out particular styles and methods for charting the relevant factors that result in anincidentonanincidentreviewchart,suchasisdemonstratedinAppendix2.Forexample,they mightusecirclesand/orboxestodefinespecificknownactionsandusedottedoutlinesofthose shapestoindicatewhereanassumptionisbeingmade.Furtherdesignatedshapescanbeusedto indicate various causal elements. 7.2Final Examination of the Storyboard Evenwhenitisthoughtthatalltheevidencehasbeenobtained,whatisexpectedtobethefinal examination of thestoryboard can often highlight something that has not been focused on.It might appearasmallorirrelevantissue,butitcouldbethemissingfactorwhichpointstowardan unexpected root cause. Such proceduresare only intended toassist theinvestigating team inassembling and studying all the information in a logical order, but once complete, photographs or video of the completed work could be useful at a later date. The storyboard should provide a helpful guide to compiling a final report that shouldrefer to all the relevant evidence and explain why conclusions have been reached from that evidence. Followingthisguidanceshouldresultinafinalreportthatidentifiesthemostprobableapparent immediateand root causes, but if thesecannot beclearlyidentified thereport should statethat and make recommendations as to what further work is needed. Thereportshouldconcludebystatingrecommendationstopreventfurthersimilaroccurrencesand what actions had been taken thus far to do so. 22IMCA SEL 016 7.3Prepare Report Form conclusions based on the total information received, testing each conclusion in the light of all evidence, making use of the storyboard (see 7.1) and any other helpful procedures. Define what seem to be the immediate and root cause(s) Draft report. Thebeginningofthereportshouldstatetheworksiteinvolved,therelevantequipment, personnel and general sequence of events.Prepare all the report in draft and test the conclusions before finalising, especially with respect to the immediate and root causes. 7.4Report Complete the incident report in keeping with company procedures and any statutory reports that may be required. Make recommendations on steps to be taken to avoid a recurrence of a similar incident. If further assistanceis required todefinetheroot causes, because theexpertisetoanalyse thefacts may not be available and if external advice is necessary, company procedures should allow for liaison withtherelevantcompanydepartmenttofacilitateprovisionofthenecessaryexpertise,perhaps through a consultant company. IMCA SEL 01623 8Subsequent Analysis Theinitialanalysismightshowtheneedforaconsultanttobeinstructed.Thevalueofthein-depth investigation is then highlighted, because a wealth of information, which had been obtained relatively easily and quickly by following company procedures, is now instantly available to a consultant. The consultant may even have enough information to prevent the need to travel to the vessel or work site. Iflitigationisinvolved(seesection9.1)thenlawyersinstructedbythecompanywillneedtoexamineallthe evidenceobtainedasquicklyaspossible,butmightalsowishtointerviewwitnessestoobtainstatements, despitetheprovisionofthewitnessreports.Thisisbecausetheywillhavetherequirementsoftheirown court processes in mind and will be aware of specific established and current legal issues, such as recent case law, which could have relevance to the circumstances of the incident.They will often, for example, require a fuller account of the background of the witness than might be included in the usual company reports and might need to explore particular issues that are not necessarily focussed on the root cause. It is possible that any further examination of the facts, from a different perspective, or using different methods, could highlight new factors that are also found to be causative. See section 10 and the relevant appendices for styles of reporting formats. 24IMCA SEL 016 9Other Considerations 9.1Litigation Concerns Asecondary,butnonethelessveryimportantreasonforanyincidentinvestigationrelatestothe possiblelitigationthatcanarise.Suchlitigationmightnotstartimmediately,butcouldcommence some considerable time after the event. Litigationmightarisebecausetherehavebeenphysicallyinjuredparties,orwherevesselsor equipmenthavebeendamagedorlost,orfrompartiestoacontractwheretherehasbeenlossof profit. Largecompanieshavelegaldepartments,butsmallercompaniesmaynot.Iflawyersareinstructed, then it is certain that they will wish to conduct their own investigation, but the provision of sufficient evidence collected as soon as possible after the event, perhaps before there has been time to instruct lawyers,couldassistthemandmightevensavesomethinginlegalcosts.Iflawyersareinstructed quickly enough, they will get to the site of the incident while the knowledge is still fresh, the evidence stillavailable,andbeforethewitnessesmoveon.Sometimesthatisnotpossible,perhapsbecause litigationhadnotbeenanticipated,orperhapsbecausethevesselorworksiteisnotimmediately accessible.Somecompanieshaveproceduresthatpreventinvestigation,particularlyofmajor incidents, either totally or in part, until their legal team is able to attend. If a company has a procedure in place that can capture and record relevant information as quickly as possible,itcouldproveextremelyuseful,helpsavelegalcostsandpossiblyavoidhugesumsinlegal damages. Wherelitigationisexpected,lawyerswillbeinstructedbythecompanyandtheywillprobablysend their own representative to investigate.This representative will be experienced in obtaining evidence from similar incidents and might also bring an expert consultant to assist on certain aspects.They will need to see all the material obtained in any previous investigation. They might, in fact, be the first to arrive on site and might effectively be the central point for the whole of the investigation. It will very much depend on the nature of the incident and their instructions. Thoserepresentingacompanyslegalinterestswillhaveadifferent,butnonethelessfarreaching, catalogue of issues to address.In taking statements from witnesses they might have to ask a range of questions which might seem to those interviewed to be either obvious or unrelated, but there will be a valid reason for asking them.They may need assistance in obtaining all the information they require.Forexample,theymaynotbefamiliarwiththecompanyprocedures,orknowforexample,where pertinentrecordsarekept.Theywillnotnecessarilyknowallthedatapointsforcollectionofthe many items of electronic data that can be stored on vessel systems.They will need to understand the operations relevant tothe incident and a rangeof matters that will becommon knowledgetothose involved with such operations on a daily basis. There is usually a vast amount of information available from correctly completed incident investigation reportsandtheywillstudythesecarefully.Theymayfindgapsintheinformation.Forexample, if most of the information is only that presented on standard company incident report forms: operational or time restraints can prevent careful completion; theformmightnotallowforenoughinformationtoberecorded.Forexample,aformmight allowfordescriptionofavesselsactivity,butnotforadescriptionofhowitwasmovingina seaway at the relevant time; companyformsareoftenwrittenwiththeassumptionthatthereaderisfamiliarwithorhas reasonable knowledge of the relevant operation.This often leaves some questions unasked. It is crucial that the legal team is made aware of all aspects of the evidence, especially any facts which might appear to negate a case against another litigant.It is only by knowing the negative as well as the positive aspects of a case that lawyers will be able to assist to the companys best advantage. Theexpenseofinstructinglawyersisnottakenlightly.Thetimethatisspentinvestigatingand preparing the evidence file can be the most cost intensive, so that the work done in this time should IMCA SEL 01625 becarriedoutasefficientlyaspossiblebyensuringthatallthoserelevanttotheinvestigationgive them every assistance in their task. 9.1.1Quantum of Claims Further to the issues of cause and liability, the lawyers will also need to secure the evidence for any claims against third parties.These will include a range of items of claim, such as loss of hire, expense of repairs or lost equipment, some surveys, and similar expenses that would not have been incurred if the incident had not happened.Proving they are recoverable is not necessarily straightforward.Without documentary evidence in support they may prove to be non-recoverable.Thus,therelevantdocumentsinsupportcaneachbeworthsignificant sums of money.The focal point or person charged with keeping the documents (see section 3.3)shouldalsobeprovidedwithrecordsofanysuchexpenditureforsafekeeping*.Documents should be kept in such a way that it is immediately apparent what they are. For instanceareport,invoiceorreceiptinaforeignlanguageshouldbeaccompaniedbyan explanatory slip. 9.1.2Privileged Documents Whencollectingevidence,itwillbenecessarytobeawarethatthereisacategoryof documents that are referred to as privileged. In litigation, privilege can be defined asthe rightofapartytorefusetodiscloseadocument,orproduceadocument,ortorefusetoanswer questions on the ground of some special interest recognised by law. In essence, if the dominant purpose for the creation of some documents is for litigation, then they may be deemed to be privileged and the company will not be bound to disclose them to opponents.This usually applies to correspondence between lawyers and their clients. It can also apply to those documents created by employees of, or consultants to the company for the purpose of providing them to lawyers to obtain legal advice. Thisguidanceisnotintendedtodealwithlegaldetailandcaselaw.Interviewingteams should check with their legal advisers before disclosing any information to other parties.It is always advisable to refer those other parties to the companys legal advisers. Somecompanieshaveacoverpageformatforuseondocumentsthataredevelopedasa result of the directions of a company instructed lawyer, wherein the report is expected to be a privileged document.A typical format is set out in Appendix 11.Note also the Privileged heading on the example report format in Appendix 5. Note also section 3.3 Who Looks After Documentary Evidence?Document Control. 9.1.3Permission for Others to Access Vessels and WorksitesItisnotuncommonforotherpartiesaffectedbytheincidenttobeinvestigatingandthey mightinadditionhaveinstructedlawyersorconsultantstodosoforthem.Otherparties usually will be interested in defining whether they can claim recompense for alleged losses. Accesstocompanypropertyisonlybyinvitationand,whilethecompanymightliaisewith otherpartiesandallowthemaccess,usually,forexample,forsurveyorstoexamineanydamagetoequipmentorvessels,companyregulationsandproceduresshouldgovernthat access, especially for instance in relation to safety aspects.Always contact your legal advisers should other parties require any such access. No admission of liability or offer of settlement should be discussed with any third party and any communication from a third party should be passed to the appropriate department in the company.Theinvestigationteamshouldnotenterintoanycorrespondenceor communications with any third parties except specifically as directed by the company. *Ifthecourtdecidesthatapartywasunderadutytomaintaincontemporaneousrecordsandhadnotdonesothenitmay,when making the assessment, give the benefit of any doubt as to quantum to the other party; as in Mustill J in Thompson [1984] 1 All ER 881 at 910. 26IMCA SEL 016 9.2Insurance Issues Insurersareinvariablyinvolvedwhereverthereisasignificantincidentresultingindeath,injury, damageorpotentialfinancialloss.Companyprocedureswillusuallyinstructthemasterto immediately inform a specific person or department in the company office of any such incident.There will then bea need for thecompany toinform theinsurersor theappropriatebroker(s) as soon as possible. Therewillbeatleast twoaspectstotheinsurance,thoseofthehullandmachinery(H&M)andthe protection and indemnity (P&I) clubs. Incidents affecting H&M coverage will usually include damage to the vessel, which is rarely 100% cover.The remainder is usually covered by P&I club insurance, which will also include third parties, accidents to and illness and death of personnel, crew repatriation, pollution and expenses arising from wreck for example.If cargo is carried there could be involvement of cargo insurers. Insurancecovervarieswidelysothatdetailsarespecifictoeachandeverypolicyandinsurerswill differ in their requirements for reporting. The insurers might have provided appropriate documents for completion and sufficient instructions on how to report but, if not, the vessel owner or operating company should provide a suitable form that will cover each type of claim. On significant claims, in certain cases, an average adjuster might be involved and the adjuster will also requiretobeprovidedwithallrelevantdocumentsrelatingtoexpensesincurred.Careshouldbe takenthatallpartiesrequiringsuchdocumentation,betheytheinvestigationteam,theinsurers, lawyersorregulatoryauthorities;areprovidedwithsufficientcopiesofthedocumentsrequired.In ordertoobtainrecompensefrominsurersforexample,theoriginalsofcertaindocumentsmaybe required. Appendix11showsatypicalcompanyflowchartforguidancethroughinsuranceclaimrequirements, followed by associated written instructions. Note also section 3.3 Who Looks After Documentary Evidence?Document Control. IMCA SEL 01627 10IMCA Incident Reporting IMCAmembersbenefitfromthreetypesofreporting:thosethatbecomeIMCAsafetyflashestoinform colleagues and encourage learning from an incident and avoidance of repetition; those that are contributed for annual safety statistics and those that are used to populate incident databases. 10.1IMCA Safety Flashes IMCAmembersareencouragedtopassonrelevantinformationfromincidentsbyuseofthesafety flashsystem.Incidentsarereportedtothesecretariat,whichthenprocessesthetextsothatitis anonymous and, once the provider has confirmed the wording of the draft, it is distributed to IMCA members.Thecompletecataloguefrom1997isavailabletomembersviaasecurewebsite.Non-members are able to view the safety flashes for the latest twelve months on the public website at www.imca-int.com/safetyflashes 10.2IMCA Safety Statistics These are compiled from data voluntarily contributed by IMCA members and published annually. 10.3DP Incidents Dynamic positioning (DP) station keeping incidents can be reported as described in information note IMCAM36/05,withreportingformsavailableinprintedandelectronicformsfromtheIMCA secretariat. 10.4Lifting Incidents Lifting incidents can similarly be reported to IMCA using a form available on request from the IMCA secretariat, distributed to members information note IMCA SEL 32/05. 10.5Security Incidents Security incidents can be reported to IMCA (imca@imca-int.com), where they can be taken forward bythesecretariatandbytheSecurityTaskForceonananonymousbasis.Aconfidentialreporting system is currently under preparation.Details on this particular initiative will be made available with other security-related material at www.imca-int.com/security 28IMCA SEL 016 11Appendices The appendices that follow are based on those kindly donated by companies and are included merely to show the sort of reporting formats that are currently in use for the purposes noted.They do not indicate a specific standard and companies will have varying requirements depending upon their operational activities. The information on IMCA safety statistics is taken from information note IMCA SEL 12/06. Companies will have their own style and their own requirements for the way in which investigation reports are presented.Thiswillbeinfluencedbythetypeofoperations,theirgeographicallocationandthegeneral company persona. Appendix 1shows a useful way of defining investigation magnitude, which will vary with companies and their operations see section 3.1. Appendix 2shows some typical flow chart symbols useful for story board compilation see 7.1. Appendix 3showsasamplereportform,whichsummarisestheinformationcollated.Itprovidesa tickboxformatforidentifyingthegeneraldetailsoftheincidentandwhetherspecific important actions were taken.The latter section goes on to require a written summary, with conclusions, a report of actions taken and other recommendations.This guidance is primarilyaimedathowthatlattersectioniscompleted.Ausefullistingsectionisthen included, which provides a record of all the witnesses, a note of what supporting evidence exists and a helpful way of categorising the general causes. A facility for a report from a complainantisprovided.Thenthereisasamplewitnessstatement,whichwillclearly need more pages if it is completed in line with this guidance. Appendix 4 shows a companys format for a management review report which is self explanatory. Appendix 5showsamoreopenformat,whichallowsgreaterfreedomforthereporter,butwhich giveslessguidanceastowhatisrequireduntilthethirdsectionisreachedwhenthe report is ordered into a list of useful headings. Appendix 6shows a pragmatic flowchart showing what is required of a particularcompany operating underUKorotherflag,whichcouldbeeasilyadaptedwiththedefaultpositionbeing whatever flag was pertinent. Appendix 7shows a sample near-miss form see section 3.3. Appendix 8indicates another type of format, for an infringement of safety zone report see 3.1.4. Appendix 9shows IMCA safety statistics reporting definitions (see 3.1.1).Appendix 10shows an example of a companys definitions. Appendix 11provides a helpful flowchart as used by a company to indicate procedures for reporting in respect of incidents where insurers are likely to be involved. Appendix 12gives an example introduction for a privileged document (see section 9.1.2). IMCA SEL 01629 Appendix 1 Sample Investigation Levels Thefollowingmatrixisatypicalexampleofhowonecompanyidentifiesinvestigationmagnitude,withthe definitions set out below. Thematrixand itsparametersin particular areonlyintendedasexampleseachcompanywill haveitsown viewsonwhat,forexample,ismeantbyaminorspill.Incomparingexistingcompanydocumentswhile preparing this guidance, examples include another company showing a minor spill as being in the order of 1bbl, orlessthan150litres,whileitsmatrixincludesalowerlevelthanminor,calledslight,whichreferstoan insignificant leak or loss.Financial losses rated against specific levels also vary noticeably between companies. Potential consequence of the incidentLikelihood of reoccurrence To peopleTo assetsTo the environment Very Low (A) Low(B) Medium (C) High (D) Very High (E) 1Insignificant injuryInsignificant damage Slight leak/spill contained Level 1Level 1Level 1Level 2Level 2 2Minor injuryMinor damage Minor leak/spill contained Level 1Level 1Level 2Level 2Level 3 3Serious injury Serious damage.Vessel safety not compromised Minor leak/spill not contained Level 2Level 2Level 3Level 3Level 3 4Near-fatality Major damage.Vessel safety compromised Significant leak/spill not contained Level 3Level 3Level 4Level 4Level 4 5Fatality Extensive damage/ sinking Major leak/spill not contained Level 4Level 4Level 4Level 4Level 4 Table 1 - Sample Incident Classification Matrix Parameters Likelihood of reoccurrence Very low (A)Has not occurred in the known past.No known chance of future re-occurrence. Low (B)Unusualcircumstance,butconceivablethatasimilaroccurrencecouldoccuragainonany vessel/location. Medium (C)The circumstances are such that this could conceivably occur on a vessel High (D)It is credible that this incident could occur on any vessel. Very high (E)It is likely that this could occur on any vessel. Investigation levels: Level 1Investigationcarried out onboard thevessel by thesafety officer or master with assistance from the crew as appropriate. Level 2Further investigation carried out by company safety officer, HSE supervisor, port captain, port engineer or equivalent. Level 3Full investigation carried out by an investigation team, normally lead by the director of safety, area safety manager, area operations manager or equivalent.The team selected will depend upon the accident or incident and will be such that the necessary competence and technical skills are available to fully determine what happened during the incident and to make effective recommendations to prevent a recurrence. Level 4Full investigation at corporate level carried out by an investigation team, normally led by the vice president of HSE, loss control and offshore personnel or equivalent. The team selected willdependupontheaccidentorincidentandwillbesuchthatthenecessarycompetence 30IMCA SEL 016 and technical skills are available to fully determine what happened during the incident and to makeeffectiverecommendationstopreventarecurrenceandtoensurethatanyadditional resourcesthatmaybedeemednecessarytomitigatefurtherloss,damageorriskare effectively applied. Consequence definitions (examples only): Asset damage: Insignificant damage US$500 or less Minor damage greater than US$500 and repair work can be completed during regular dockside visit with no off-payroll downtime Serious damage vessel safety not compromised and repair work requires up to 48 hours off payroll downtime to complete Major damage vessel safety compromised and repair work requires more than 48 hours off payroll downtime to complete Extensive damage/sinking Environmental damage: NBspill contained means no pollution event.If any pollutants entered the environment, no matter how small,thenitwouldbeconsiderednotcontained,makingtheincidentapollutioneventrequiringa minimum Level 2 investigation. Slight leak/spill contained 4 litres (I gallon) or less of a pollutant, contained Minor leak/spill contained Over 4 litres (1 gallon) of a pollutant, contained Minor leak spill/not contained Any pollutant released into the environment Significant leak/spill not contained Over 100 litres (25 gallons) pollutant released into the environment Major leak/spill not contained, sinking IMCA SEL 01631 Appendix 2 Typical Flowchart Symbols Examples Incident The most serious event that took place; the reason for the investigation Shown in the proposed sequence of the events and follows the rules of events Enclosed in a circle and connected to events by solid arrows. Events Each box is a step (action) in the sequence; use one action per box Each box tells who did what or what equipment did what Sequence is from left to right; use arrows to connect boxes showing sequences direction Use job titles, not peoples names May include date/times above boxes Actions should be factual, non-judgemental, precise and quantified if possible Dashed line boxes indicate assumptions or events that have not been proven An event sequence may have parallel paths (multiple simultaneous sequences) Conditions Explain the action that took place in the attached box Should be factual, non-judgemental, precise and quantified if possible May be arranged in a cause/effect hierarchy (one condition is related to another) Dashed ovals indicate assumptions or conditions that have not been proven Should not include action steps Causal Factors Conditions (and occasionally events) that, if eliminated, could have prevented the incident or reduced its severity Designated by darkened squares Causal factors are incorrect actions or equipment functioning in an unintended way If multiple, related conditions are part of a problem, the causal factor is the most general problem.Attach the related conditions to the causal factor in a cause and effect hierarchy Include all ovals attached to a causal factor in the root cause analysis of that causal factor IMCA SEL 01633 Appendix 3 Sample Company Incident Reporting Form This form is to be completed in respect of every alleged accident or incident. See company procedure for further guidance. General Information Vessel: Master: Client: Reference: Client informed: Vessel location: Date occurred: Time occurred: Type of incident: Injury Illness Third party Hull Machinery Cargo Pollution Vessel movement: Moored at dock Manoeuvring around dock Manoeuvring inconfined waters Underway offshore Standby duties Cargo transfer Moored to buoy At anchor Dodging heavy weather Fast rescue craft (FRC)/ daughter craft (DC) duties Other, please detail: Was a JSA/risk assessment carried out? Yes No Weather conditions and time of alleged incident: Wind strength and direction: Sea state: Tide/current strength and direction: Visibility: Weather: Task being performed: Routine bridge operations Engine room operations Personnel transfer basket Personnel transfer swing Ship maintenance (routine deck work) Mooring/ anchoring operations Handling dangerous substances Movement about ship (slips, trips and falls) Cargo operations Towing/anchor handling Lifting/carrying by hand Lifting/carrying mechanically Electrical work FRC/DC Catering Other, please detail: Personal data: Names of persons injured Job title Employer On duty Hours worked prior to incident Nature of injuries 34IMCA SEL 016 Incident Detail Brief description of incident, including location of incident, injuries, damage: Briefly list treatment given or repairs undertaken onboard: Treatment given by: Date/time incident reported: To whom incident reported: Was casualty sent ashore for treatment? If so: Yes No How: When: Where: Describe actual events or circumstances leading up to the incident: Masters signature: Date IMCA SEL 01635 Investigation Results Based on the investigation, describe the facts and circumstances of the incident: Continue on a separate sheet if necessary Was any other investigation carried out? Yes No Conclusions of investigation: Continue on a separate sheet if necessary Actions taken to prevent re-occurrence: Further actions recommended: Details of investigation carried out: Site inspection carried out Photographs Sketch/plans/ drawings Interviews Witness statements Correct systems of work verified Timeline established Facts established Contradictory evidence investigated Conclusions & recommendations Supporting evidence attached: Witness statements Sketch/plan Photographs Timeline Other (list): 36IMCA SEL 016 Witness List This form is to be completed in respect of every alleged accident or incident where there is a complaining party illness, injury or damage to assets.See company procedure for further guidance Full Name (please print)Employee IDJob Title Statement Yes/No Signature Cause/Triggering Event and Other Contributing Factors Please list below the primary cause/triggering event and any other contributing factors Insert P for the primary cause and for all other contributing factors that apply Procedures/Policy/Pre-Job PlanningTools/Equipment/PPEOther Party Actions Lack of proceduresInadequate assessment of needsActs of God (error enforcing condition) Use of wrong procedures Inadequate human factors/ergonomics considerations Weather Lack of understanding proceduresInadequate standards or specificationsSea state Inadequate proceduresInadequate adjustment/repair/maintenanceVisibility Lack of communicationInadequate removal/replacementActions by non-company personnel Not following procedures/policyEquipment failure/defectActions by other crew member No pre-job planningImproper useActions by management Inadequate pre-job planningFailure of PPERiot, civil unrest Inadequate management of changeImproper or not using PPEUnderwater hazards Physical Capabilities/ConditionKnowledge/TrainingHouse Keeping (including deck area) Sensory deficiencyLack of experienceImproper house keeping Physical disabilities permanent/temporary Inadequate trainingImproper storage/securing Inability to sustain body positionMisunderstood instructionLack of house keeping Restricted range of body movementNo training providedLack of timely house keeping Improper body placement/positionImproper training Over exertionExposure to hazards materialsMaintenance/RepairsWatch Keeping Improper/lack of hygieneInadequate preventative maintenanceNo watch keeping FatigueInadequate corrective maintenanceInadequate watch keeping Use/abuse of medication or drugsInadequate audit/inspection/monitoringImproper watch keeping Previous injury or illnessWrong maintenance/repairJudgmental error Over maintenance HasteEngineering/DesignSkill LevelPreoccupation with other tasks/ eventsInadequate designInadequate assessment of required skillsPerceived hasteImproperly designedInadequate practice/performance of skills Self applied hasteDesign failure/flaw Horse play Person completing form to sign below: Name (print clearly) Employee ID Sign Date Office use only: Reviewed by Date Further action Severity IMCA SEL 01637 Report of ComplainantPlease complete and provide as much factual information as possible Vessel: Master: Client: Reference: Describe when, where and how the incident occurred: What, in your opinion, was the cause of the accident? Continue on a separate sheet if necessary What were you doing at the time of the incident? Continue on a separate sheet if necessary What work was being carried out at the time of the incident? Were you involved in that work and, if so, how? What instructions had you received prior to carrying out the work? List any machinery or equipment involved: List what personal protective equipment you were using: Detail any injury, illness or damage: Supporting evidence attached: Witness statements Sketch/plan Photographs Timeline Other (list): Complaining party: Name (print clearly) Position Sign Date Received by master: Name (print clearly) Position Vessel master Sign Date Office use only: Reviewed by Date Further action 38IMCA SEL 016 Witness Statement Vessel: Master: Client: Reference: Full name and address: Date incident occurred: Time incident occurred: Describe when, where and how the incident occurred: Supporting evidence attached: Sketch/plan Photographs Timeline Other (list): Complaining party: Name (print clearly) Position Sign Date Received by master: Name (print clearly) Position Vessel master Sign Date Office use only: Reviewed by Date Further action IMCA SEL 01639 Appendix 4 Sample Incident Management Review Report Format To be completed by the appropriate onshore manager Reference: Name of vessel: Date of alleged incident: Investigation reviewed by: Name of complaining party: Any further investigation necessary? If so, what? Any further recommendations or comments? List actions and by whomBy date: Name (print clearly) Position Sign Date IMCA SEL 01641 Appendix 5 Sample Company Investigation Report Format Note comments regarding privilege (see section 9.1.21.3) 1Cover Page PRIVILEGED Prepared in anticipation of litigation SIGNIFICANT INCIDENT INVESTIGATION Vessel/worksite name Incident number Risk level Date of incident Incident report prepared by: Date: Report version history: 42IMCA SEL 016 2Sign-Off Page Completed byDateSignature Draft significant incident investigation report completed (latest 30 days after incident) Investigation leader Proposed actions and recommendations acceptedCompany president Actions captured in incident databaseIncident and safety review co-ordinator Actions closed out in incident databaseIncident and safety review co-ordinator Review by risk management board completedHealth, safety and security manager Close-out of incident investigation endorsedCompany president Incident closed out in incident databaseIncident and safety review co-ordinator IMCA SEL 01643 3Report Contents The report contents would be included here, at the front of the report, with following pages left blank under the above headings. Purpose .................................................................................................................................................................................Executive summary ............................................................................................................................................................Events leading up to incident ..........................................................................................................................................Incident description and consequential damage or injuries ....................................................................................Incident review ...................................................................................................................................................................Cause analysis .....................................................................................................................................................................Actions to avoid recurrence ...........................................................................................................................................Reference section .............................................................................................................................................................. A sample executive summary table is shown below No.CauseRecommendation/actionActionee(s)Target dateCompletion IMCA SEL 01645 Appendix 6 Sample Incident Flowchart IncidentAre you inUK waters?Does the incidentmeet statutoryreporting criteria?YesAre you ina UK port?Are youoperating eitheron a pipeline or insupport of anoffshoreinstallation?NoDid incident occurduring access oronboard vessel?Is vesselregistered inthe UK?Complete internalincident reportComplete otherrelevant companyformsComplete insurancereport form (IRF)Complete internalincident reportComplete otherrelevant companyformsYesNoYesYesWas victimworking?YesComplete internalincident reportNoComplete internalincident reportComplete insurancereport form (IRF)Liaise with client andcompany regarding anyspecific administrativerequirementsCom