Incidents can happen from time to time in the marine industry and these may be major accidents or even near misses. When these do happen, they must be investigated because it is demanded by many flag administration rules and international agreements. This is referred to as marine investigation analysis which is designed for helping organizations learn from their mistakes and past performance and come up with better strategies to improve safety.
The main purpose behind marine investigation analysis is not simply to figure out “how” or “what” happened but “why” it happened. So this process starts with collecting data which is then organized and evaluated using different methods like fault tree analysis, factor charting, etc. The goal is to figure out why an incident took place.
How is marine investigation analysis carried out?
Causal factors are the ones which contributed to it like problems, human errors, or external factors, which could have either been controlled or eliminated. So, once the incident has been understood, the causes are identified for every causal factor and these root causes are basically deficiencies which is why the causal factors exist. So, recommendations are ultimately developed and deployed to do away with such causes and prevent their recurrence. For this, 2 levels of analysis must be undertaken; an apparent cause one and a root cause one.
Steps to analyze marine investigations:
- To begin with, you have to determine whether an incident must be analyzed; this means finding out if an incident actually needs to be investigated. If the real or potential effects of that incident are found to be not that important, it can be simply recorded in the database. But if the incident is found to be necessary for investigation, a CAR or corrective action request gets generated. Thereafter, a decision must be taken whether that incident needs to be analyzed then or at a later date.
- Next, preparation for that investigation starts; this includes defining what happened and assembling a team that will take care of fact-finding for the investigation.
- The data thus gathered must be preserved; data can be grouped under electronic, paper, people, position, or physical categories. This information is needed to understand why an incident happened.
- The data is then analyzes using different tools like the fault tree, causal factor chart, and 5 Whys technique. You may use others like operability analysis and hazard. When you analyze data you often come across data that you still need for a proper analysis, and you may have to go back a step to collecting more information.
- The next step is to identify the root causes, human errors, equipment or structural issues which could have led to this incident. Toot cause analysis allows a better understanding of the underlying causes.
- The following step is to come up with recommendations because identifying causes is not simply enough. Definite changes must be made once causes have been pinpointed. Recommendations can be short-term or long-term.
- Finally, the investigation must be completed as everything that has been discovered is complied into a report. Results now are communicated to those who had not been part of the investigating team. The investigation process is then reviewed.