Accident Investigation. When does it improve safety and quality?
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Lianne van der Veen about incidents and accidents registration and research for pilot organizations by Dutch Safety Board
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Accident Investigation. When does it improve safety and quality?
- 1. Accident Investigation When does it improve safety and quality? Lianne van der Veen ISPO Conference – Rotterdam – June 22nd 2017
- 2. Dutch Safety Board Multi- modal No blame Mission Its main focus is those situations in which civilians are dependent on the government, companies or organisations for their safety. Indepen- dent Impartial Objective
- 4. Dutch Safety Board Multi modal No blame Mission Its main focus is those situations in which civilians are dependent on the government, companies or organisations for their safety. Maritime
- 5. Maritime obligation (IMO, EU) Very serious casualty Loss of life Total loss of the ship Severe pollution Serious casualty Fire, explosion, grounding, contact, heavy weather, hull cracking resulting in: •Structural damage (unseaworthy) •Pollution (any quantity) Obligation to investigate Assessment IMO Casualty Investigation Code (Resolution MSC.255(84)) (Marine casualty or incident) PART 1 General Provisions Chapter 1 Para 1.2 A Marine Safety Investigation should be separate from, and independent of, any other form of investigation
- 6. What is the main cause of accidents? Human error… “The point of an investigation is not to find where people went wrong – it is to understand why their assessments and actions made sense at the time” (Sydney Dekker 2002)
- 7. Gathering information S - Software H - Hardware E - Environment L – Liveware
- 8. Gathering information Now you can start to understand the “circumstances”, that possibly have influenced the central person.
- 9. Analysis What does analysis actually mean? Van Dale: the separating of any material or abstract entity into its constituent elements. … A systematic approach to solving a problem. Complex issues are made simpler by dividing them into more understandable elements.
- 10. Analysis What? Chronology Identify all casualty and accident events Human Factors How? Methods (Step, Tripod, Bowtie, HFACS etc) 5 times “Why” To determine safety issues and deficiencies
- 11. Manag’t/Organizational Factors Operational Factors Human Error and Other Failure Mechanisms Accident Events What? Why/How? Why? Why? Why? Equipment Failure Human error Human error Lapse Observation error Slip Oxygenation Omission Error in intention Brittle fracture Interpretation error Wear Workload Supervision Noise Safety Manag’t Use of Tugs BRM Weather routing Fatigue Familiarisation Training Communications Planning error Chemical Experience Health Cleanliness Culture Safety Manag’t Equipment design Emergency proc’s SOPs Circulars VTS Practices Safety Policy Drills Regulations Training Policy Recruitment Policy Scheduling Maintenance policy Supply of Tugs Safety AuditsPilots Food ContributingFactors Corrosion Wave on board reaction Vibration Spares handling Heat Stability Poor maintenance Monitoring failure Communication failure Hazardous Material effect Pipe failure Environmental effect Position error Error in action Casualty Events Loss of control Collision Grounding Structural failure Flooding Fatality Injury Capsize Fire Human error Master/Pilot Navigational Manag’t. Spares policy 5 times “Why”
- 13. Reporting • Determine your audience • A report does not have to be long • Make a distinction between “need to know/nice to know” • Try to avoid (technical) jargon and make a list of symbols • Describe facts without premature analysis • Describe your analysis (maybe also the theories that didn’t work) • Let the reader draw their own conclusions before they finish the report And remember, how thorough your investigation might have been, the message stands (or falls) with the quality of your report!
- 14. When does AI improve safety and quality? Accident investigaton Analyse Report Look inside SHELL
- 15. International Standard for maritime Pilot Organizations
- 16. Thank you! l.vanderveen@safetyboard.nl www.safetyboard.nl ISPO Conference – Rotterdam – June 22nd 2017
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