In an exclusive interview to SAFETY4SEA, Marcelo Covelli who is the National Director of the Marine and Inland Waters Investigations Directorate of the Transport Safety Board (Junta de Seguridad en el Transporte) of Argentina, highlights the importance of considering the human and organizational factors from a systemic approach in an incident investigation.
n that regard, we can understand why the accident happened and thus be able to issue recommendations to avoid its recurrence. ‘It wasn’t the crew who had the accident, it was the entire system’’ he states, referring to recent incidents they have investigated and alarming patterns noticed. As he explains, they have recently identified there were safety issues related to sea state forecasts, warnings which are very important for captains. In that regard, they have recently issued two recommendations and relaunched the Voluntary Observing Ships (VOS) program in Argentina in an effort o ensure that complete, accurate and timely information is disseminated
SAFETY4SEA: When it comes to incident investigation, what are the key challenges and what should be industry’s top priorities?
Marcelo Covelli: One of the key challenges is for investigators to collect all the factual facts, the quality of the analysis and conclusions of the investigation will definitely depend on this. It is not always possible to reach the scene quickly, and it sometimes happen that it has been altered when investigators arrive without, changes having been registered. Coordination with other authorities also usually delays immediate access to material and interviews with crew members. In this sense, one of the priorities for the industry could be the adoption of an action protocol for the initial actions of crews in case of accidents, that will be investigated within the framework of Resolution MSC 255 (84). With such a protocol, the crew could collect and preserve all investigation material for delivery to investigators and thus prevent the investigation from being affected or frustrated.
S4S: From your professional experience, what are the most important factors to consider when investigating maritime accidents?
M.C.: An investigation is a great opportunity to analyze the complex interactions of the socio-technical system that makes up maritime transport. If we were to find out only what happened moments before the occurrence, the only thing we will get to know is what happened and how the sequence of events developed, but that alone will not allow us to avoid another similar accident. In that sense, it is necessary to understand the operational context where the occurrence took place, many times we have to take the investigation further away in time and space from the actions that triggered the accident. Therefore, it is important to consider human and organizational factors from a systemic approach, to understand why the accident happened and thus be able to issue recommendations to avoid its recurrence. It wasn’t the crew who had the accident, it was the entire system.
S4S: What are the key lessons learned from industry’s recent accidents that have been investigated by your organization?
M.C.: An example of a key lesson learned from our organization’s investigation is the one published in the Safety Note (NSO) about the launch of a life raft in adverse sea conditions. During the investigation of the shipwreck of the fishing vessel REPUNTE, we noticed that the instructions for the launching of the inflatable raft did not contemplate the specificities of the context, which misled the crew, that even when following the instructions, found difficulties to embark on the collective rescue device. Additionally, we were able to corroborate another 15 cases where similar situations occurred thus confirming that we were facing a systemic issue and not an isolated event. The NSO is illustrated with a video, in Spanish and English, to facilitate its interpretation.
S4S: Following analysis of the last years, what are the most reoccurring factors that result to maritime accidents/incidents? Have you identified any alarming trends/topics?
M.C.: Yes, of course, we have identified some patterns that deserve urgent action to change the trend, for example, within the factors linked to fishing boat wrecks, we find safety aspects related to sea state forecasts, these warnings are very important for captains as they help them make decisions. That is why it is vital that complete, accurate and timely information is disseminated, among which the parameters of significant height, direction and period of the wave cannot be missing. In that sense, we have issued two recommendations (RSO) and we carry out a safety action together with the National Meteorological Service by which we relaunched the Voluntary Observing Ships (VOS) program in Argentina. One of the RSOs is aimed at improving information on the state of the sea in the routine weather bulletins issued to navigators, and the other refers to implementing a system for collecting and classifying meteorological data during ongoing alerts so that these are available as a reference for forecasters and the rest of the ships that could require any of it.
S4S: Following your investigations during the last years, have you identified any particular needs for regulatory update/ best practices?
M.C.: Regarding good practices related to national regulations, we have issued an RSO with the aim of implementing a system to guarantee the quality of the stability manual of fishing vessels, given that we systematically find that stability logbooks are very different from each other, there is no standardized format or clear definitions towards key stability parameters. If the same authority that has to enforce the regulations, and the professionals who have to apply them, do not agree with the interpretation of the rules, we are facing a problem that requires an immediate solution. It is usual for stability notebooks to be incomplete and presented in a way that does not provide a tool for the captain to make a quick and easy calculation in unexpected situations, which is practically the raison d’être of these manuals. In some cases, they do not include all the expected operating conditions; the information contradicts the plans of the ship or are not reflected in the safety management system; there is confusing information about the fuel tanks, fresh water, ballast, fixed ballast and flood angles; in addition, the use of openings is not contemplated for operational issues in bad weather, or as to the particular case of emergency exits.
The views presented hereabove are only those of the author and do not necessarily reflect those of SAFETY4SEA and are for information sharing and discussion purposes only.