In an exclusive interview to SAFETY4SEA, Oessur Hilduberg, Head of the Danish Maritime Accident Board (DMAIB), explains that the investigation bodies now use a variety of new data collection strategies and analytical frameworks. This methodological shift is based on the recognition that marine operations are complex in nature, and has a substantial effect on what can be learned from accidents.
However, the challenge posing investigation bodies is to develop new methods for data collection, analysis and report writing which supports this new methodology, he highlights and refers to other challenges of the maritime casualty investigations community and how these affect lessons learned from accidents. Concluding, Oessur notes that recent investigations have highlighted the need for training and best practices in how to design a safety management system.
SAFETY4SEA: When it comes to incident investigation, what are the key challenges and what should be industry’s top priorities?
Oessur Hilduberg: There is a dissonance between investigating accidents aimed at obtaining learning to prevent future accidents and other investigations which apportion blame and responsibility with the aim to resolve civil liability or for supporting judicial processes. That dissonance tends to hinder cooperation between accident investigation bodies and ship management companies which affects learning from accidents.
S4S: From your professional experience, what are important factors to consider when investigating maritime accidents?
O.H.: I have found that three overall factors are important.
1. Any investigation is only as good as the data available. It is therefore vital to allocate time and resources to collect data on site and in ship management offices.
2. The investigation’s outcome depends on which analytical framework is applied on a given accident. It is therefore important to be cognizant of which analytical tool to use and how it might affect the findings i.e., it matters if the investigator is using a root cause tool rather than a systemic analytical tool such as Accimap. Knowing the pros and cons of analytical tools is therefore paramount.
3. Overall, the purpose of our investigations is to learn from accident to prevent future accidents. However, what constitutes learning depends on who the special interest group is e.g., next of kin, flag state administrations, coastal states, insurance companies, ship management companies, etc., all of which have divergent interests. It is therefore important to keep the target audience in mind when designing and writing accident reports.
S4S: What shift is currently happening in the maritime casualty investigation community?
O.H.: In recent years, investigation bodies have made more use of contemporary safety thinking which includes a variety of new data collection strategies and analytical frameworks. This methodological shift is based on the recognition that marine operations are complex in nature, and accidents cannot be explained by solely focusing on the behavior of sharp end operators. Thereby, it is acknowledged that accidents typically involve a multitude of factors e.g., goal conflicts, use and implementation of technology, manning, etc., which coincide resulting in adverse events. This shift in how accident events are investigated has had a substantial effect on what can be learned from accidents. However, the challenge posing investigation bodies is to develop new methods for data collection, analysis and report writing which supports this new methodology.
S4S: What are the key lessons learned from industry’s recent accidents that have been investigated by DMAIB?
O.H.: In 2021, DMAIB and MAIB published a report on the use of ECDIS. It was found that investigation of groundings since 2008 have repeatedly shown that where ECDIS was the primary means of navigation it was not being used to its full potential. There was a significant mismatch between the intention of the performance standards and system designers, and the way the watchkeepers were using the system. This investigation exemplified how the implementation of technology on ships lacks strategic consideration of user-friendly design and training. Additionally, DMAIB has on several occasions found that safety management systems mitigate several types of risk besides the safety-related risk, inducing goal conflicts and making the system complex. Furthermore, that procedures are static tools to be used in a dynamic situation. This creates a discrepancy for seafarers to bridge on an everyday basis. In the wake of an accident this will be perceived as an anomaly and a causal factor. Rather than pointing to the seafarers’ abilities and will to follow procedures, DMAIB suggests taking a critical look at the performance of the procedures as a safety measure.
S4S: Following DMAIB investigations during the last years, have you identified any particular needs for best practices?
O.H.: Safety management procedures are increasingly being designed to meet compliance demands and are not designed to support the work of seafarers. Additionally, most ship management companies do not have personnel with specialized competencies in designing operational procedures which often seriously affects the quality. Therefore, there is a need for training and best practices in how to design a safety management system in such a way that it is usable in a dynamic work environment.
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.
