Incidents are a sad reality of every hazardous workplace, such as a ship, and their investigation is a key part of most Safety Management Systems. However, this investigation is not a simple task as it requires strict handling with respect to crew members’ wellbeing on the aftermath of traumatic events.
A vital part of an incident investigation is to interview witnesses to find out what they saw. This normally occurs as soon as possible after the incident, when the memories are still fresh and unaffected. The interested parties may include, not only inspectors and surveyors, but also numerous lawyers representing the shipping company or different other parties. Investigators are not there to apportion blame, though they do need to verify compliance with procedures.
Incident investigation in shipping
Flag state administrators are generally required to investigate all incidents occurring to ships under their flag. These include any casualties in which a worker was hurt, as well as “near misses”, in which a crew member might have been hurt if the circumstances had been slightly different. Investigation of casualties are required under:
- SOLAS regulation I/21
- MARPOL, articles 8 and 12,
- Load Lines Convention, article 23 of
- UNCLOS, article 94
- IMO Casualty Investigation Code
In addition, each Member State has an impartial permanent investigative body competent in matters relating to marine casualties and incidents. Be it a fatality, injury, illness, near miss or an incident involving the vessel, an incident investigation has a double role: It not only provides employers and workers the opportunity to identify hazards in their operations, but it also enables them to identify and implement the corrective actions necessary to prevent future incidents.
Conducting the interview after an incident
Data from people is one of the primary sources of information for most investigations and are usually gathered through interviews.
- Ask open-ended questions: Promote an uninterrupted narrative. Give the interviewee some initiative and do not guide the discussion. “Tell me what you saw” is a good example to start with.
- Silence is your ally: Be quiet and let the witness talk. The point of asking these open-ended questions is to let the witness take you wherever he or she wants to go.
- Don’t be too smart: Sometimes, pretending ignorance enables the witnesses to put the facts in better order inside their mind by taking no statements for granted, as well as to provide more details and clarifications.
- Ask for opinions at the end: The witnesses’ own judgements are often helpful source of information. However, if these questions are asked too early in the interview, the witnesses may do much more filtering of their data.
Watch for people’s mental health
The most important point to have in mind when conducting an investigation is that everyone involved, either involved parties or just witnesses, may have been affected and that any wrong handling could re-ignite traumatic feelings. Lack of empathy and trust or a ‘blame the ship’ mentality is sometimes what crews have to deal with during an incident investigation, even though the aim of an investigation is to shed light on what happened and not to apportion blame. As a result, any investigation should take place with the crews’ welfare in mind.
…empathy doesn’t have to be confined to managers. Crew should look out for each other in the days and weeks after a serious incident and after interviews where they recall events. They should take the time to check up on each other and ask how they’re doing,
…advise Alvin Forster and Ross Waddell from the North Club.
Understanding the human element
Lack of training on human element is a major issue highlighted by a white paper written as part of the EU-funded SAFEMODE project exploring Safety Culture in maritime and aviation. Following several interviews with both seafarers and investigators, the paper found substantial differences between investigators and active seafarers’ views about the contributory factors and the positive safety factors in incidents.
“It seems seafarers focus more on the enhancement of their immediate surrounding (their crew and ship) while investigators include higher-level factors such as design and ergonomics or organizational factors. This indicates the need for a common language between investigators and seafarers on the real factors that contribute to incidents and accidents at sea,
…the paper reads.
The paper also underlines the importance of Just Culture. The concept describes a working environment in which people are not punished for honest mistakes and is seen in many industries as a driver and enabler for honest reporting in accidents, incidents and near misses, and hence underpinning a healthy Reporting Culture. If you have Just Culture, you get good reporting, and if you get good reporting, you will be safer.
Investigating differently
A different approach on incident investigation means focusing on learning and throwing blaming overboard. This means that the language and nature of investigative interviews must be non-pejorative and include a narrative as part of the investigation, i.e., what the witness said, in their own words.
“Ultimately, investigation is a form of sense-making, trying to make sense of an unplanned, unfortunate event that nobody meant to happen. Investigation intends to make sense of the event to a number of parties: those caught up in it, their parent organisation, the loved ones of those injured or killed, judiciaries, society as a whole, and of course the industry that wants to do better next time. It is important for Safety Learning to retain the original sense-making of those at the heart of the event. Simple narratives are the best way to achieve this,
…the paper suggests.
