Gard notes that
Incident investigations often conclude with placing the blame for an incident on the crew.
Some causes around incidents are identified as procedural violations, incompetence, lack of situational awareness or the catch all, human error. It is up to the investigator to implement a fact based investigation and understand the conditions that prevailed during the incident is sometimes derailed by their focus on finding a guilty individual.
This is also known as the "blame instinct", which Gard notes that undermines the goal of the investigation, which is to find the root cause and prevent a similar occurrence happening in the future.
Concerning an incident, a grounding took place because the officer on watch fell asleep. Investigations of such incidents would usually blame the fatigued officer or the Master when the investigation is limited to individuals.
The questions included in the investigation are
- Why he fell asleep?
- Were last port operations too strenuous on the officer?
- Was the manning adequate for the vessel’s operations?
- What commercial pressures were at play?
- How would the company have reacted if the master was to request a delayed departure citing fatigue as a reason?
- What is the company culture like?
The above questions can provide an overview of the conditions that led to the incident and to help understand the underlying issues.
Therefore, it is important to understand when investigating incidents, that it is not about the individual or group of individuals involved in the incident, but multiple interacting causes which make up the conditions surrounding the incident.