Maritime Accident Investigation and

Risk Assessment Data

with
the Review of the Costa Concordia Case

Split, 16. i 17.06.2012

Capt. Davor Vidan dipl.ing.

Subjects
MARITIME ACCIDENT INVESTIGATION
Accident Investigation Methods
Formal Safety Assessment
Non-Conformities, corrective and preventive actions, NearMiss and Best (Safe) Practice
Risk Assessment
Data required for Risk Assessment
Emergency preparedness
Ship size and consequences
CONCLUSIONS

MARITIME ACCIDENT INVESTIGATION

By SOLAS Chapter XI-1, in force from 1 January 2010, Code
of International Standards and Recommended Practices for a
Safety Investigation into a Marine Casualty or Marine
Incident (Casualty Investigation Code) is mandatory;
Also mandatory by EU 2009/18/EC;
GOALS:
To determine:
All causes to the accident;
Safety recommendations;

And to:
Publish the results of the investigation reports;
Report to IMO and EU.

Accident Investigation Methods

Regardless of the investigation methods used, the
investigation has to determine:
The Direct Cause (s) of the accident at the sharp end (operators
level) ACTIVE FAILURES, and
The Indirect Causes of the accident at all organisational levels
LATENT FAILURES.

The most popular visual explanation of the accident

causation is given by James Reasons Swiss Cheese Model:

The Reason Model 1990

The later variant of the Reason Model

Costa Concordia Case

Without speculating into what caused the
Costa Concordia case, I have to ask
myself:
What measures could be taken in order to
prevent this accident?
At what level?

What could have been the latent errors in

case of Costa Concordia?

Formal Safety Assessment

Part of IMO rule-making process, FSA, was
adopted in 2002, with the goal to ensure that
action is taken before a disaster occurs ACTIVE
REGULATORY APPROACH
Unlike the more common practice in the past, and
now, that the new regulations are adopted as a
consequence or answer to the serious accidents REACTIVE REGULATORY APPROACH:
"Titanic" or
"Estonia".

FSA steps:
Identification of hazards (What might go wrong?)
List of all relevant accident scenarios with potential causes and
outcomes);

Assessment of risks (How bad and how likely?)

Evaluation of risk factors;

Risk control options (Can matters be improved?)

Devising regulatory measures to control and reduce the identified
risks;

Cost - benefit assessment (What would it cost and how much

better would it be?)
Determining cost effectiveness of each risk control option; and

Recommendations for decision-making (What actions?)

Information about the hazards, their associated risks and the cost
effectiveness of alternative risk control options is provided.
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All Errors in ALARP range:

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Operator Error over ALARP range

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Hardware and Operator Error over the

ALARP range

12

Non-Conformities, corrective and preventive

actions, Near-Miss and Best (Safe) Practice
Company has to implement the procedures ensuring that
non-conformities, accidents and hazardous situations are
reported to the Company, investigated and analyzed with the
objective of improving safety and pollution prevention, and
establish procedures for the implementation of corrective
action, including measures intended to prevent recurrence
"Just Culture" organization - a large number of such cases
will be reported;
"Blame Culture" organizations - most of these cases will
remain unreported;
corrective or preventive actions will not be implemented, and
hazardous occurrence may easily happen again, unnoticed until it
becomes an accident that can not be hidden.
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Heinrich Ratio Accident Near Miss

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Costa Concordia Case

if the error was in the hardware, construction of the ship
water tightness system, the risk of the damage that have
actually occurred could not be reduced by operators actions,
but only triggered by operators error;
If the vessel could sustain such the damage, she could at
least be towed to the port big enough to accommodate the
ship of such size;
Could the Costa Concordia case be avoided if it was
reported as a non-conformity or near-miss:
Unauthorized deviation from voyage plan?
Approaching dangerously close to the shore with one of the
largest passenger ships in the world?

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Risk Assessment
Required by:
ISM
GOAL-BASED STANDARDS NEW IMO RULES
FSA Formal Safety Assessment
Risk-based ship design

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Data required for Risk Assessment

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Emergency preparedness

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Ship size and consequences

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CONCLUSIONS

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Questions?
Thank You.