TECHOP Conducting Effective DP Incident Investigations

TECHOP
TECHNICAL AND OPERATIONAL GUIDANCE

(TECHOP)
TECHOP (G-04 - Rev1 - Jan21)
CONDUCTING EFFECTIVE AND COMPREHENSIVE

DP INCIDENT INVESTIGATIONS
JANUARY 2021
TECHOP (G-04 - Rev1 - Jan21) CONDUCTING EFFECTIVE AND COMPREHENSIVE DP INCIDENT INVESTIGATIONS 1
TECHOP
DISCLAIMER AND LIMITATION OF LIABILITY

The information presented in this publication of the Dynamic Positioning Committee of the Marine
Technology Society (“DP Committee”) is made available for general information purposes without
charge. The DP Committee does not warrant the accuracy, completeness, or usefulness of this
information. Any reliance you place on this publication is strictly at your own risk. We disclaim all
liability and responsibility arising from any reliance placed on this publication by you or anyone who
may be informed of its contents.
2 TECHOP (G-04 - Rev1 - Jan21) CONDUCTING EFFECTIVE AND COMPREHENSIVE DP INCIDENT INVESTIGATIONS
TECHOP
SUMMARY
This MTS TECHOP provides general guidance on conducting effective and comprehensive DP
Incident Investigations. A conscious decision was made not to address DP Incident Reporting in this
document. Nothing in this document is intended to negate the need to report incidents per applicable
requirements (e.g. Statutory, Company Policy, Charterer’s Requirements).
The MTS DP Committee believes that Learnings From Incidents (LFIs) should be a clear outcome of
DP incident reporting and any subsequent analysis or investigations. Incident investigations should
consciously incorporate generation of the LFI amongst the primary objectives. Such LFIs should be
promulgated across industry. The format of the LFI and its promulgations should be such that they can
be perused in a proactive manner to address and mitigate against the potential for such incidents.
Vessel owners should be able to incorporate processes within their own management systems to
leverage these LFIs to demonstrate a proactive approach to address DP station keeping risks by
effective mitigations.
The guidance provided in this TECHOP follows the proven approach of addressing management of
DP Operations through a focus on Design, Operations, People and Process.
TECHOP
CONTENTS
SECTION PAGE
1 INTRODUCTION 7
1.1 PREAMBLE 7
1.2 TECHOP NAMING CONVENTION 7
1.3 MTS DP GUIDANCE REVISION METHODOLOGY 7
2 SCOPE AND IMPACT OF THIS TECHOP 8
2.1 PREAMBLE 8
2.2 SCOPE 8
2.3 FOCUS OF THIS TECHOP 9
2.4 IMPACT ON PUBLISHED GUIDANCE 9
2.5 ACKNOWLEDGEMENTS 9
3 CASE FOR ACTION 10
3.1 REPEAT INCIDENTS 10
3.2 PROACTIVE MEASURE 10
3.3 DEMONSTRATING MEANS OF CONTROLLING RISK 10
4 STRUCTURE FOR A COMPREHENSIVE DP INCIDENT INVESTIGATION 11
4.1 GENERAL 11
4.2 EXPLANATION OF THE FISH BONE STRUCTURE 11
5 DETAIL OF THE FISH BONE STRUCTURE 13
5.1 THE UPPER TAIL SECTION- THE INCIDENT 13
5.2 THE PATHWAY 14
5.3 THE UPPER HALF 14
5.4 DESIGN 14
5.5 OPERATIONS 16
5.6 PROCESS 18
5.7 PEOPLE 20
5.8 THE LOWER HALF 21
5.9 CAUSAL AND CONTRIBUTORY FACTORS – DESIGN 21
5.10 CAUSAL AND CONTRIBUTORY FACTORS – OPERATIONS 22
5.11 CAUSAL AND CONTRIBUTORY FACTORS – PROCESS 22
5.12 CAUSAL AND CONTRIBUTORY FACTORS – PEOPLE 22
5.13 ACTIONS THE HEAD 22
5.14 SHORT TERM REMEDIAL ACTIONS 22
5.15 MEDIUM TERM REMEDIAL ACTIONS 23
5.16 LONG TERM REMEDIAL ACTIONS 23
5.17 THE LOWER TAIL SECTION - THE LFI 23
6 LEVERAGING LFI 24
6.1 ANONYMITY 24
6.2 PROMULGATION 24
6.3 EXTRACTING VALUE FROM LFI 24
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FIGURES
Figure 4-1 Fish Bone Diagram 12
APPENDICES
APPENDIX A TEMPLATE TO SUPPLEMENT INCIDENT REPORTING
APPENDIX B COMPREHENSIVE DP INCIDENT INVESTIGATION TOOL
APPENDIX C WORKED EXAMPLE OF A DP INCIDENT INVESTIGATION USING THE TOOL
APPENDIX D EXAMPLE LFI
APPENDIX E TEMPLATE TO GENERATE LFI
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ABBREVIATIONS
CAM Critical Activity Mode

ESD Emergency Shut Down
F&G Fire & Gas
FMEA Failure Modes Effects Analysis
HEMP Hazard Effects Management Processes
LFI Learning from Incidents
OEM Original Equipment Manufacturer
TAM Task Appropriate Mode
USCG United States Coast Guard
TECHOP
1 INTRODUCTION
1.1 PREAMBLE
1.1.1 The guidance documents on DP (Design and Operations and People) were published by
the MTS DP Technical Committee in 2011, 2010 and 2012, respectively. Subsequent
engagement has occurred with:
• Classification Societies (DNV, ABS)
• United States Coast Guard (USCG)
• Marine Safety Forum (MSF)
• Oil Companies International Marine Forum (OCIMF)
1.1.2 Feedback has also been received through the comments section provided in the MTS DP
Technical Committee Web Site.
1.1.3 It became apparent that a mechanism needed to be developed and implemented to
address the following in a pragmatic manner.
• Feedback provided by the various stakeholders.
• Additional information and guidance that the MTS DP Technical Committee wished
to provide and a means to facilitate revisions to the documents and communication
of the same to the various stakeholders.
1.1.4 The use of Technical and Operations Guidance Notes (TECHOP) was deemed to be a
suitable vehicle to address the above. These TECHOP Notes will be in the following
categories:
• General TECHOP (G)
• Design TECHOP (D)
• Operations TECHOP (O)
• People TECHOP (P)
1.2 TECHOP NAMING CONVENTION

1.2.1 The naming convention, TECHOP (CATEGORY (G / D / O / P) – Seq. No. – Rev.No. –
MonthYear) TITLE will be used to identify TECHOPs as shown in the examples below:
Examples:
• TECHOP (D-01 - Rev1 - Jan21) Addressing C³EI² to Eliminate Single Point Failures
• TECHOP (G-02 - Rev1 - Jan21) Power Plant Common Cause Failures
• TECHOP (O-01 - Rev1 - Jan21) DP Operations Manual
Note: Each Category will have its own sequential number series.
1.3 MTS DP GUIDANCE REVISION METHODOLOGY

1.3.1 TECHOPs as described above will be published as relevant and appropriate. These
TECHOP will be written in a manner that will facilitate them to be used as standalone
documents.
1.3.2 Subsequent revisions of the MTS Guidance documents will review the published
TECHOPs and incorporate as appropriate.
1.3.3 Communications with stakeholders will be established as appropriate to ensure that they
are notified of intended revisions. Stakeholders will be provided with the opportunity to
participate in the review process and invited to be part of the review team as appropriate.
TECHOP
2 SCOPE AND IMPACT OF THIS TECHOP

2.1 PREAMBLE
2.1.1 This TECHOP provides general high-level guidance on DP incident investigations. It is
intended to be utilized by personnel responsible for managing delivery of incident free DP
operations (e.g. Vessel Owners, Charterers, Trade Organizations, Forums etc.) and
specialist consulting organizations providing services in relation to management of DP
Operations when called upon to investigate DP incidents.
2.1.2 Lessons learned from review of loss of position incidents have been summarized within
the guidance documents published by the MTS DP Committee (Design, Operations and
Development of People and various TECHOPS).
2.1.3 During the course of development of the MTS DP Guidance documents, loss of position
incidents were reviewed to glean learnings for incorporation. It became apparent that it
was not unusual to attribute operator error as the causal factor for incidents. There was a
failure to recognize that there were elements of Design, Operations and Process as causal
and contributory factors.
2.1.4 In several instances, this failure to recognize contributions of design, operations and
process to the incident precluded effective mitigations, leading to repeat incidents which
could have been avoided.
2.1.5 It was concluded that there were very few instances of DP incidents where operator error
alone was the single causal factor. DP incidents typically had contributions from the four
main themes of Design, Operations, People and Process.
2.1.6 It was further concluded that an effective and comprehensive DP incident investigation
was one which delivered an LFI that identified those elements of Design, Operations,
Process and People that contributed to the incident. Once identified, mitigations could be
put in place to address these elements.
2.1.7 It was also recognized that the implementation of these mitigations could potentially be in
three distinct time horizons – short, medium and long term. Short and medium term
mitigations would more than likely be procedural in nature and perhaps adaption of proven
approaches, while the long term mitigations could involve identification of opportunities for
improvement with a view to ‘designing out’ the potential for such incidents.
2.1.8 Structured and comprehensive LFIs as described above were identified as a key
deliverable from an effective DP incident investigation.
2.1.9 Promulgation of such LFIs across industry provides others with the opportunity to
proactively assess and implement applicable recommendations on their own vessels. This
is viewed as an effective way to minimize the potential for repeat incidents.
2.2 SCOPE
2.2.1 This TECHOP provides information on a suggested:
• Format of reporting a DP incident and capturing relevant information.
• Method to structure DP Incident Investigations.
• Structure for an LFI.
• Method to leverage LFIs to proactively manage and deliver Incident Free DP
Operations.
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2.3 FOCUS OF THIS TECHOP

2.3.1 The focus of this TECHOP is to provide a structured approach to conducting
comprehensive DP incident investigations and generating LFIs while facilitating
standardization and consistency.
2.3.2 This TECHOP can be used to supplement existing practices of incident reporting to deliver
LFIs.
2.4 IMPACT ON PUBLISHED GUIDANCE

2.4.1 This TECHOP provides supplementary information to the existing guidance published by
the MTS DP Committee but does not alter or invalidate the information contained within.
2.5 ACKNOWLEDGEMENTS
2.5.1 The DP Committee of the Marine Technology Society greatly appreciates the contribution
of Kongsberg Maritime, Lloyds Energy and USCG, serving members of the subcommittee
on Guidance and Standards who championed and guided the development of this
TECHOP.
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3 CASE FOR ACTION

3.1 REPEAT INCIDENTS
3.1.1 A review of reported and known incidents indicates that a significant number were of a
repeat nature. The causal and contributory factors identified had manifested themselves
in earlier incidents.
3.1.2 A holistic view of the above phenomenon revealed that LFIs should be one of the key
outputs of an incident investigation.
3.1.3 Comprehensive incident investigations, conducted in a structured manner, are essential
for generating a quality LFI for promulgation across industry.
3.1.4 The structure provided in this TECHOP is one method of conducting such a
comprehensive incident investigation.
3.2 PROACTIVE MEASURE

3.2.1 This TECHOP also provides guidance on how the LFIs generated using this process could
be used proactively to reduce the potential for repeat incidents. Further details are
provided in Section 6.
3.3 DEMONSTRATING MEANS OF CONTROLLING RISK

3.3.1 Implementing the guidance provided in this TECHOP as part of their own processes,
provides stakeholders with a means to demonstrate diligence in identifying, managing and
mitigating DP station keeping risk.
TECHOP
4 STRUCTURE FOR A COMPREHENSIVE DP INCIDENT

INVESTIGATION
4.1 GENERAL
4.1.1 It is acknowledged that several proven processes to investigate incidents exist. It is not
the intent of this TECHOP to negate the use of such processes.
4.1.2 This TECHOP provides a guided approach to conducting comprehensive DP incident
investigations in a structured manner which strives to achieve the objectives of
standardization and consistency and delivers an LFI as part of the output.
4.1.3 The fish bone diagram was developed by Dr Kaoru Ishikawa in 1982 as an aid to root
cause analysis. It has been adapted in this TECHOP as a means to achieve a structured
approach to address the elements of design, operations, people and process while
investigating DP incidents.
4.1.4 The composition of the incident investigation team needs to be given careful consideration.
The DP incident investigation team should have members of the DP operation team,
members of the vessel’s technical team, and may have members of the shore based
engineering or management team and depending on the specific incident may also need
to be supplemented with equipment vendor team members.
4.2 EXPLANATION OF THE FISH BONE STRUCTURE

4.2.1 The fish bone architecture has been leveraged to provide the structure to conduct a
comprehensive DP incident investigation.
4.2.2 The fish bone structure shown in Figure 4-1 lends itself to provide a guided approach to
the investigation as well as a means to succinctly summarize the output of the
investigation.
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Figure 4-1 Fish Bone Diagram
4.2.3 The anatomy of the fish bone includes:

• Top of Tail (Reported Incident).
• Main Bone (Pathway).
• Top Sub Bone (Four In Number) Design, Operations, Process, People.
• Top Sub Sub Bone (Elements within Design, Operations, Process, People. (Threads
to be pulled on).
• Bottom Sub Bone (Results of investigation, Four in Number, Design, Operations
Process & People).
• Bottom Sub Sub Bone (Causal and contributory factors to the incident).
• Head of Fish Bone Structure – Triangle.
• Vertical side – Short Term Actions.
• Top - Medium Term Actions.
• Bottom - Long Term Action.
• Bottom of Tail ( LFI)- Note LFI is an output of the process - not an input.
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5 DETAIL OF THE FISH BONE STRUCTURE

5.1 THE UPPER TAIL SECTION- THE INCIDENT
5.1.1 The incident investigation team should be given the pertinent information about the
incident. Appendix A contains an example list of pertinent information that should be
gathered as part of an incident report.
Note:- The information in Appendix A has been provided as an example and may be used
to supplement or further develop suitable incident report templates appropriate for the
vessel.
5.1.2 Data gathering and preservation of the data is crucial to an effective incident investigation.
Data should be captured and preserved to cover a period of the incident as well as for a
period of a minimum of up to 30 minutes before the incident.
• Data includes screen shots, record of alarms, alarm printouts,
• Sources of data include DP Operator stations, history stations, data loggers,
PMS/VMS systems, Position Reference Sensors, Field stations, local controls for
drives, thrusters, engines.
• Attention is drawn to the limited data retention capability provided in most DP related
equipment. Data is logged to a buffer storage and as the buffer gets full, older data
is over written. It is imperative that relevant data covering a minimum period starting
from 30 minutes prior to the event is captured. It should also be recognized that
such data stored in the buffer may be lost if the equipment is reset.
• A data capture and retention strategy along with the associated procedures to the
level of detail required should be developed and implemented on all DP vessels.
• Vendor support may be required to ensure that the procedures are appropriate for
the equipment on the vessel.
• Crew training and familiarization should include a specific section on data capture
and data retention for relevant personnel with a role for the conduct of DP operations
on a vessel.
• Physical evidence or damage reports also provide data.
5.1.3 Effective incident investigations rely on the ability to correlate often seemingly
unconnected events. To establish correlation, time stamps should be synchronized across
a multitude of equipment. Divergence of time stamps should be monitored and addressed.
Note: Time stamps on distributed data acquisition systems may be time stamped at the
process station or at a central location. In the case of the latter (central location) time
stamps can be unreliable during an event because of congestion of the network due to
volume of alarms. Time stamps need to have sufficient time resolution in order to be
useful.
5.1.4 It is important to record details of the activities that were being undertaken before the
incident, even if they appear to be unrelated. Examples of such activities are:
• Inspection Repair Maintenance.
• SIMOPS.
5.1.5 There have been numerous instances where failures have manifested themselves soon
after an inspection repair maintenance activity.
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5.1.6 Incidents have manifested themselves when seemingly unrelated activities were being
conducted (e.g. SIMOPs). The trigger points have been the manifestation of some
functionality, usually caused by an inadvertent erroneous operator configurable setting.
The propagation path for such incidents has usually been facilitated by a lack of
information/visibility and or guidance in the operations manual.
5.1.7 The information provided following an incident should be clearly identified and labelled as
factual, opinion, deduction etc and the basis of this categorization should be substantiated
by supporting documentation.
5.1.8 Appendix A contains a table that may be used as a tool to gather pertinent information to
report incidents with a view to facilitate incident investigations. The tool could also be
used to compare existing formats/forms used for incident reporting to identify opportunities
for improvement.
5.2 THE PATHWAY

5.2.1 The pathway is metaphorical for the steps that are undertaken to systematically review
each element of the four identified elements, Design Operations, Process and People.
5.2.2 To the left of the pathway is what we look at (characterized as sub elements) in a
systematic manner inside each of these elements (What was referred to as the top sub
sub bone in the figure of the fish bone structure).
5.2.3 To the right of the pathway is what was found to be causal and contributory factors for
each of these elements and is captured in the boxes (referred to as the bottom sub sub
bone in the structure.
5.2.4 As a visualization aid, the pathway should be seen as the sieve through which the
identified causal and contributory factors of the incident pass through to fill the elements in
the lower half of the fish bone structure. These are the factors that need to be addressed
to prevent recurrence of such incidents.
5.3 THE UPPER HALF

5.3.1 The upper half contains the four main elements, Design, Operations, Process and People.
This is referred to as the top sub bone in the fish bone structure.
5.3.2 Within each of these elements (or sub bones), there are multiple sub elements (sub sub
bones) which reflects the various focus areas that need to be specifically addressed during
the incident investigation. The effectiveness of the investigation is wholly dependent upon
the diligence and discipline of the participants to review the pertinence of each of the focus
areas. Diligence and discipline can be documented by positive verification that the
identified focus areas have been reviewed even if there were no observations or findings
in that particular focus area.
5.3.3 Incident investigations should systematically work through the sub elements and document
the same. Positive verification should be provided that all the sub elements have been
reviewed.
5.4 DESIGN
5.4.1 This element is depicted as item 2A in the fish bone structure.
5.4.2 The seven pillars (autonomy, Independence, segregation, differentiation, fault tolerance,
fault resistance and fault ride through) that have been identified in the MTS DP Design
Philosophy document should be leveraged during the conduct of the DP incident
investigation to identify pertinent design related threads that need to be pulled on to
uncover causal and contributory factors to the incident.
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5.4.3 Cross connections between redundant groups are a common source of fault propagation
path leading to incidents. Diligence should be exercised to uncover and analyse such
cross connections.
5.4.4 Personnel engaged in investigations should be made aware of the potential for hidden or
not intuitively obvious cross connections across redundant groups. The need to
consciously and actively look for such insidious fault propagation paths should be
emphasized. The incident investigation opportunity should be leveraged to look beyond
the immediate and obvious failed equipment by evaluating adjacent equipment and or
interfaces with the failed equipment to identify potential fault propagation paths and
mitigations. For example, revelation of a hidden fault propagation path introduced by
commonality and or cross connections between redundant equipment groups in the
generators should prompt a review of the distribution system with a view to identifying
similar commonalities or cross connections in that system.
5.4.5 In addition to the seven pillars, attention needs to be focused on ergonomics and
configuration errors, external interfaces, commonality as potential causal and contributory
factors.
5.4.6 Hidden failures: The potential for hidden failures to defeat redundancy and fault tolerance
should be considered when conducting a DP incident investigation.
5.4.7 Hidden failure is the term used to describe undetected, pre-existing faults in redundant
systems which have the potential to defeat the redundancy concept when a subsequent
fault occurs.
5.4.8 Hidden failures may manifest themselves in several ways including reduced performance
in active redundancy, failure of standby equipment and failure of protective functions to
operate on demand. The possibility that a system was already in a partially failed condition
before the incident occurred should be considered.
5.4.9 Alarms and periodic testing are accepted methods of revealing hidden failures. Learnings
from incidents attributed to hidden failures as a causal or contributory factor should
address such periodic testing or implementation of alarm capability.
5.4.10 These sub elements have been summarized under the element “Design” and depicted as
2AA in the fish bone structure.
• Autonomy
• Independence
• Segregation
• Differentiation
• Fault tolerance
• Fault Resistance
• Fault ride through
• Ergonomics
• Configurations/Configurable Settings
• Commonality
• External Interfaces
• Potential for Hidden Failures, Alarm capability and alarm monitoring.
Note: Where Cross Connections are identified, additional emphasis should be placed on
Fault Tolerance, Fault resistance, Fault ride through and Protective functions.
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5.4.11 Protective functions are required to ensure redundant systems are ‘fail-safe’ and also to
isolate fault propagation paths between redundant groups created by cross connections.
Not all protective functions are fully selective and therefore may not contribute to the fault
tolerance of the system. Potential design flaws associated with protection systems should
be considered in incident investigations.
5.4.12 The effectiveness of the investigation is wholly dependent upon the diligence and
discipline in reviewing pertinence of each of the focus areas in relation to the equipment
that was associated with the DP incident. Incident investigation documentation should
contain positive verification that the identified focus areas have been reviewed even if
there were no observations or findings in that particular focus area.
5.4.13 The tool in Appendix B illustrates the approach identified above.
5.5 OPERATIONS
5.5.1 This element is depicted as 3A in the fish bone structure.
5.5.2 The MTS DP Committee Guidance documents (Design and Operations) draw attention to
the need to supplement the requirements of DP Equipment Class with a focus on the
Industrial Mission.
5.5.3 The guidance documents have introduced the concepts of configuring the vessel in either
the critical activity mode (CAM) or task appropriate mode (TAM). The choice of mode that
the vessel is configured in CAM or TAM, to conduct the operation is usually made taking
into account the consequences of a loss position.
5.5.4 The configuration includes a determination of the position references sensors required to
be able to undertake the specific activity and clearly outlining limitations if any.
5.5.5 The Industrial Mission that is being undertaken may require special modes, features or
functionality within the DP control system to facilitate the execution of the activity, and
maximizing predictable outcomes - i.e. delivery of incident free operations. Such special
modes and features may require operator configurable settings. Errors in operator
configurable settings can lead to unpredictable and undesirable outcomes.
5.5.6 All DP Operations should be undertaken within the identified and validated post failure
capability of the vessels. The default criteria for establishing post failure capability should
be the worst case failure and based on the equipment that will remain functional and
capable of operating to the performance specifications after the occurrence of the worst
case failure.
• A conscious decision may be made to use alternate criteria for post failure DP
capability, with a view to achieving higher operability limits.
• Alternate failure criteria should only be used with the explicit acknowledgement and
acceptance that the potential for the occurrence of a loss of position exists if a failure
effect occurs that exceeds the severity of the failure effect that was used to establish
the higher operability limit.
• Such alternate failure criteria should not be used for operations identified as
requiring CAM. Risk assessments should unambiguously identify and document the
potential for a loss of position and accept the associated consequences. Due
diligence should be exercised in providing mitigations against such an occurrence
even if operating in TAM.
5.5.7 DP station keeping equipment installed on a DP vessel is usually there to provide active
redundancy and should not be treated as installed spares. Post failure capability should be
established on equipment that is operational and being used, not on the basis of what is
installed on the vessel.
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5.5.8 Inspection, Repair and Maintenance (IRM) activities may render equipment temporarily
unavailable for use. Post failure capability should be reassessed if equipment is not
available and the vessel should operate within the reassessed post failure capability. The
default condition should be not to carry out IRM activities when conducting operations
requiring CAM.
5.5.9 Protective Functions (defending protective functions and restoration of same if disabled for
IRM).
Protective functions can play a significant role in ensuring systems intended to provide
redundancy are independent of each other and fail-safe. Protective functions can be
applied for many different reasons including, the safety of personnel and limiting the
potential for damage to equipment.
In the case of fault tolerant system, based on redundancy, they may be provided to isolate
cross connections between otherwise separate and independent systems. In other cases,
their role is to ensure systems fail safe.
Disabled or faulty protective functions can compound the effects of any subsequent failure
leading to effects of a much greater severity.
5.5.10 Reinstatement of equipment post intrusive maintenance or post failure comes with an
increase in vulnerability to the potential for a subsequent failure. Due consideration should
be given to this potential and additional mitigations should be put in place. Examples of
such mitigations are:
• Choosing an optimum time to reinstate equipment.
• Suspending operations and moving out of the 500 m zone
• Bringing vessel activities to a safe position, configuring vessel in CAM prior to
reinstating equipment
• Imposing positioning standby to bring personnel to a heightened state of awareness
and in position to prevent escalation of the consequences of a failure.
5.5.11 There has been a growing tendency to provide Operator Configurable Settings on DP
Equipment. This has been done usually with a view to
• Provide optimization of performance.
• Provide diagnostic capability ( IRM focus)
5.5.12 Erroneous operator configurable settings have been the source of a considerable number
of incidents. Controls should be in place to prevent the potential for such errors to be
introduced.
5.5.13 These sub elements have been summarized under the element “Operations” and depicted
as 3AA in the fish bone structure.
• CAM/TAM Considerations ( Choice of configuration vessel is operating in)
• CAM/TAM Validation ( Validation that vessel is operating in identified configuration)
• Position reference sensors (e.g. Position reference sensor are suitable for the job
and configured accordingly, choice of absolute and relative position reference
sensor, acoustics rated for water depth, redundancy requirements in principle,
Configurable settings)
• Modes and Features (Vessel was being operated in the appropriate mode (e.g. Auto
position, Follow target etc)
• Industrial Mission Specific Modes and Features (e.g. External Force Compensation,
Heavy Lift Mode, Mode of inputting external forces).
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• Management of external Interfaces (e.g. ESD systems, Fire and Gas Safety Shut
down systems, tensioner inputs).
• Post failure capability.
• IRM and reassessment of post failure capability.
• Protective functions and restoration of same if disabled for IRM.
• Reinstatement of equipment post failure.
• Automatic change overs/automatic reinstatement of failed equipment.
5.5.14 The tool in Appendix B illustrates the approach identified above.
5.6 PROCESS
5.6.2 Process, for the purpose of this TECHOP on incident investigation, encompasses the
following three main areas:
• Verification and Validation
• Hazard Recognition
• Controls
Each of these areas are further discussed herein.
Note: Incident investigations should systematically address the sub elements listed below
and identify relevant causal and contributory factors (depicted as 4AA in the fish bone
structure). Positive verification of same should be documented in the output of the incident
investigation.
5.6.3 Verification and Validation as discussed herein refers to the assurance activities that have
been put in place to identify gaps of existing documents/processes against a defined
performance standard. Measurement against the performance standard should be
accomplished by objective methods to the extent achievable. Assurance in this context is
broad and encompasses self, independent third party, as well as audits and inspections by
regulatory/statutory or client stakeholders,
Key Documents / Processes / Actions to be Verified Validated are:
• DP FMEAs (e.g. minimum performance standard DNV RP D102).
• FMEA AND PROVING TRIALS GAP ANALYSIS (e.g. objective evaluation - MTS
published gap analysis tool).
• Annual Trials (e.g. Minimum performance standard IMCA M 190/M 191).
• Annual Trials Gap Analysis (e.g. objective evaluation - MTS DP Committee
published gap analysis tools).
• DP Operations Manual (e.g. Minimum performance standard – MTS DP Committee
guidance document).
• DP Operations Manual Gap Analysis (e.g. objective evaluation – MTS DP
Committee published gap analysis tool).
• Documented evidence of closure and closure path of identified gaps.
• Closure of findings and observations from audits.
• Implementation of Applicable Technical Guidance from Vendors.
• Implementation of Actions arising from Lessons learned:
• Lessons learned within Company.
• Lessons learned within Industry.
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• Adherence to Original Equipment Manufacturer’s Recommendation:

• IRM processes.
• Performance testing.
• Post failure testing.
• Testing following Extensive intrusive maintenance.
5.6.4 Hazard recognition as referenced herein is the application of Hazards and Effects
Management Processes (HEMP) to manage the risks and associated consequences due
to a loss of position incident on a DP vessel.
5.6.5 This requires a thorough understanding of the activities associated with the Industrial
Mission and the consequences of a loss of position. The consequences can span the
spectrum of loss of life, damage to the environment, damage to the asset (exposure to
process safety events) at one end to non-productive time at the other.
5.6.6 HEMP processes are to be utilized to determine whether the vessel should be configured
for CAM or TAM. Usually, these activities should be pre-determined and listed out. It is
acknowledged that the dynamic nature of the execution may result in the potential that not
all activities may be predetermined. The discipline to diligently apply the HEMP processes
for such unplanned activity should be adhered to. The trigger points to initiate these
HEMP processes should be unambiguously identified. The tendency to normalize
deviance should be consciously guarded against.
5.6.7 Any and all means should be used to clearly define the boundary conditions for the
execution of the activities associated with the industrial mission. Company expectations
and instructions to the vessel management team should clearly outline that the vessel is to
be operated within the defined boundary conditions. Experience levels of the crews is
acknowledged and respected with the view that such experience will be used to exercise
stop work authority diligently before these boundary conditions are breached. Use of
experience levels to justify conscious breach of such boundaries on board a vessel, should
be avoided. Consideration of the potential to breach established boundary conditions
should have the validation and explicit approval from the appropriate personnel who have
accountability for delivery. Such personnel are usually shore based personnel. The basis
of validation and approval to breach boundary conditions should be well documented.
Effective hazard recognition and mitigations, usually for non-routine or unplanned activities
during the conduct of the industrial mission, may require supplementing skills of personnel
on board with specialist support. The potential need for such support should be
recognized and catered to.
5.6.8 Sub elements that need to be systematically reviewed during the incident investigation are:
• CAM/TAM operation of the vessel ( Was the vessel being operated in the
configuration appropriate for the task? - Was this identified as part of the process?)
• HEMP Processes used (If a field decision was made were the HEMP processes
utilized)
• Activity (Routine or non-routine, Departure from established procedures) - Was the
activity being conducted of a routine nature in relation to the Industrial mission?
• Are roles and responsibilities clearly identified?
• Hazard Recognition and Management – Was there a clear recognition of the
Hazards and an appreciation for the consequences of a loss of position incident.
TECHOP
5.6.9 Controls as referenced herein are tools, processes or barriers that are used to enhance
robustness of mitigations to prevent the potential for causal and contributory factors to
manifest themselves and result in a loss of position.
Examples of such controls are:
• Requirements for permit to work ( PTW).
• Toolbox talks.
• Job safety analysis.
• Task risk assessments.
• Imposition of positioning standby.
• Imposition of requirements to assess impacts of IRM and reassessment of post
failure capability.
• Management of permitted operations ( MOPOs).
• SIMOPS.
• 500 m entry checklists.
• Harsh weather precautions and checklists.
• Checklists validating configuration of vessel in accordance with the ASOG/WSOG.
• Checklists validating appropriate values for configurable settings.
5.7 PEOPLE
5.7.2 People or personnel element for the purpose of this TECHOP addresses a broad range of
5.7.3 factors which have manifested themselves as causal and contributory factors for DP
incidents. These factors range from the relatively tangible, e.g. training and competence
to the intangible, e.g. cultural factors, inbuilt biases (e.g. personal biases and biases
developed from previous experiences).
Sub elements (depicted as 5AA in the fish bone structure) that need to be systematically
reviewed during incident investigation are:
• Training and competence (Are minimum training and competence requirements
met?)
• Industry standards.
• Company standards.
• Client stipulated requirements.
• On Job Training (OJT):
• Structured OJT.
• Drills and Exercises including contingency planning.
• Communication of expectations (Have expectations of adherence to requirements
been clearly and unambiguously communicated?). As examples:
• Adherence to ASOG / WSOG.
• Defending the redundancy concept.
• Addressing IRM.
• Notification protocols and return to work authorization following a change of DP
status.
• Looking for and guarding against biases (personal and experience based).
TECHOP
• Mode of communication of expectations (how is this communicated?)

• Guided or unguided (e.g. are personnel pointed to written documents and
asked to figure it out themselves? – The potential for reading comprehension
issues).
• Reflective methods- (e.g. using known incidents to develop and emphasize
messages and have personnel consciously reflect how such a situation can
manifest itself in their area of responsibility, what steps they are going to take
to recognize such potential and mitigate against the same).
• Availability of Coaching and Mentoring.
• Cultural Factors:
• Ability to exercise stop work authority.
• Ability to be comfortable with chronic unease.
• Ability to feel empowered to challenge unsafe practices.
• Fatigue:
• Duty cycles.
• Impacts of ongoing activities and demands placed on individuals (e.g.
prolonged duration of positioning standby).
• Crew change rotations.
• Pressure to perform (Pressure may be real or perceived and result in temptation to
breach established boundaries).
• Performance under pressure ( capability to demonstrate consistency and focus on
delivery of incident free DP operations all the time irrespective of pressure induced
by ongoing activities)
5.8 THE LOWER HALF

5.8.1 The lower half is a mirror image of the top of the pathway discussed in section 5.2 and
contains the same four main elements, Design Operations, People and Process. These
elements have been discussed in the sections 5.4, 5.5, 5.6 and 5.7.
5.8.2 Section 5.2.4 describes visualizing the pathway as a sieve where the identified causal and
contributory factors of the incident pass through and are captured in the elements to the
right of the pathway.
5.8.3 In essence the sub elements contained within the elements in the lower half are the
identified causal and contributory factors of the incident.
5.8.4 Addressing the sub elements identified in the lower half effectively and promulgating the
information widely, using the LFI as a vehicle, is expected to reduce the potential for a
recurrence of such incidents.
5.9 CAUSAL AND CONTRIBUTORY FACTORS – DESIGN

5.9.1 This is depicted as 2B in the figure of the fish bone structure.
5.9.2 A systematic review of 5.4 should result in the identification of the relevant causal and
contributory factors pertaining to the element of ‘Design’.
5.9.3 These are captured as sub elements within 2B and are depicted as 2BB in the fish bone
structure.
5.9.4 2A, 2AA, 2 B and 2 BB are to be viewed as one complete theme addressing the element
of ‘Design’.
TECHOP
5.10 CAUSAL AND CONTRIBUTORY FACTORS – OPERATIONS

5.10.1 This is depicted as item 3B in the fish bone structure.
contributory factors pertaining to the main element ‘Operations’.
structure.
5.10.4 3A, 3AA, 3B and 3BB are to be viewed as one complete theme addressing ‘Operations’.
5.11 CAUSAL AND CONTRIBUTORY FACTORS – PROCESS

5.11.1 This is depicted as 4B in the fish bone structure.
contributory factors pertaining to the main element ‘Process’.
structure.
5.11.4 4A, 4AA, 4B and 4BB are to be viewed as one complete theme addressing ‘Process’.
5.12 CAUSAL AND CONTRIBUTORY FACTORS – PEOPLE

5.12.1 This is depicted as 5B in the fish bone structure.
contributory factors pertaining to the main element ‘People’.
structure.
5.12.4 5A, 5AA, 5B and 5BB are to be viewed as one complete theme addressing ‘People’.
5.13 ACTIONS THE HEAD

5.13.1 This is depicted as the triangle in the figure of the fish bone structure.
5.13.2 The head is to be viewed as the actions that result from the incident investigation and the
three sides of the triangle represent the short, medium and long term actions.
5.13.3 Short, medium and long term actions are depicted as item 6A, 6B and 6C respectively in
the fish bone structure.
5.13.4 Technical (engineering), operational support as well as vendor support may be required to
develop and / or validate actions proposed to be implemented as outcome of the incident
investigation.
5.13.5 MOC processes should be adhered to.
5.14 SHORT TERM REMEDIAL ACTIONS

5.14.1 Short term remedial actions are usually actions that can be implemented immediately
without taking the vessel out of service for an extended period of time.
5.14.2 These actions are usually procedural in nature or may involve replacement of components
like-for-like.
TECHOP
5.14.3 Short term remedial actions, as a means of resolution, are usually associated with:
• Incidents which should have resulted in effects not exceeding the severity of worst
case failure but manifested in a loss of position or a significant event due to existing
barriers being defeated (e.g. incorrect configurations, failure to follow procedures
etc.)
• Lack of training or adherence to procedures
• Failure effects of a severity that is within the worst case failure design intent but
greater than predicted.
5.15 MEDIUM TERM REMEDIAL ACTIONS

5.15.1 Medium term remedial actions are also usually actions that can be implemented without
taking the vessel out of service for an extended period of time but may have to wait until
solutions can be developed.
5.15.2 These actions may require engineered solutions and usually are adaptation of proven
remedial actions.
5.15.3 Vendor engagement should be planned for.
5.15.4 Some level of verification and validations processes may need to be undertaken, (e.g.
addendum to FMEA analysis and associated proving trials).
5.16 LONG TERM REMEDIAL ACTIONS

5.16.1 Long term remedial actions are usually necessitated as a means to ‘design out’ the
potential for such incidents to be repeated. It takes into account that short term and
medium term remedial actions usually incorporate procedural barriers and such procedural
barriers have the potential to be defeated.
5.16.2 Defeating procedural barriers is not uncommon in industry and evidence exists in the form
of repeat incidents that have been experienced for the same causal and contributory
factors and often times even on the same vessel. Designing out such potential causal and
contributory factors should be the preferred objective.
5.16.3 Such long term remedial actions will require engineering and potentially vendor support.
5.16.4 The level of verification and validation for long term remedial actions is usually higher and
may need to be addressed in an addendum to FMEA and proving trials.
5.17 THE LOWER TAIL SECTION - THE LFI

5.17.1 Generating learnings from incident should be included as one of the key objectives of any
incident investigation.
5.17.2 The true value of learnings from incidents is realized when they are effective in proactively
preventing the potential for similar incidents across the industry. Sharing of such learning
across industry is crucial.
5.17.3 The LFI should contain the following sections:
• What happened.
• Why it happened.
• Additional information (if applicable).
• Lessons learned.
• Recommendations.
5.17.4 Teams involved in DP incident investigations should be coached and mentored on being
effective in capturing and communicating learnings from incidents.
5.17.5 An example LFI is contained in Appendix D.
TECHOP
6 LEVERAGING LFI
6.1 ANONYMITY
6.1.1 The desire for anonymity should be respected. The value of an LFI is not reduced by lack
of identification of the vessel, or the owner/manager of the vessel.
6.1.2 Authors of LFIs, should consciously strive for anonymity and provide information with the
intention of promulgating learnings across industry.
6.2 PROMULGATION
6.2.1 The value generated by an LFI is exponential to the promulgation. Conscious efforts
should be made to promulgate LFIs to as broad an audience as achievable.
6.2.2 MTS DP Committee welcomes the submission of LFIs and will commit to respecting
anonymity of submitters. LFIs submitted to the MTS DP committee will be posted on the
website and be made available for a free download in line with other guidance documents
and TECHOPs.
6.2.3 A template for LFIs is contained within this TECHOP in Appendix E. The template is also
available for download from the MTS website (http://dynamic-positioning.com)
6.3 EXTRACTING VALUE FROM LFI

6.3.1 LFIs as described in this TECHOP are designed to deliver value to all stakeholders who
have an interest or a role to play in the delivery of incident free DP operations. Examples
of stakeholders are
• Vessel Owners / Managers
• Charterers
• Regulators
6.3.2 Vessel Owners / Managers having identified that station keeping is safety critical, should
address this in their management systems with the appropriate focus. This includes having
processes in place to proactively seek and apply learnings from incidents to minimize
potential for incidents.
6.3.3 Vessel’s within the fleet should be screened against the backdrop of such LFIs. Positive
verification should be documented that the vessels have been assessed for application of
the recommendations or learnings. Such documentation should include remedial actions
implemented to proactively address learnings from LFIs. If the activity results in the
conclusion that the LFI is not applicable or relevant to a vessel and or fleet, this should
also be documented along with a summary of how and or why such a conclusion has been
reached.
6.3.4 The above approach can be used by vessel owners to demonstrate that the safety critical
nature of station keeping is recognized and managed appropriately.
6.3.5 Charterer’s contractor evaluation processes usually assess contractor’s capability to
effectively manage risk during execution. Such processes usually include a focus on
safety critical elements identification and management.
6.3.6 Charterer’s questionnaire for evaluation of Contractor’s executing scope, which involves
use of DP vessels, should include questions which elicit an understanding of how station
keeping risks are being managed and one way to achieve this is to seek to understand
what activities are undertaken to implement learnings or recommendations from such LFIs.
TECHOP
6.3.7 Regulators with a mandate to oversee compliance with Coastal State or other regulatory
requirements usually have an interest in those elements which affect safety of personnel,
assets or protection of the environment. It is not unusual to impose requirements on
Stakeholders conducting activities within areas under their jurisdiction to demonstrate that
Safety Critical elements are being managed.
6.3.8 Vessel Owners, Lease Operators/Charterers should be able to utilize active management
of such LFIs as a potential means to demonstrate effectiveness of safety management
processes.
TECHOP
APPENDICES
Appendices TECHOP (G-04 - Rev1 - Jan21) CONDUCTING EFFECTIVE AND COMPREHENSIVE DP INCIDENT INVESTIGATIONS
TECHOP
APPENDIX A TEMPLATE TO SUPPLEMENT INCIDENT REPORTING
TECHOP (G-04 - Rev1 - Jan21) CONDUCTING EFFECTIVE AND COMPREHENSIVE DP INCIDENT INVESTIGATIONS App A
TECHOP
SUPPLEMENT TO DP INCIDENT REPORTING

DP Equipment may have
limited storage capability
Vendor specific procedures to
Data gathering and preservation of the data is crucial to an (buffer storage) Data should
capture information should be
effective incident investigation. Data should be captured and be captured at first
followed. Vendor support
preserved to cover a period of the incident as well as for a opportunity post incident.
should be obtained as
period of a minimum of up to 30 minutes before the incident. Care should be taken to
necessary.
capture data prior to resetting
of equipment.
Ability to distinguish
Time stamps to be monitored for divergence. Divergence if IRM activities (ongoing or just parameters (colour) to be
any to be recorded and offsets in time stamps to be completed, first use after IRM) considered when capturing
documented. to be documented. data in print or visual media
(colour copies suggested)
DATA GATHERING
Data capture from
Screen shots Trends ( T-30 min)
buffer storage
Main DP OS screens Y/N Heading Y/N DP OS Y/N
PRS Y/N Current Y/N PRS Y/N
FIELD
PMS Y/N Position Y/N Y/N
STATIONS
Local
VMS Y/N Thrust loads Y/N Y/N
Controllers
Medium - paper Y/N Wind Y/N Any other Insert as
Medium - electronic Y/N Gen Loads Y/N source applicable
ACTIVITIES BEING UNDERTAKEN Inspection Repair and Maintenance (IRM)

Ongoing IRM Insert Text
INDUSTRIAL MISSION Insert text
When was last IRM Carried out? Insert Text
Failed
Y/N- insert text
Equipment Is this first use after IRM?
as appropriate
Task within Industrial mission Insert text
Was IRM being carried out on any Y/N- insert text
Peripheral or adjacent or peripheral equipment? as appropriate
adjacent Were there any anomalies
Y/N- insert text
SIMOPS Insert text equipment experienced on adjacent or
as appropriate
peripheral equipment?
TECHOP (G-04 - Rev1 - Jan21) CONDUCTING EFFECTIVE AND COMPREHENSIVE DP INCIDENT INVESTIGATIONS App A-1
TECHOP

necessary.
of equipment.
DATA GATHERING
Incident Related Information
Examples of explanatory Relevant information from
Typical incident questions
questions incident
specific task within industrial mission
What activity of the industrial mission was being undertaken? ( e.g. transferring riser, transferring Insert Text as appropriate
fuel, running casing etc.
Was loss of position or heading
What happened and what were the consequences to the Industrial
experienced. Did it result in Insert Text as appropriate
Mission?
damage
Thruster was seen to ramp up,
What were the observations made by the vessel staff? position reference sensor jumped, Insert Text as appropriate
tensions increased, etc.
number of generators online,
What were the configurations of the incident related equipment, inclusive number of position reference
Insert Text as appropriate
of DP mode, thrusters online, generators online, etc. ? systems enabled to DP, main bus
bar status, etc.
Were any 24VDC control voltage
Were there any configuration changes carried out to the incident related
configurations changed, standby Insert Text as appropriate
equipment's?
pumps changed over, etc.
Wave current, wind wave, heading,
What were the environmental conditions at the time of the incident? Insert Text as appropriate
DP current, etc.
App A-2 TECHOP (G-04 - Rev1 - Jan21) CONDUCTING EFFECTIVE AND COMPREHENSIVE DP INCIDENT INVESTIGATIONS
TECHOP

necessary.
of equipment.
DATA GATHERING
Any additional information to
What were the activities being undertaken prior to the incident, e.g.
supplement information that has Insert Text as appropriate
Inspection, repair, maintenance, SIMOPs, etc.?
been captured above
Contingency planning, ensure no
Operator actions during and immediately after incident? Insert Text as appropriate
reinstatement of equipment, etc.
Screen shots, trend and alarms
Are screen shots, alarm printouts and alarm records captured from the
recorded as captured in the Data Insert Text as appropriate
incident related equipment's?
Gathering section.
From DP OS, PRS, Field stations,
Is data logged as buffer storage in DP related equipment collected? as captured in the Data gathering Insert Text as appropriate
section.
Divergence between DP system,
Are the time stamps across the incident related equipment's
Vessel Management system, etc Insert Text as appropriate
synchronized?
captured
Summary of Investigations carried out post incident by on board vessel management team (VMT)
What investigation steps were carried out
What was focused on
Why was this focused
What was outcome
What supporting information can be provided on above
Confidence level on outcomes High Medium Low
Basis of confidence Substantiate why you have high medium or low confidence
TECHOP (G-04 - Rev1 - Jan21) CONDUCTING EFFECTIVE AND COMPREHENSIVE DP INCIDENT INVESTIGATIONS App A-3
TECHOP
APPENDIX B COMPREHENSIVE DP INCIDENT INVESTIGATION TOOL
App B TECHOP (G-04 - Rev1 - Jan21) CONDUCTING EFFECTIVE AND COMPREHENSIVE DP INCIDENT INVESTIGATIONS
TECHOP
https://dynamic-positioning.com/files_mailing/MTS%20LFI%20Toolkit.zip
TECHOP (G-04 - Rev1 - Jan21) CONDUCTING EFFECTIVE AND COMPREHENSIVE DP INCIDENT INVESTIGATIONS App B-1
TECHOP
APPENDIX C WORKED EXAMPLE OF A DP INCIDENT INVESTIGATION

USING THE TOOL
App C TECHOP (G-04 - Rev1 - Jan21) CONDUCTING EFFECTIVE AND COMPREHENSIVE DP INCIDENT INVESTIGATIONS
Guidance from Techop
Main Elements
DESIGN OPERATIONS PEOPLE PROCESS
INCIDENT DATA
LFI
DESIGN OPERATIONS PEOPLE PROCESS
Operations Causal and Contributory Factors

Process (Main elements)
Causal or contributory
Sub elements of Process Element definition Examples of defined principles factor (Yes/No) If yes, description of failure If no, short description of basis for ruling it out Link to evidence (Ctrl to select multiple)
ETO / Electrician, Junior DPO,

DP FMEAs (minimum performance
Activities that have been put in standard DNV RP D102, MTS tools
place to identify gaps of existing for FMEA and proving trials gap
documents/processes against a analysis, Annual Trials to IMCA
1 Verification and Validation defined performance standard M190 / M191 etc. Yes Demo
2 DP FMEA Sub element of V and V Minimum DNV RP D102 No Demo
FMEA and proving trials gap

3 analysis Sub element of V and V MTS tools available No Demo
4 Annual trials Sub element of V and V Minimum IMCA M190/191 Yes Demo
5 Annual trials gap analysis Sub element of V and V MTS tools available Yes Demo
Minimum MTS DP Committee

6 DP Operations manual Sub element of V and V guidance document No Demo
DP Operations Manual Gap Screenshots, Relevant drawings,

7 Analysis Sub element of V and V MTS tools available No Demo
Documented evidence of
closure and closure path of
8 identified gaps Sub element of V and V PM work orders No Demo
Closure of findings and

9 observations from audits Sub element of V and V Vendor support, PM work orders No Demo
Implementation of applicable
technical guidance from
10 Vendors Sub element of V and V Routine review of processes No Demo
Operations
Implementation of actions from
11 lessons learned Sub element of V and V Post action summaries No Demo
Adherence to original
equipment manufacturer's
recommendation for IRM,
Performance testing, Post
failure testing and testing Verification and validation should
following extensive intrusive extent to planned maintenance
12 maintenance Sub element of V and V routines and testing procedures No Demo
Application of Hazards and To determine whether vessel

Effects Management Processes should be configured as CAM /
(HEMP) to manage risks and TAM, all activities within defined
associated consequences due to boundary conditions, potential
a loss of position incident on a need of specialist support should be
13 Hazard recognition DP vessel recognised and catered to No Demo
Risk assessment carried out to

CAM/TAM operation of the Sub element of hazard quantify the consequences of a
14 vessel recognition position excursion Yes Demo
Sub element of hazard Field decisions to be made with

15 HEMP processes used recognition HEMP processes utilized Yes Demo
Sub element of hazard
recognition. Routine or non-
routine activities, departure
from established procedures Risks of both routine and non
due to extenuating routine activities should be clearly
16 Activity circumstances assessed Yes Demo
Sub element of hazard If an incident occurs, the right

recognition. Roles and personnel should be at the right
Roles and responsibilities clearly responsibilities of personnel stations to restrict the severity of
17 defined clearly defined the consequences No Demo

recognition. Clear recognition of
the hazards and an appreciation
Hazard recognition and for the consequences of a loss of
18 management position incident Proper HEMP procedures followed No Demo
Tools, processes or barriers that

are used to enhance robustness
of mitigations to prevent the
potential for causal and
contributory factors to manifest PTW, tool box talks, task risk
themselves and result in a loss assessments etc. as enumerated
19 Controls of position below Yes Demo
Requirements for permit to Cold work/ hot work / working at

20 work Sub element of controls height Yes Demo
21 Tool box talks conducted Sub element of controls All jobs discussed Yes Demo
22 Job safety analysis conducted Sub element of controls As part of related tasks No Demo
Task risk assessments

23 performed Sub element of controls As part of related tasks No Demo
Imposition of positioning
24 standby? Sub element of controls If deemed by operational guidance No Demo
Imposition of requirements to
assess impacts of IRM and
reassessment of post failure
25 capability Sub element of controls If deemed by operational guidance No Demo
Management of permitted
26 operations Sub element of controls If deemed by operational guidance Yes Demo
27 Simultaneous Operations Sub element of controls As per title Yes Demo
28 500m entry checklists Sub element of controls Engine room / bridge checklists No Demo
Harsh weather precautions and

29 checklists Sub element of controls Capability analysis to be referred to No Demo
Checklists validating
configuration of vessel in
accordance with the ASOG /
30 WSOG Sub element of controls As per title No Demo
Checklists validation appropriate DP Gain values, Position reference

31 values for configurable settings Sub element of controls rejection limits etc. No Demo
Use this space to fill in any other

32 Any additional comments relevant information Any point that is not covered above No Demo
People (Main elements)
Sub elements of People Element definition Examples of defined principles factor (Yes/No) If yes, description of failure If no, short description of basis for ruling it out Link to evidence (Ctrl to select multiple)
Industry standards, company Chief Engineer, OIM,

Are minimum training and standards, client stipulated
1 Training and competence competence requirements met? requirements Yes Demo
Provision for structured on the Physical evidence / damage reports, Relevant

job training. Provision of drills Periodic partial and complete drawings,
and exercises including blackout recovery carried out by the
2 On the job training contingency planning crew No Demo
Adherence to ASOG / WSOG,

Have expectations of adherence defending the redundancy concept,
to requirements been clearly addressing IRM, looking for and
and unambiguously guarding against biases both
3 Communication of expectations communicated? personal and experience based Yes Demo
Guided / unguided, reflective

methods like using known incidents
to develop and emphasize
messages and have personnel
consciously reflect how such a
Mode of communication of The mode of communicating situation can manifest itself in their
4 expectations expectations as defined above area of responsibility No Demo
More addressable techniques for

Is there time and resources coaching and mentoring used
Availability of coaching and devoted to coaching and instead of just following normal
5 mentoring mentoring of crew? handover procedures Yes Demo
Ability to exercise stop work

authority, ability to be comfortable
with chronic unease, ability to feel
empowered to challenge unsafe
6 Cultural factors Having mixed cultural crewing practices Yes Demo
impacts of ongoing activities and

demands placed on individuals,
duty cycles, crew change Prolonged duration of positioning
7 Fatigue rotations standby Yes Demo
Pressure may be real or

perceived and result in Client pressure on approaching
temptation to breach deadlines
8 Pressure to perform established boundaries No Demo
Capability to demonstrate
consistency and focus on
delivery of incident free DP E.g. quick response by master to
operations all the time control vessel using alternative
irrespective of pressure induced control means when the DP control
9 Performance under pressure by ongoing activities system fails No Demo

Operations
Operations (Main elements)
Sub elements of Operations Element definition Examples of defined principles factor (Yes/No) If yes, description of failure If no, short description of basis for ruling it out Link to evidence (Ctrl to select multiple)
CAM when operating within the Investigation reports, ASOG / WSOG,

Choice of configuration taking 500m zone and TAM when
into account the consequences operating without any structures in
1 Vessel configuration (CAM/TAM) of a loss of position the vicinity Yes Demo
Validation that the vessel is Checking operating guidance to Trends (T-30 min), Incident related
operating in the identified ensure all aspects of the DP system information,
2 CAM/TAM validation configuration are configured correctly No Demo
Redundancy requirements in
PRSs to be configured according principle followed even without
3 PRS configurations to the job being performed structures in the vicinity No Demo
Vessel is to be operated in the Auto position, follow track, follow

4 Modes and features for DP appropriate mode target etc. Yes Demo
Industrial mission specific IM specific modes should be External force compensation, heavy
5 modes and features validated then followed lift mode No Demo
Third party equipment having an

Management of external effect over the DP system ESD systems, F & G shutdowns,
6 interfaces should be checked tensioner inputs No Demo
All DP operations should be

undertaken within the identified Alternate failure criteria should not
and validated post failure be used for CAM. For TAM risk
7 Post failure capability capability of the vessels. assessments should be conducted No Demo
Inspection, repair and Witness statements, , Chief Engineer, , OIM,

maintenance activities may Redundant equipment may not be Captain,
IRM and reassessment of post render equipment temporarily available and this post failure
8 failure capability unavailable for use capability should be reassessed Yes Demo
Disabling or reinstating protective

functions can compound the effects
Protective functions and Defending protective functions of any subsequent failure. E.g.
restoration of same if disabled and restoration of same if disabling generator protection
9 for IRM disabled for IRM modules during DP operations No Demo
Reinstatement of equipment
post intrusive maintenance or
post failure comes with an Choose an optimum time to
increase in vulnerability to the reinstate equipment, suspend
potential for a subsequent operations and move out of the
failure. Due consideration 500m zone, bringing vessel
should be given to this potential activities to a safe position,
Reinstatement of equipment and additional mitigations configuring vessel in CAM prior to
10 post failure should be put in place reinstating equipment Yes Demo
Operations
Automatic changeover of input

Automatic change overs / supplies to UPSs or Thrusters or
automatic reinstatement of automatic reinstatement of Algorithms like Thruster automatic
11 failed equipment failed equipment recovery logic (TARL) No Demo
Operator settings containing

Erroneous operator configurable illegal inputs should be alarmed User suppressed alarms , settings
12 settings / not used etc. should be identifiable Yes Demo
Operations (Main elements)
Sub elements of Operations Element definition Examples of defined principles factor (Yes/No) If yes, description of failure If no, short description of basis for ruling it out Link to evidence (Ctrl to select multiple)

13 Any additional comments relevant information Any point that is not covered above Yes Demo
Design (Main elements)
Sub elements of Design Element definition Examples of defined principles factor (Yes/No) If yes, description of failure If no, short description of basis for ruling it out Link to evidence (Ctrl to select multiple)
Control of main machinery Logged alarms - Machinery, Logged alarms DP,

should be decentralised to the Position reference sensor logs,
point where it makes itself ready Thruster control systems with UPS
1 Autonomy for DP control support and independent auxiliaries Yes Demo
Services for main machinery Screenshots, Relevant drawings,

should be designed to limit the
effects of single failures to one Separate control, protection and
2 Independence generator or thruster monitoring systems for generators No Demo
Redundant systems should have Local controller logs for drives, thrusters and
as few common points as Thruster input supply, DC supplies engines, Vendor reports,
possible to prevent fault coupled through diodes, common
3 Segregation propagation battery charger supplies Yes Demo
Task within industrial mission, Ongoing IRM,

Where redundancy depends on
multiple data sources create
diversity in the measurement
methods to reduce the potential Position reference sensors, vessel
4 Differentiation for common mode failures sensors No Demo
Ensure systems are single fault DP System FMEA , DP System FMEA Proving Trials,
tolerant based on the principles Each system to have tolerance and
of protection, detection and means to provide functionality
performance. Redundancy through a single fault or in some
means more than just cases a hidden fault and a single
5 Fault tolerance duplication fault Yes Demo
Select high reliability equipment

that is resistant to internal and
external influences and suitable
for the harsh marine Fire retardant cables to be used in
6 Fault resistance environment high risk areas Yes Demo
Equipment must be able to

tolerate the effects of failures in
other equipment to which it
may be connected – voltage Voltage dip ride through capabilities
7 Fault ride through dips, network storms for electronics No Demo
Thruster deselections should be

double push and covered, DP mode
The design of the operator selection should be covered to
control functions should be prevent maloperation. PRS
intuitive and not provide monitors should be within view of
8 Ergonomics avenues for maloperation the DP control station Yes Demo
Configurations should be changed

Configurations / Configurable only after a clear review of its
9 Settings Operator controlled settings repercussions Yes Demo
Commonality or cross
connections between redundant Common FW cooling systems,
equipment groups should be Isolation boxes for sensors etc.
10 Commonality reviewed should be carefully considered No Demo
Operations
External interfaces having an
indirect impact on DP
equipment and controls should ESD systems, fire & gas controlled
11 External Interfaces be reviewed stops, riser angle warnings etc. No Demo
Design (Main elements)
Sub elements of Design Element definition Examples of defined principles factor (Yes/No) If yes, description of failure If no, short description of basis for ruling it out Link to evidence (Ctrl to select multiple)
Hidden failure is the term used

to describe undetected, pre-
existing faults in redundant
systems which have the
potential to defeat the
redundancy concept when a
subsequent fault occurs. The
possibility that a system was
Potential for Hidden Failures, already in a partially failed Alarms should be checked, time
Alarm capability and alarm condition before the incident delays should be sufficient for the
12 monitoring occurred should be considered failure effects Yes Demo

Note: Where cross connections are identified, additional emphasis should be placed on fault tolerance, fault resistance, fault ride through and protective functions.
Process (Causal and contributory factors)
Extracted from main pathway
Sub elements of Process Element definition Examples of defined principles factor (Yes/No) Description of failure Link to evidence
ETO / Electrician, Junior DPO,

DP FMEAs (minimum performance
Activities that have been put in standard DNV RP D102, MTS tools
place to identify gaps of existing for FMEA and proving trials gap
documents/processes against a analysis, Annual Trials to IMCA
1 Verification and Validation defined performance standard M190 / M191 etc. Yes Demo
4 Annual trials Sub element of V and V Minimum IMCA M190/191 Yes Demo
5 Annual trials gap analysis Sub element of V and V MTS tools available Yes Demo
Risk assessment carried out to

CAM/TAM operation of the Sub element of hazard quantify the consequences of a
14 vessel recognition position excursion Yes Demo
Sub element of hazard Field decisions to be made with

15 HEMP processes used recognition HEMP processes utilized Yes Demo

recognition. Routine or non-
routine activities, departure Risks of both routine and non
from established procedures due routine activities should be clearly
16 Activity to extenuating circumstances assessed Yes Demo
Tools, processes or barriers that

are used to enhance robustness
of mitigations to prevent the
potential for causal and
contributory factors to manifest PTW, tool box talks, task risk
themselves and result in a loss of assessments etc. as enumerated
19 Controls position below Yes Demo
Cold work/ hot work / working at

20 Requirements for permit to work Sub element of controls height Yes Demo
21 Tool box talks conducted Sub element of controls All jobs discussed Yes Demo
Process (Causal and contributory factors)
Sub elements of Process Element definition Examples of defined principles factor (Yes/No) Description of failure Link to evidence
Management of permitted
26 operations Sub element of controls If deemed by operational guidance Yes Demo
Operations
27 Simultaneous Operations Sub element of controls As per title Yes Demo
People (Causal and contributory factors)
Sub elements of People Element definition Examples of defined principles factor (Yes/No) Description of failure Link to evidence
Operations (Causal and contributory factors)
Sub elements of Operations Element definition Examples of defined principles factor (Yes/No) Description of failure Link to evidence
CAM when operating within the Investigation reports, ASOG / WSOG,

Choice of configuration taking 500m zone and TAM when
into account the consequences operating without any structures in
1 Vessel configuration (CAM/TAM) of a loss of position the vicinity Yes Demo
Vessel is to be operated in the Auto position, follow track, follow

4 Modes and features for DP appropriate mode target etc. Yes Demo
Inspection, repair and Witness statements, , Chief Engineer, , OIM,

maintenance activities may Redundant equipment may not be Captain,
IRM and reassessment of post render equipment temporarily available and this post failure
8 failure capability unavailable for use capability should be reassessed Yes Demo
Reinstatement of equipment
post intrusive maintenance or
post failure comes with an Choose an optimum time to
increase in vulnerability to the reinstate equipment, suspend
potential for a subsequent operations and move out of the
failure. Due consideration should 500m zone, bringing vessel activities
be given to this potential and to a safe position, configuring vessel
Reinstatement of equipment additional mitigations should be in CAM prior to reinstating
10 post failure put in place equipment Yes Demo
Operator settings containing

Erroneous operator configurable illegal inputs should be alarmed User suppressed alarms , settings
12 settings / not used etc. should be identifiable Yes Demo

13 Any additional comments relevant information Any point that is not covered above Yes Demo
Operations (Causal and contributory factors)
Sub elements of Operations Element definition Examples of defined principles factor (Yes/No) Description of failure Link to evidence
Operations
Design (Causal and contributory factors)
Sub elements of Design Element definition Examples of defined principles factor (Yes/No) Description of failure Link to evidence
Control of main machinery Logged alarms - Machinery, Logged alarms

should be decentralised to the DP, Position reference sensor logs,
point where it makes itself ready Thruster control systems with UPS
1 Autonomy for DP control support and independent auxiliaries Yes Demo
Redundant systems should have Local controller logs for drives, thrusters and
as few common points as Thruster input supply, DC supplies engines, Vendor reports,
possible to prevent fault coupled through diodes, common
3 Segregation propagation battery charger supplies Yes Demo
Ensure systems are single fault DP System FMEA , DP System FMEA Proving
tolerant based on the principles Each system to have tolerance and Trials,
of protection, detection and means to provide functionality
performance. Redundancy through a single fault or in some
means more than just cases a hidden fault and a single
5 Fault tolerance duplication fault Yes Demo
Select high reliability equipment

that is resistant to internal and
external influences and suitable
for the harsh marine Fire retardant cables to be used in
6 Fault resistance environment high risk areas Yes Demo
Thruster deselections should be

double push and covered, DP mode
The design of the operator selection should be covered to
control functions should be prevent maloperation. PRS monitors
intuitive and not provide should be within view of the DP
8 Ergonomics avenues for maloperation control station Yes Demo
Configurations should be changed

Configurations / Configurable only after a clear review of its
9 Settings Operator controlled settings repercussions Yes Demo
Design (Causal and contributory factors)
Sub elements of Design Element definition Examples of defined principles factor (Yes/No) Description of failure Link to evidence
Hidden failure is the term used
to describe undetected, pre-
existing faults in redundant
systems which have the
potential to defeat the
redundancy concept when a
subsequent fault occurs. The
possibility that a system was
Potential for Hidden Failures, already in a partially failed Alarms should be checked, time
Alarm capability and alarm condition before the incident delays should be sufficient for the
12 monitoring occurred should be considered failure effects Yes Demo
Operations
Incident investigation support data tracking sheet
Attached data checklist Brief description of attachment Description of data used Link to attachment
1 Logged alarms - Machinery Alarm logs - Note there are limited logging facilities
2 Logged alarms DP DP logs for covering at least 30 mins before the incident
3 Position reference sensor logs PRS logs and positioning / error data
4 Field Station logs Controller logs of data through field stations
Local controller logs for drives, thrusters

5 and engines Controller logs for equipment like drives, thrusters and engines
6 Vendor reports Vendor investigation reports
7 Physical evidence / damage reports Reports made by shit staff on any physical damage
8 Relevant drawings Relevant wiring diagrams, P and ID schematics etc.
Screenshots of DP operator stations, IAS operator stations,

9 Screenshots Generator monitoring etc.
Information about IM being undertaken during the incident,

10 Industrial mission information configuration for the IM, risk analysis etc.
Operations
Information about specific tasks being undertaken during the
11 Task within industrial mission incident e.g.. Transferring riser, FO transfer, running casing etc.
Information on any ongoing inspection, repair and maintenance

12 Ongoing IRM processes
13 Failed equipment When was last IRM carried out, is this the first use after IRM?
Was IRM being carried out on any adjacent or peripheral

14 Peripheral or adjacent equipment equipment?
Observations made during the incident, environment conditions,

15 Incident related information report of what happened with reference to the vessel itself
16 Trends (T-30 min) Any trends on the generators and thrusters to be captured
17 DP System FMEA DP systems FMEA report
18 DP System FMEA Proving Trials FMEA proving trials report
19 Investigation reports IMCA incident report, third party investigation reports etc.
20 ASOG / WSOG IM configuration tools and other DST records

Incident investigation support data tracking sheet
Attached data checklist Brief description of attachment Description of data used Link to attachment
21 Witness statements Witness statements from the vessel crew to describe the incident
21 a) Captain
21 b) OIM
21 c) Chief Engineer
21 d) Chief Mate
21 e) Senior DPO
21 f) Junior DPO
21 g) ETO / Electrician
Note: Data should be captured and preserved to cover a period of the incident as well as for a period of a minimum of up to 30 minutes before the incident
LEARNING FROM INCIDENT
PLEASE ENTER RELEVANT INCIDENT
TOPICS SUB - TOPICS DETAILS BELOW HELP TEXT
Title Example of LFI Provide a title describing the nature of the incident
-Charterers
-Owners
Target audience for -Vessel crew
the LFI -Industry Enumerate the target audience for the LFI
Provide incident related information (Refer techop appendices for examples,

What happened Demonstration of the tool provide vessel statistics, configuration, activities, environmental conditions etc.)
Provide summary of investigations carried out post incident by onboard vessel

Why it happened To demonstrate the tool management team (VMT) (Refer techop appendices for examples)
•The following steps were carried out

What investigation steps •List steps
were carried out •More steps
What was focused on Checking for bugs
Why was this focused To get the TECHOP tool working
What was the outcome The tool seems to be working

Confidence level on
outcomes High
Basis of confidence Testing
Following lessons were learned:

- Lesson A
- Lesson B What information can be dessiminated to the industry from this incident and its
Lessons learned - Lesson C investigation
Describe how the findings of the incident report were addressed by short,
medium and long term measures. Comment on how other stakeholders could
apply the learnings from this incident so as to manage similar risks to which
Recommendations The following remedial actions are proposed they may be exposed
Short term remedial

actions Fix the problem, find out root cause
Medium term remedial Check company wide, does similar problem exist? Fix, verify root
actions cause was correctly identified
Long term remedial Remove the root cause from design if possible, else mitigate.
actions Future designs shouldn't repeat. Spread to industry.
Additional notes None Any other pertinent information

The chart below shows the breakdown of the causal and The data below is automatically generated from the worksheets. Please do not
contributory factors as defined within the four criteria of Design, edit any of the below items. If they seem to be wrong, kindly recheck the other
Results breakdown Operations, People and Process. worksheets
Design 7 24.14%
Operations 6 20.69%
People 5 17.24%
Process 11 37.93%
Results Breakdown
24%
38% Design
Operations
People
Process
21%
17%
Design sub topics

Ergonomics was a causal or contributory factor
Commonality wasn't a causal or contributory factor
External Interfaces weren't a causal or contributory factor
The above Design sub topics have been found to be causal or contributory factors in many learning from incidents and are thus highlighted separately
TECHOP
APPENDIX D EXAMPLE LFI
App D TECHOP (G-04 - Rev1 - Jan21) CONDUCTING EFFECTIVE AND COMPREHENSIVE DP INCIDENT INVESTIGATIONS
TECHOP
TECHOP (G-04 - Rev1 - Jan21) CONDUCTING EFFECTIVE AND COMPREHENSIVE DP INCIDENT INVESTIGATIONS App D-1
TECHOP
App D-2 TECHOP (G-04 - Rev1 - Jan21) CONDUCTING EFFECTIVE AND COMPREHENSIVE DP INCIDENT INVESTIGATIONS
TECHOP
APPENDIX E TEMPLATE TO GENERATE LFI
App E TECHOP (G-04 - Rev1 - Jan21) CONDUCTING EFFECTIVE AND COMPREHENSIVE DP INCIDENT INVESTIGATIONS
TECHOP
TECHOP (G-04 - Rev1 - Jan21) CONDUCTING EFFECTIVE AND COMPREHENSIVE DP INCIDENT INVESTIGATIONS App E-1

TECHOP Conducting Effective DP Incident Investigations

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TECHOP

TECHNICAL AND OPERATIONAL GUIDANCE

TECHOP (G-04 - Rev1 - Jan21)

CONDUCTING EFFECTIVE AND COMPREHENSIVE

DISCLAIMER AND LIMITATION OF LIABILITY

CAM Critical Activity Mode

1.2 TECHOP NAMING CONVENTION

1.3 MTS DP GUIDANCE REVISION METHODOLOGY

2 SCOPE AND IMPACT OF THIS TECHOP

2.3 FOCUS OF THIS TECHOP

2.4 IMPACT ON PUBLISHED GUIDANCE

3 CASE FOR ACTION

3.2 PROACTIVE MEASURE

3.3 DEMONSTRATING MEANS OF CONTROLLING RISK

4 STRUCTURE FOR A COMPREHENSIVE DP INCIDENT

4.2 EXPLANATION OF THE FISH BONE STRUCTURE

Figure 4-1 Fish Bone Diagram

4.2.3 The anatomy of the fish bone includes:

5 DETAIL OF THE FISH BONE STRUCTURE

5.2 THE PATHWAY

5.3 THE UPPER HALF

• Adherence to Original Equipment Manufacturer’s Recommendation:

• Mode of communication of expectations (how is this communicated?)

5.8 THE LOWER HALF

5.9 CAUSAL AND CONTRIBUTORY FACTORS – DESIGN

5.10 CAUSAL AND CONTRIBUTORY FACTORS – OPERATIONS

5.11 CAUSAL AND CONTRIBUTORY FACTORS – PROCESS

5.12 CAUSAL AND CONTRIBUTORY FACTORS – PEOPLE

5.13 ACTIONS THE HEAD

5.14 SHORT TERM REMEDIAL ACTIONS

5.15 MEDIUM TERM REMEDIAL ACTIONS

5.16 LONG TERM REMEDIAL ACTIONS

5.17 THE LOWER TAIL SECTION - THE LFI

6.3 EXTRACTING VALUE FROM LFI

APPENDIX A TEMPLATE TO SUPPLEMENT INCIDENT REPORTING

SUPPLEMENT TO DP INCIDENT REPORTING

ACTIVITIES BEING UNDERTAKEN Inspection Repair and Maintenance (IRM)

SUPPLEMENT TO DP INCIDENT REPORTING

SUPPLEMENT TO DP INCIDENT REPORTING

APPENDIX B COMPREHENSIVE DP INCIDENT INVESTIGATION TOOL

APPENDIX C WORKED EXAMPLE OF A DP INCIDENT INVESTIGATION

DESIGN OPERATIONS PEOPLE PROCESS

DESIGN OPERATIONS PEOPLE PROCESS

Operations Causal and Contributory Factors

ETO / Electrician, Junior DPO,

2 DP FMEA Sub element of V and V Minimum DNV RP D102 No Demo

FMEA and proving trials gap

Minimum MTS DP Committee

DP Operations Manual Gap Screenshots, Relevant drawings,

Closure of findings and

Application of Hazards and To determine whether vessel

Risk assessment carried out to

Sub element of hazard Field decisions to be made with

Sub element of hazard If an incident occurs, the right

Sub element of hazard

Tools, processes or barriers that

Requirements for permit to Cold work/ hot work / working at

Task risk assessments

27 Simultaneous Operations Sub element of controls As per title Yes Demo