Practical Incident Investigation

and Root Cause Analysis

Course documentation
Practical Incident Investigation and Root Cause Analysis

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 Practical Incident Investigation and Root Cause Analysis

Content
1. Maritime Incident Investigations……………………… …………………………………………… …………………………………………….….4
2. Marine Incident Investigation Process………………………………………………………………………………………………………..……..6
3. Areas of human factors inquiry………………………………………………………………………………………………………………..…….….7
4. Gathering evidence…………………………………………………………………………………………………………………………………..………..9
5. Event and Casual Factor Charting…….…………………………………………………………………………………………………..…….…..11
6. STEP – Sequential Time Event Plotting…………………………………………………………………………………………………………….14
7. Barrier analysis………………………………………………………………………………………………………………………………………………….17
8. Change analysis…………………………………………………………………………………………………………………………………………………18
9. MSCAT………………………………………………………………………………………………………………………………………………………… …..21
10. Control areas for improvement actions………………………………………………………………………………………………… …..25
11. Summary of important international requirements relevant to incident and incident investigation… …26

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 Practical Incident Investigation and Root Cause Analysis

1 Maritime Incident Investigations

Incident investigation is not only carried out because of legal requirements. The industry has a natural interest to investigate the causes of
incidents and incidents. When we know how incidents are caused we might be able to prevent them in future. This is why incident analysis
and emergency response was incorporated into the ISM Code and is highlighted again in other industry standards.

Apart from pure legal requirements a number of good logical considerations can be mentioned here to justify why a shipping company
should make efforts to investigate incidents and incidents. Basically it, it is not about blaming individuals, but rather learning from incidents
in order to avoid them in future.

Safety is a question of money, too. This means not necessarily more money - more safety. No, what we understand by the relationship
between safety and money is, that incidents are quite costly and only a fraction of the damage caused by incidents is insured. A large
portion of the costs is not insured and has to be covered by the shipping company. In addition there are a number of issues linked to
incident that can hardly be quantified, such as damage to the reputation of a shipping company, loss of business and goodwill etc.

Incidents do not come “out of the blue”. Usually incidents have a history. They occur due to a special combination of specific circumstances.
If we carefully investigate incidents we might be able to gather data allowing us to hopefully identify alarming trends that might lead to
bigger incidents in future. Researches have always tried to find out about the relationship between major and minor incidents. It started with

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Herbert W. Heinrich in 1931, who found out that before major incidents occur, minor incidents and unsafe acts resulting from the same
source could eventually indicate that the risk of a major incident exists. Frank Bird studied the same subject in 1969 and found an incident
ratio where each major incident can be preceded by 10 minor incidents, 30 property damage incidents and 600 near misses. This should
encourage incident and incident reporting and investigation.

No matter if we believe that the ratio is exactly 1:10:30:600 or not (some researchers say its more, some say it is less) there is a
relationship between small scale and large scale incidents and incidents. It is just only a combination of circumstances, which decides if an
unsafe act results into a catastrophe, or not. If we therefore carefully study incident reports and try to identify the causes, we might be able
to prevent large scale incidents by eliminating root causes. This is not an absolute guarantee, but it is worth trying.

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2 Marine Incident Investigation Process

An investigation should be carried out as soon as possible after an occurrence. The quality of
evidence, particularly that relying on the accuracy of human recollection, can deteriorate rapidly with
time, and delayed investigations are usually not as conclusive as those performed promptly. A
prompt investigation is also a good demonstration of commitment by all those concerned.

Before an incident can be analysed, an investigation is required to gather all available evidences.
The level of investigation will differ depending on an evaluation of the loss potential for the event.
High Potential Events will require thorough investigation.

Initial response will focus on stopping further losses, providing first aid to those in need, preserve
evidences from alteration or removal, notification of all interested parties.

There are four sources of information that should be considered in any investigation.
• Position Information
• People Information
• Parts Information
• Paper Information
• Electronic Information
Collected information must be analysed to determine basic or root causes. Immediate causes are
relatively easily to determine but they are only symptoms. Root causes are much more difficult to
identify and the companies should use preferred root cause analysis.

Finding and report should focus on these actions which will correct immediate and root causes. Safety recommendations should focus on
responses to deficiencies in the organisations management system. Effectiveness of implemented corrective actions should be monitored
with frequency determined by severity of loss potential.

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3 Areas of Human Factors Inquiry

Ships operate in a highly dynamic environment; frequently the people on board follow a set
routine of shift work disrupted by arrival at, working in, and sailing from port. This is an
existence which involves living in the place of work for prolonged periods, creating a unique
form of working life which almost certainly increases the risk of human error.

Human Error contributes to about 80% of all marine incidents: these are the mistakes, slips,
lapses and poor decisions which directly lead to accidents. The 20% of accidents which are
not caused by Human Error might involve mechanical failure, environmental factors or,
conceivably, an “act of god”.

However, all of these categories, including an “act of god”, involve Human Factors or the
Human Element.

Human factors which contribute to marine casualties and incidents may be broadly defined
as the acts or omissions, intentional or otherwise, which adversely affect the proper
functioning of a particular system, or the successful performance of a particular task.
Understanding human factors thus requires a study and analysis of the design of the
equipment, the interaction of the human operator with the equipment, and the procedures
followed by crew and management.

For complex systems, where there are numerous interactions between the component
elements, there is constant danger that critical information will be overlooked or lost during
an investigation.

Use of the SHEL model as an organizational tool for the investigator's workplace data collection helps avoid downstream problems because:
1. it takes into consideration all the important work system elements;
2. it promotes the consideration of the interrelationships between these work system elements; and
3. it focuses on the factors which influence human performance by relating all peripheral elements to the central liveware
element.

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The process initially attempts to answer the more simplistic questions of "what, who, and when" and then moves to the more
complicated questions of "how and why". The resulting data becomes, for the most part, a collection of events and circumstances comprised
of acts and conditions. Some of these will be of interest as unsafe acts and unsafe conditions.

Liveware
The most valuable and flexible component in the system is the human element, the
Hawkins 1987, liveware, placed at the centre of the model. Each person brings his or her own
SHEL Model capabilities and limitations, be they physical, physiological, psychological, or
psychosocial. This component can be applied to any person involved with the operation
or in support of the operation. The person under consideration interacts directly with
each one of the four other elements. Each person and each interaction, or interface,
constitute potential areas of human performance investigation.
The following questions are designed to aid the investigator while investigating for
human factors. Skilful questioning can help the investigator eliminate irrelevant lines of
inquiry and focus on areas of greater potential significance.

Hardware
Hardware refers to the equipment part of a transportation system. It includes the design
of work stations, displays, controls, seats, etc.

Software
Software is the non-physical part of the system including organizational policies, procedures, manuals, checklist layout, charts, maps,
advisories and, increasingly, computer programs.

Environment
Environment includes the internal and external climate, temperature, visibility, vibration, noise and other factors which constitute the
conditions within which people are working. Sometimes the broad political and economic constraints under which the system operates are
included in this element. The regulatory climate is a part of the environment inasmuch as it affects communications, decision-making,
control, and co-ordination.

Liveware (perypherial)
The peripheral liveware refers to the system's human-human interactions, including such factors as management, supervision, crew
interactions and communications.

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4 Gathering evidence

Different tools can be used in order to support the systematic gathering of evidence. These tools include, e.g., checklists, tables, matrixes etc. Below is a
suggestion for simple tables to be used in gathering evidence on your own ship and other relevant locations.

Evidence on your own ship

No. Item (What is it?)
Where (Where can it be Comments (Do you have it
Why (Why is this important
found, who can give it to already, whom do you need
evidence?)
you?) to contact …?)

Evidence in other locations

No. Item (What is it?)
Where (Where can it be Comments (Do you have it
Why (Why is this important
found, who can give it to already, whom do you need
evidence?)
you?) to contact …?)

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Evidence Matrix

The evidence matrix is a support tool intended to facilitate the systematic gathering of evidence. Before any major event or finding is confirmed in an
investigation the evidence matrix can be used in order to list information or evidence that confirms or questions this event or finding. By evaluating the
confirming or questioning information an investigator is able to agree or disagree on this event or finding for its further use in the investigation. There are a
few steps to be observed when using this simple tool.

• Identify major findings or causal elements

Look through the factual information you have gathered about the incident so far and identify key findings and events that had a decisive influence
on the incident development that need to be supported by evidence in order to stand in any dispute
• Identify supporting or questioning evidence
Identify evidence linked to the event/finding in question which may confirm or dispute the event/finding and list it accordingly
• Describe the source of evidence clearly
Provide technical specifications/references to statements made by witnesses or experts
• Add comments
Depending on the stage of your investigation you can add comments about the progress made in securing the evidence or where it was filed or
stored

Evidence Matrix Worksheet

Major findings or causal Evidence (both Pro and Source of Evidence Comments
element Con)

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5 Event and Causal Factor Charting

Event and causal factor charting is a commonly used tool which in a very effective way supports and organizes your investigation. The basic
idea is to distinguish between events (active) of actors in the incident development and surrounding conditions (passive) in the environment
(natural and organizational) of the incident scene. Any event is usually influenced by conditions (navigation at night, driving in rain,
reasoning when tired etc.). The idea behind event and causal factor charting is that usually unsuitable conditions in combinations with an
unsafe act (active event) cause incidents. While we do have limited influence on individual performance of actors we do have more chances
to influence the surrounding conditions for the better. Thus, in an incident investigation the task is to identify these unsuitable conditions
and remove them for the future. In order to do that a few general considerations should be observed.

• Assess the incident information available

When you start with your event and causal factor chart you may only have rudimentary information about the incident. This is normal
and should not worry you. The first event and causal factor chart is therefore quite basic. However, an event and causal factor chart
does not only facilitate the analysis of an incident. It also organizes the investigation. Therefore, you need to go through the
information you have at the time you start with your first chart and filter it accordingly.
• Identify events and conditions
When going through the information provided about the incident you need to identify events and conditions describing the
development of the incident. Clearly distinguish between events (active) and conditions (passive).
• Establish a timeline and associate conditions and events
Start putting the events into a certain order and link them to a timeline. Look at the conditions identified by you in earlier steps and
ask yourself which events were influenced by them in which way.
• Identify data gaps
When you look at your map it is certainly possible to find out where information is missing. Where are questions about the validity of
events (supported by evidence – evidence matrix)? Where are questions about the right timing? Where are conflicting statements
etc? Identifying such data gaps will help you focusing on the next steps of your investigation where you have to go back to the field
and gather more information to be entered into your event and causal factor chart.
• Start analyzing
When you look at your event and causal factor chart – it should be possible to focus after a while on the conditions. Investigate the
conditions by asking two questions: Why did the system allow the condition to exist? How did the condition originate?
• Supplement your analysis
Once the investigation is finished and you are satisfied with your chart try to supplement your analysis with other tools in order to
identify recommendations (e.g. by applying MSCAT).

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Guidelines for Events and Causal Factor Charts

Symbols
Incident

Event

Condition

Presumptive Event

Presumptive Condition

Connected Events

Connected Conditions

Transfers one line to another

Events • Are active (e.g., crane strikes building)

• Should be stated using one noun and one active verb
• Should be quantified as much as possible and where applicable (e.g., 3 tons of oil were
spilled into the sea rather than oil was spilled into the sea)
• Should indicate the date and time of the event, when they are known
• Should be derived from the event or events and conditions immediately preceding it.
Conditions • Are passive (e.g., fog in the area)
• Are the results of events
• Describe states or circumstances rather than occurrences or events
• As practical, should be quantified
• Should indicate date and time if practical/applicable
• Are associated with the corresponding event.

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6 STEP (Sequential timed events plotting)

Steps involved Causal relationships of events

• Gather information about events with STEP

cards
• Start drawing a STEP worksheet
o Assign actors
o Relate events to the actors
o Identify the relationships between the
actors and the events
o Identify when the event took place
• Consider BackSTEP, if needed
• Control the location of events in your
worksheet
o Event pairing to Truth-Test
o Row-Test
o Column-Test
o Necessary and Sufficient-Test
• Provide recommendations

Guidelines

• Simple matrix - actions (rows) and times (columns)

• One row for each actor
• No linear time scale needed – the sequence is the important issue
• Event – one actor performing an action
• An actor is a person or an item with a direct influence on events leading to an incident

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STEP (Sequential timed events plotting) card

Event Card Identifier (number,

letter ...)

Actor (who has carried out aactivities)

Action (what was done by the actor)

Time event began

Event duration

Data source/evidence (what

confirms the action)

Event location

Description (of the action)

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STEP (Sequential timed events plotting) Example

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7 Barrier Analysis

At the end of your investigation you have to draw some conclusions. You do not want to have a similar incident to occur in future. For this
reason you check your existing barriers and assess if they had failed.

Step 1 Identify the hazard and the target. Record them at the top of the worksheet.

Step 2 Identify each barrier. Record them in column 1.

Step 3 Identify how the barrier performed (What was the barrier’s purpose? Was the barrier in place or not in place? Did the barrier fail?
Was the barrier used if it was in place?). Record the findings in column 2.

Step 4 Identify and consider probable causes of the barrier failure. Record the findings in column 3.

Step 5 Evaluate the consequences of the failure in this incident. Record your conclusions in column 4.

Barrier Analysis Worksheet

Hazard: Target:

What were the barriers? How did each barrier Why did the barrier fail? How did the
perform? barrier affect
the incident?

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8 Change Analysis

Prerequisites for the Change Analysis

Anything that can help to compare the incident sequence to the same situation in an incident-free state – the operation prior to the incident
– to determine differences and thereby identify incident causal factors

• Blueprints • Job/task descriptions

• Equipment description documents • Personal qualifications
• Drawings • Results of hazard analysis
• Schematics • Performance indicators
• Operating and maintenance procedures • …
• Roles and responsibilities

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Change Analysis Worksheets (according to DoE Incident Investigation Workbook)

In Change Analysis, differing events and conditions are systematically reviewed and analysed to determine the potential causes.
Investigators should first categorize the changes according to the questions shown in the left-hand column of the worksheet. That is, the
investigator should determine if the change pertained to, for example, a difference in:

• What events, conditions, activities, or equipment were present in the incident situation that were not present in the baseline
(incident-free, prior, or ideal) situation (or vice versa)

• When an event or condition occurred or was detected in the incident situation versus the baseline situation

• Where an event or condition occurred in the incident situation versus where an event or condition occurred in the baseline situation

• Who was involved in planning, reviewing, authorizing, performing, and supervising the work activity in the incident versus the
incident-free situation

• How the work was managed and controlled in the incident versus the incident-free situation

Change Analysis Worksheet

Factors Incident Situation Prior, Ideal or Incident Difference Evaluation of Effect

Free Situation
WHAT (Conditions, occurrences,
activities, equipment)

WHEN (Occurred, identified,

facility status, schedule)

WHERE (Physical location,

environmental conditions)

WHO (Staff involved, training,

qualification, supervision)

HOW (Control chain, hazard

analysis monitoring)

OTHER

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Change Analysis Summary

Prior or Ideal Condition Present Condition Difference (Change) Recommendation

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9 MSCAT Marine Systematic Cause Analysis Technique

Root cause analysis is the heart of the investigation process. Unless basic or root causes are properly identified, any corrective actions will
almost certainly be ineffective. Actions will address only the immediate cause or symptoms, in which case it is likely the same problems will
repeat. The DNV GL Loss Causation Model shown in below provides a simple concept that is vital to effective cause analysis. It shows that
loss events are the result of a chain of immediate causes, basic causes ultimately a lack of management control. Incident investigation is the
process of understanding this causation in order to identify the management system failure that has caused the loss event. Once this is
known, improvement actions can be targeted to efficiently address the root cause of incidents and thereby prevent them being repeated.

Since cause analysis is not intuitive, organization’s must use recognized cause analysis methods and tools to ensure a systematic and
comprehensive analysis process. The M-SCAT is developed to aid you in the analysis of marine incidents. The M-SCAT is best used as an
“aide de memoir” to guide the investigator, rather than a compulsory check list where all points rigorously have to be checked off.

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Immediate causes - Substandard act

Something done or not done by person. The action taken by the person didn’t meet the standard expected of them e.g. did not follow a
procedure or did not do something in accordance with specifications. It therefore assumes that a standard has, or could be, defined. Such
omissions are either ‘unintentional acts’ or ‘intentional failures’.

1. Unintentional or intentional action

First it is necessary to determine whether the error or violation was an

unintentional or intentional action. "Did the person intend the action?" If the
answer to that question is no, then it is an unintentional action.
Unintentional actions are actions that do not go as planned; these are errors
in execution. If the answer to the question "Did the person intend the
action?" is yes, then the action is intentional. Intentional actions are actions
that are carried out as planned but the actions are inappropriate; these are
errors in planning.

2. Error type or violation

The second sub-step is the selection of the error type or violation that best
describes the failure, keeping in mind the decision regarding intentionality.
There are four potential error/violation categories, i.e., slip, lapse, mistake
The GEMS Framework (Adapted
from Reason, 1990)
and violation. A slip is an unintentional action where the failure involves
attention. These are errors in execution. A lapse is an unintentional action
where the failure involves memory. These are also errors in execution. A
mistake is an intentional action, but there is no deliberate decision to act against a rule or plan. These are errors in planning. A violation is a
planning failure where a deliberate decision to act against a rule or plan has been made. Routine violations occur everyday as people
regularly modify or do not strictly comply with work procedures, often because of poorly designed or defined work practices. In contrast, an
exceptional violation tends to be a one-time breach of a work practice, such as where safety regulations are deliberately ignored to carry out
a task. Even so, the intention was not to commit a malevolent act but just to get the job done.

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Substandard condition

Hazards created due to workplace condition e.g. engineering barrier not meeting performance standard, no barrier being present, or impact
of external factors such as weather etc. the use of the word ‘substandard’ therefore assumes that a standard has, or could be, defined.
These conditions may also increase that chance of a substandard act (e.g. human error or procedural violation).

Basic causes/Personal factors

Acts or omissions by people and the reasons for them.

1. Inadequate Physical / Physiological Capability

2. Inadequate Mental / Psychological Capability

3. Physical or Physiological Stress

4. Mental or Psychological Stress

5. Lack of Competence

6. Improper Motivation

Basic causes/Job factors

7. Unclear organisation structure

8. Inadequate leadership

9. Inadequate supervision/coaching

10. Inadequate Management of Change

11. Inadequate supply chain management

12. Inadequate maintenance/inspection

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13. Excessive Wear/Tear

14. Inadequate Tool/Equipment/Machinery/Device

15. Inadequate Product/Service

16. Inadequate Work / Production Standards

17. Inadequate Communication/Information

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10 Control areas for improvement actions

These are the management system factors that need to be in place and working in order to avoid the potential causes of loss above.
The structure and content below are an outline of the International Sustainability Rating System which is a best practice description of
the management processes required for an organisation to ensure safe and sustainable operations.

A management system is a framework of controls to manage key processes, organizational risks and drive
continual improvement. The management system is important to the operation of every business because it
guides the behaviour of personnel in the organization. The management system is the management team’s
main tool for ensuring safe and sustainable operations. The challenge facing organizations is “How can we get
our management system to work more effectively?”.

The ISRS contains 30 years of best practice experience in safety and sustainability management. Using ISRS
gives necessary personnel the ability to measure, improve and demonstrate the implementation of their
management system. The ISRS is

ISRS seventh and eighth editions are structured with 15 processes embedded in a continuous improvement
loop:

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11 Summary of important international requirements relevant to incident and incident

investigation

United Nations Convention on the Law of the Sea, 1982

Relevant Regulations

Article 2
Legal status of the territorial sea, of the air space over the territorial sea and of its bed and subsoil

1. The sovereignty of a coastal State extends, beyond its land territory and international waters and, in the case of an archipelagic
State, its archipelagic waters, to an adjacent belt of sea, described as the territorial sea.
2. This sovereignty extents to the air space over the territorial sea as well as to its bed and subsoil.
3. The sovereignty over the territorial sea is exercised subject to this Convention and to other rules of international law.

Article 27
Criminal jurisdiction on board a foreign ship

1. The criminal jurisdiction of the coastal State should not be exercised on board a foreign ship passing through the territorial sea to
arrest any person or to conduct any investigation in connection with any crime committed on board the ship during its passage, save
only in the following cases:
(a) if the consequences of the crime extend to the coastal State;
(b) if the crime is of a kind to disturb the peace of the country or the good order of the territorial sea;
(c) if the assistance of the local authorities has been requested by the master of the ship or by a diplomatic agent or consular
officer of the flag State; or
(d) if such measures are necessary for the suppression of illicit traffic in narcotic drugs or psychotropic substances.
2. The above provisions do not affect the right of the coastal State to take any steps authorized by its laws for the purpose of an arrest
or investigation on board a foreign ship passing through the territorial sea after leaving internal waters.
3. In the cases provided for in paragraphs 1 and 2, the coastal State shall, if the master so requests, notify a diplomatic agent or
consular officer of the flag State before taking any steps, and shall facilitate contact between such agent or officer and the ship's
crew. In cases of emergency this notification may be communicated while the measures are being taken.
4. In considering whether or in what manner an arrest should be made, the local authorities shall have due regard to the interests of
navigation.

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5. Except as provided in Part XII or with respect to violations of laws and regulations adopted in accordance with Part V, the coastal
State may not take any steps on board a foreign ship passing through the territorial sea to arrest any person or to conduct any
investigation in connection with any crime committed before the ship entered the territorial sea, if the ship, proceeding from a foreign
port, is only passing through the territorial sea without entering internal waters.

Article 94
Duties of the flag State

1. Every State shall effectively exercise its jurisdiction and control in administrative, technical and social matters over ships flying its
flag.
2. In particular every State shall:
(a) maintain a register of ships containing the names and particulars of ships flying its flag, except those which are excluded from
generally accepted international regulations on account of their small size; and
(b) assume jurisdiction under its internal law over each ship flying its flag and its master, officers and crew in respect of
administrative, technical and social matters concerning the ship.
3. Every State shall take such measures for ships flying its flag as are necessary to ensure safety at sea with regard, inter alia, to:
(a) the construction, equipment and seaworthiness of ships;
(b) the manning of ships, labour conditions and the training of crews, taking into account the applicable international instruments;
(c) the use of signals, the maintenance of communications and the prevention of collisions.
4. Such measures shall include those necessary to ensure:
(a) that each ship, before registration and thereafter at appropriate intervals, is surveyed by a qualified surveyor of ships, and has
on board such charts, nautical publications and navigational equipment and instruments as are appropriate for the safe navigation of
the ship;
(b) that each ship is in the charge of a master and officers who possess appropriate qualifications, in particular in seamanship,
navigation, communications and marine engineering, and that the crew is appropriate in qualification and numbers for the type, size,
machinery and equipment of the ship;
(c) that the master, officers and, to the extent appropriate, the crew are fully conversant with and required to observe the
applicable international regulations concerning the safety of life at sea, the prevention of collisions, the prevention, reduction and
control of marine pollution, and the maintenance of communications by radio.
5. In taking the measures called for in paragraphs 3 and 4 each State is required to conform to generally accepted international
regulations, procedures and practices and to take any steps which may be necessary to secure their observance.
6. A State which has clear grounds to believe that proper jurisdiction and control with respect to a ship have not been exercised may
report the facts to the flag State. Upon receiving such a report, the flag State shall investigate the matter and, if appropriate, take
any action necessary to remedy the situation.

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7. Each State shall cause an inquiry to be held by or before a suitably qualified person or persons into every marine casualty or incident
of navigation on the high seas involving a ship flying its flag and causing loss of life or serious injury to nationals of another State or
serious damage to ships or installations of another State or to the marine environment. The flag State and the other State shall
cooperate in the conduct of any inquiry held by that other State into any such marine casualty or incident of navigation.

Article 97
Penal jurisdiction in matters of collision or any other incident of navigation

1. In the event of a collision or any other incident of navigation concerning a ship on the high seas, involving the penal or disciplinary
responsibility of the master or of any other person in the service of the ship, no penal or disciplinary proceedings may be instituted
against such person except before the judicial or administrative authorities either of the flag State or of the State of which such
person is a national.
2. In disciplinary matters, the State which has issued a master's certificate or a certificate of competence or licence shall alone be
competent, after due legal process, to pronounce the withdrawal of such certificates, even if the holder is not a national of the State
which issued them.

3. No arrest or detention of the ship, even as a measure of investigation, shall be ordered by any authorities other than those of the flag
State.

Article 218
Enforcement by port States

1. When a vessel is voluntarily within a port or at an off-shore terminal of a State, that State may undertake investigations and, where
the evidence so warrants, institute proceedings in respect of any discharge from that vessel outside the internal waters, territorial sea
or exclusive economic zone of that State in violation of applicable international rules and standards established through the
competent international organization or general diplomatic conference.
2. No proceedings pursuant to paragraph 1 shall be instituted in respect of a discharge violation in the internal waters, territorial sea or
exclusive economic zone of another State unless requested by that State, the flag State, or a State damaged or threatened by the
discharge violation, or unless the violation has caused or is likely to cause pollution in the internal waters, territorial sea or exclusive
economic zone of the State instituting the proceedings.
3. When a vessel is voluntarily within a port or at an off-shore terminal of a State, that State shall, as far as practicable, comply with
requests from any State for investigation of a discharge violation referred to in paragraph 1, believed to have occurred in, caused, or
threatened damage to the internal waters, territorial sea or exclusive economic zone of the requesting State. It shall likewise, as far
as practicable, comply with requests from the flag State for investigation of such a violation, irrespective of where the violation
occurred.
4. The records of the investigation carried out by a port State pursuant to this article shall be transmitted upon request to the flag State
or to the coastal State. Any proceedings instituted by the port State on the basis of such an investigation may, subject to section 7,

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be suspended at the request of the coastal State when the violation has occurred within its internal waters, territorial sea or exclusive
economic zone. The evidence and records of the case, together with any bond or other financial security posted with the authorities of
the port State, shall in that event be transmitted to the coastal State. Such transmittal shall preclude the continuation of proceedings
in the port State.

Article 220
Enforcement by coastal States

1. When a vessel is voluntarily within a port or at an off-shore terminal of a State, that State may, subject to section 7, institute
proceedings in respect of any violation of its laws and regulations adopted in accordance with this Convention or applicable
international rules and standards for the prevention, reduction and control of pollution from vessels when the violation has occurred
within the territorial sea or the exclusive economic zone of that State.
2. Where there are clear grounds for believing that a vessel navigating in the territorial sea of a State has, during its passage therein,
violated laws and regulations of that State adopted in accordance with this Convention or applicable international rules and standards
for the prevention, reduction and control of pollution from vessels, that State, without prejudice to the application of the relevant
provisions of Part II, section 3, may undertake physical inspection of the vessel relating to the violation and may, where the evidence
so warrants, institute proceedings, including detention of the vessel, in accordance with its laws, subject to the provisions of section
7.
3. Where there are clear grounds for believing that a vessel navigating in the exclusive economic zone or the territorial sea of a State
has, in the exclusive economic zone, committed a violation of applicable international rules and standards for the prevention,
reduction and control of pollution from vessels or laws and regulations of that State conforming and giving effect to such rules and
standards, that State may require the vessel to give information regarding its identity and port of registry, its last and its next port of
call and other relevant information required to establish whether a violation has occurred.
4. States shall adopt laws and regulations and take other measures so that vessels flying their flag comply with requests for information
pursuant to paragraph 3.
5. Where there are clear grounds for believing that a vessel navigating in the exclusive economic zone or the territorial sea of a State
has, in the exclusive economic zone, committed a violation referred to in paragraph 3 resulting in a substantial discharge causing or
threatening significant pollution of the marine environment, that State may undertake physical inspection of the vessel for matters
relating to the violation if the vessel has refused to give information or if the information supplied by the vessel is manifestly at
variance with the evident factual situation and if the circumstances of the case justify such inspection.
6. Where there is clear objective evidence that a vessel navigating in the exclusive economic zone or the territorial sea of a State has, in
the exclusive economic zone, committed a violation referred to in paragraph 3 resulting in a discharge causing major damage or
threat of major damage to the coastline or related interests of the coastal State, or to any resources of its territorial sea or exclusive
economic zone, that State may, subject to section 7, provided that the evidence so warrants, institute proceedings, including
detention of the vessel, in accordance with its laws.

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7. Notwithstanding the provisions of paragraph 6, whenever appropriate procedures have been established, either through the
competent international organization or as otherwise agreed, whereby compliance with requirements for bonding or other appropriate
financial security has been assured, the coastal State if bound by such procedures shall allow the vessel to proceed.
8. The provisions of paragraphs 3, 4, 5, 6and 7 also apply in respect of national laws and regulations adopted pursuant to article 211,
paragraph 6.

Article 221
Measures to avoid pollution arising from maritime casualties

1. Nothing in this Part shall prejudice the right of States, pursuant to international law, both customary and conventional, to take and
enforce measures beyond the territorial sea proportionate to the actual or threatened damage to protect their coastline or related
interests, including fishing, from pollution or threat of pollution following upon a maritime casualty or acts relating to such a casualty,
which may reasonably be expected to result in major harmful consequences.
2. For the purposes of this article, "maritime casualty" means a collision of vessels, stranding or other incident of navigation, or other
occurrence on board a vessel or external to it resulting in material damage or imminent threat of material damage to a vessel or
cargo.

Article 226
Investigation of foreign vessels

1. (a) States shall not delay a foreign vessel longer than is essential for purposes of the investigations provided for in articles 216,
218 and 220. Any physical inspection of a foreign vessel shall be limited to an examination of such certificates, records or other
documents as the vessel is required to carry by generally accepted international rules and standards or of any similar documents
which it is carrying; further physical inspection of the vessel may be undertaken only after such an examination and only when:
(i) there are clear grounds for believing that the condition of the vessel or its equipment does not correspond substantially
with the particulars of those documents;
(ii) the contents of such documents are not sufficient to confirm or verify a suspected violation; or
(iii) the vessel is not carrying valid certificates and records.
(b) If the investigation indicates a violation of applicable laws and regulations or international rules and standards for the
protection and preservation of the marine environment, release shall be made promptly subject to reasonable procedures such as
bonding or other appropriate financial security.
(c) Without prejudice to applicable international rules and standards relating to the seaworthiness of vessels, the release of a
vessel may, whenever it would present an unreasonable threat of damage to the marine environment, be refused or made conditional
upon proceeding to the nearest appropriate repair yard. Where release has been refused or made conditional, the flag State of the
vessel must be promptly notified, and may seek release of the vessel in accordance with Part XV.
2. States shall cooperate to develop procedures for the avoidance of unnecessary physical inspection of vessels at sea.

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Overview of applicable regulations in IMO instruments

SOLAS
Chapter I, Regulation 11, Maintenance of conditions after survey

(a) The condition of the ship and its equipment shall be maintained to conform with the provisions of the present regulations to ensure
that the ship in all respects will remain fit to proceed to sea without danger to the ship or persons on board.
(b) After any survey of the ship under regulations 7, 8, 9 or 10 has been completed, no change shall be made in the structural
arrangements, machinery, equipment and other items covered by the survey, without the sanction of the Administration.
(c) Whenever an incident occurs to a ship or a defect is discovered, either of which affects the safety of the ship or the efficiency or
completeness of its life-saving appliances or other equipment, the master or owner of the ship shall report at the earliest opportunity
to the Administration, the nominated surveyor or recognized organization responsible for issuing the relevant certificate, who shall
cause investigations to be initiated to determine whether a survey, as required by regulations 7, 8, 9 or 10, is necessary. If the ship is
in a port of a Contracting Government, the master or owner shall also report immediately to the appropriate authorities of the port
State and the nominated surveyor or recognized organization shall ascertain that such a report has been made.

Chapter I, Regulation 21, Casualties

(a) Each Administration undertakes to conduct an investigation of any casualty occurring to any of its ships subject to the provisions of
the present Convention when it judges that such an investigation may assist in determining what changes in the present regulations
might be desirable.
(b) Each contracting Government undertakes to supply the Organization with pertinent information concerning the findings of such
investigations. No reports or recommendations of the Organization based upon such information shall disclose the identity or
nationality of the ships concerned or in any manner fix or imply responsibility upon any ship or person.

Chapter XI-1, Regulation 6, Additional requirements for the investigation of marine casualties and incidents

Taking into account regulation I/21, each Administration shall conduct investigations ofmarine casualties and incidents, in accordance with
the provisions of the present Convention, as supplemented by the provisions of the Code of the International Standards and Recommended
Practices for a Safety Investigation into a Marine Casualty or Marine Incident (Casualty Investigation Code) adopted by resolution
MSC.255(84), and:
.1 the provisions of parts I and II of the Casualty Investigation Code shall be fully complied with;
.2 the related guidance and explanatory material contained in part III of the Casualty Investigation Code should be taken into account to
the greatest possible extent in order to achieve a more uniform implementation of the Casualty Investigation Code;

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.3 amendments to parts I and II of the Casualty Investigation Code shall be adopted, brought into force and take effect in accordance
with the provisions of article VIII of the present Convention concerning theamendment procedures applicable to the annex other than
chapter I; and
.4 part III of the Casualty Investigation Code shall be amended by the Maritime Safety Committee in accordance with its rules of
procedure.”

MARPOL
Article 12, Casualties to ships

(1) Each Administration undertakes to conduct an investigation of any casualty occurring to any of its ships subject to the provisions of
the regulations if such casualty has produced a major deleterious effect upon the marine environment.
(2) Each Party to the Convention undertakes to supply the Organization with information concerning the findings of such investigation,
when it judges that such information may assist in determining what changes in the present convention might be desirable.

Load Line
Article 23, Casualties

(1) Each Administration undertakes to conduct an investigation of any casualty occurring to ships for which it is responsible and which are
subject of the present Convention when it judges that such an investigation may assist in determining what changes in the
Convention might be desirable.
(2) Each contracting Government undertakes to supply the Organization with pertinent information concerning the findings of such
investigations. No reports or recommendations of the Organization based upon such information shall disclose the identity or
nationality of the ships concerned or in any manner fix or imply responsibility upon any ship or person.

Maritime Labour Convention (MLC 2006)

Regulation 5.1.6 – Marine casualties

1. Each Member shall hold an official inquiry into any serious marine casualty, leading to injury or loss of life that involves a ship
that flies its flag. The final report of an inquiry shall normally be made public.
2. Members shall cooperate with each other to facilitate the investigation of serious marine casualties referred to in paragraph 1
of this Regulation.

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STCW
Regulation I/5, National provisions

1 Each Party shall establish processes and procedures for the impartial investigation of any reported incompetency, act, omission or
compromise to security that may pose a direct threat to safety of life or property at sea or to the marine environment by the holders of
certificates or endorsements issued by that Party in connection with their performance of duties related to their certificates and for the
withdrawal, suspension and cancellation of such certificates for such cause and for the prevention of fraud.
2 Each Party shall take and enforce appropriate measures to prevent fraud and other unlawful practices involving certificates and
endorsements issued.
3 Each Party shall prescribe penalties or disciplinary measures for cases in which the provisions of its national legislation giving effect to
the Convention are not complied with in respect of ships entitled to fly its flag or of seafarers duly certificated by that Party.
4 In particular, such penalties or disciplinary measures shall be prescribed and enforced in cases in which:
.1 a company or a master has engaged a person not holding a certificate as required by the Convention;
.2 a master has allowed any function or service in any capacity required by these regulations to be performed by a person holding an
appropriate certificate to be performed by a person not holding the required certificate, a valid dispensation or having the documentary proof
required by regulation I/10, paragraph 5; or
.3 a person has obtained by fraud or forged documents an engagement to perform any function or serve in any capacity required by these
regulations to be performed or filled by a person holding a certificate or dispensation.
5 A Party, within whose jurisdiction there is located any company which, or any person who, is believed on clear grounds to have been
responsible for, or to have knowledge of, any apparent non-compliance with the Convention specified in paragraph 4, shall extend all
co-operation possible to any Party which advises it of its intention to initiate proceedings under its jurisdiction.

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