1. Reporting to IMO of marine safety investigations and marine casualties and incidents TAIEX Workshop on Marine Casualty Investigation 5-6 September 2012 David Wheal Principal Inspector of Marine Accidents UK Marine Accident Investigation Branch

2. Value of reporting Single marine casualty or incident Safety investigation report local / global safety deficiencies and resulting safety recommendations Safety bulletin (early alert) global safety deficiencies and resulting safety recommendations Safety flyer / Safety Digest global lessons to be learned

3. Fire on Star Princess 23 March 2006

4. Outcome Marine casualty – 23 March 2006 Safety bulletin – April 2006 Report published – October 2006 December 2006: Retro-fit of flame-retardant materials Smoke detectors fitted SOLAS fire protection amendments

5. Value of reporting Multiple marine casualties or incidents Safety study abstract data analysis Data collation MAIB database European Marine Casualty Information Platform (EMCIP) database Global Integrated Shipping Information System (GISIS) marine casualty and incident module

6. Purpose of GISIS To identify safety issues from multiple marine casualties and incidents for the purpose of making recommendations. historical risk assessment frequency of unsafe acts and underlying factors severity of consequences to which they relate. To identify trends for further research historical trends factual information of particular relevance.

7. MSC-MEPC.3/Circ.3 Annex 1 particulars of each ship involved time, location and type of casualty consequences Annex 2 unsafe acts underlying factors Annex 3 safety investigation findings action taken search and rescue assistance given

8. MSC-MEPC.3/Circ.3 Annex 4 – dangerous goods / pollutants Annex 5 – damage and intact stability Annex 6 – fire casualty Annex 7 – Global Maritime Distress and Safety System Annex 8 – fatigue Annex 9 – spillage of harmful substance Annex 10 – life-saving appliance casualty Safety investigation report (additional detail and quality assurance)

9. Unsafe acts Human erroneous action Equipment failure Hazardous material effect Environmental effect External agencies

10. Human erroneous action Perception, intention, action SHEL S - Regulations, procedures H - Equipment, ergonomics E - Environment L – Social factors, management style

11. Individual factors TemporaryFatigueStressPermanent Perception abilities Personality

19. Summary Means of data collection and abstract analysis Historical risk assessment of unsafe acts, underlying factors and consequences Historical trends of relevant factual information Safety recommendations and further research MSC-MEPC.3/Circ.3 Safety investigation report

20. Thank you for your attention www.maib.gov.uk