Schedule 2
(Regulation 17(1))
SAFETY INVESTIGATION REPORT
FOREWORD
This Part identifies the sole objective of the safety investigation and indicates that a safety recommendation does not create a presumption of liability or blame and that a report is not written, in terms of content and style, with the intention of being used in legal proceedings.
The report should make no reference to witness evidence or [link/connect] anyone who is referred to in the report to a person who has given evidence during the course of the safety investigation.
1. SUMMARY
This Part outlines the basic facts of the marine casualty or incident: what happened, when, where and how it happened; it also states whether a death or injury of a person, damage to the ship, cargo, third party or environment occurred as a result.
2. FACTUAL INFORMATION
This Part includes a number of discrete paragraphs, providing sufficient factual information that the investigating body uses to interpret the facts, substantiate an analysis and ease understanding.
These paragraphs include, in particular, the following information —
(a) ship particulars —
(i) flag or register,
(ii) identification,
(iii) main characteristics,
(iv) ownership and management,
(v) construction details,
(vi) minimum safe manning,
(vii) authorized cargo;
(b) voyage particulars —
(i) ports of call,
(ii) type of voyage,
(iii) cargo information,
(iv) manning;
(c) marine casualty or marine incident information particulars —
(i) type of marine casualty or marineincident,
(ii) date and time,
(iii) position and location of the marine casualty or incident,
(iv) external and internal environment,
(v) ship operation and voyage segment,
(vi) place on board,
(vii) human factors data,
(viii) consequences for people, ship, cargo, environment, other;
(d) shore authority involvement and emergency response particulars —
(i) persons involved,
(ii) means used,
(iii) peed of response,
(iv) actions taken,
(v) results achieved.
3. NARRATIVE
This Part reconstructs the marine casualty or marine incident through a sequence of events, in a chronological order leading up to, during and following themarine casualty or marine incident and the involvement of each actor, that is the person, material, environment, equipment or external agent. The period covered by the narrative depends on the timing of those particular accidental events that directly contributed to the marine casualty or marine incident. This Part also includes any relevant details of the safety investigation conducted, including the results of examinations or tests.
4. ANALYSIS
This Part includes a number of discrete sections, providing an analysis of each accidental event, with comments relating to the results of a relevant examinations or tests conducted during the course of the safety investigation and to a safety action that may already be taken to prevent a marine casualty.
These paragraphs should cover issues such as —
(a) accidental event context and environment;
(b) human erroneous actions and omissions, events involving hazardous material, environmental effects, equipment failures, and external influences;
(c) contributing factors involving person-related functions, shipboard operations, shore management or regulatory influence.
The analysis and comment enable the report to reach logical conclusions, establishing all of the contributing factors, including those with risks for which existing defences aimed at preventing an accidental event, or those aimed at eliminating or reducing its consequences, are assessed to be either inadequate or missing.
5. CONCLUSION
This Part consolidates the established contributing factors and missing or inadequate defenses, such as material, functional, symbolic or procedural defenses for which safety actions should be developed to prevent marine casualties.
6. SAFETY RECOMMENDATION
When appropriate, this Part of the report contains safety recommendations derived from the analysis and conclusions and related to particular subject areas, such as legislation, design, procedures, inspection, management, health and safety at work, training, repair work, maintenance, shore assistance and emergency response.
The safety recommendations are addressed to persons that are best placed to implement the recommendations, such as ship owners, managers, recognized organizations, maritime authorities, vessel traffic services, emergency bodies, international maritime organizations and institutions, with the aim of preventing marine casualties.
This Part also includes interim safety recommendations that were made or any safety actions that were taken during the course of a safety investigation.
7. APPENDICES
When appropriate, the following non-exhaustive list of information is attached to the report in paper or electronic form —
(a) photographs, moving images, audio recordings, charts, drawings;
(b) applicable standards;
(c) technical terms and abbreviations used;
(d) special safety studies;
(e) miscellaneous information.