Incident Investigation

Which of the following definitions is that of a “blame culture”?

>One where people look no further than “human error”

Which of the following are possible consequences of accidents, incidents and near-misses? (Select all applicable answers).

>Personal injury

>Material damage

>Lost time

>Adverse publicity

>Loss of reputation

>Low morale and poor attitude amongst the workforce

If accidents are investigated and the information obtained is constructively fed back

Into the system, which of the following might reasonably be anticipated?

>A reduction, or even elimination of such accidents in the future

This program featured a study conducted by the North of England P&I Club which used the example of a man and a ladder alongside the accident pyramid. What relationship did this illustration suggest?

>That the severity of accidents depends on the degree of hazard

What broad rule is often referred to by safety investigators when explaining the selective investigation of reported incidents?

>The 80 / 20 rule

Which piece of international legislation directly resulted from the sinking of the “Herald of Free Enterprise”?

>The International Safety Management (ISM) Code

Which maritime Code requires shipping companies to provide for safe practices in ship operation and a safe working environment, establish safeguards against all identified risks and to continuously improve safety management skills of personnel ashore and aboard ships, including preparing for emergencies related both to safety and environmental protection?

>The International Safety Management (ISM) Code

Within the context of this training module, which of the following is the definition of an “incident”?

>An uncontrolled development in the course of an operation which has resulted in unintended harm or damage, or the potential for legal action, or is not consistent with acceptable standards

Within the context of this training module, which of the following is the definition of a “near-miss”?

>An unintended or unwanted event, or uncontrolled development in the course of an operation, that almost resulted in unintended harm or damage, or potential for legal action, or is not consistent with acceptable standards

Which safety initiative, launched by the Oil Companies International Marine Forum in 1993, takes the form of a risk-assessment tool for charterers, ship operators, terminal operators and government bodies and was intended to address concerns over sub-standard shipping?

>The SIRE Programme

As described in this training program, an accident is generally caused by contact with which of the following? (Select all applicable answers).

>A source of energy

>A substance above the threshold limit of the body concerned

In terms of investigation, which of the following may be considered as the results or effects of an accident?

>The loss experienced at the end of a sequence of events

Which of the following are examples of “hidden” costs? (Select all applicable answers)

>Lost time

>Reduced capacity

>Increased premiums

>Reduced profits

>Loss of future business

Which of the following are examples of “latent factors” behind an accident? (Select all applicable answers)

>Design

>Incorrect installation

>Faulty maintenance

>Management decision

>Inadequate procedures

The maximum safe working load of a crane has been exceeded. When the operator attempted the lift, the retaining bolts at the foot of the crane mounting sheared and the crane toppled over. Which of the following may be considered as evidence of “fallibility” in this situation? (Select all applicable answers)

>Incompetence

>Recklessness

>Negligence

>Lack of monitoring

>Lack of communication

>Ongoing management failure

A Junior Engineer is injured during the replacement of a main engine cylinder liner. Immediately before the accident, which two distinct types of actions, referred to in this training program, may have been performed by the 1st Engineer, who was supervising the operation and by the other members of the maintenance team?

>Omission

>Commission

Following an incident, the situation may develop in one of two ways. What are they?

>It may continue to deteriorate

>It may be recovered

An investigator arrives on board to conduct an inquiry into an incident involving some damaged containers, several of which have collapsed and fallen forward onto the back of the forecastle deck. Which of the following will he initially seek to identify?

>The transfer of energy

Which of the following are examples of transfer of energy by contact?

>Seafarer struck and injured when cradle collapses and a number of empty nitrogen cylinders are spilled onto deck

>Chief Cook slipping and falling down ladder from galley to refrigerator flat

>Pumpman caught by chemical under pressure when he attempts to release the bolts holding a flange

>Damage to spare parts in storage cabinet sustained when work bench broke loose in the electrician’s workshop during heavy weather

>Steward opens locker door and is hit by falling crockery as ship rolls

Drag and drop the methods onto the questions, to show the techniques that an investigator will use at the corresponding stages of an incident investigation.

>1 Observation>What?

>1 Evidence

>3 Analysis>Why?

>3 Reasoning

Which of the following are examples of substandard practises? (Select all applicable answers)

>Operating equipment without authority

>Over-riding or bypassing safety devices

>Operating at an improper or unsafe speed

>Failure to use personal protective equipment

Which of the following are examples of substandard conditions? (Select

>Inadequate, improper or missing personal protective equipment

>Congested or restricted work area

>Inadequate or defective warning systems

>Exposure to excessive high or low temperatures

Which of the following are examples of abnormal behaviour? (Select all applicable answers)

>Removing a “nitrogen tag” from the lid of a cargo tank, unclipping the securing dogs, opening the lid and climbing inside

>Allowing a colleague to walk along a poorly-lit catwalk, towards an area where the gratings have been lifted for maintenance on a pump underneath and no protective barriers have been erected, without issuing a warning

>Commencing the overhaul of a ballast valve, without first checking that it has been properly isolated and the appropriate warning notices put in place in the control room

>Operating a workshop drill without using eye protection

>Operating a manifold crane on which no training and familiarization has been delivered

Basic causes are generally divided into which two of the following categories?

>Personal factors

>Job factors