The key stages (основные этапы) in the accident investigation

Deal with immediate risks (решай непосредственную проблему)

Select the level of investigation (выбери уровень исследования проблемы)

Investigate the event (исследуй проблему)

Record and analyze the results (запиши и проанализируй результаты)

Review the process (следи за поставарийной ситуацией)

Deal with immediate risks (решай непосредственную проблему)

When accidents and incidents occur, immediate action may be required to:

• raise the necessary alarms and implement the appropriate company emergency procedures,

• make the situation safe and prevent further injury,

• help, treat (оказать медицинскую помощь) or, in some cases, rescue injured persons,

• secure the site (огородить место несчастного случая/происшествия) to protect valuable information,

• immediately inform the management company and the appropriate authorities.

Select the level of investigation (выбери уровень исследования проблемы)

• All accidents / incidents need to be reported in the first place to the designated person (Master, Senior Officer).

• The Master will immediately inform the management company and where required, the appropriate authorities.

• Although there are lessons to be learned from every accident, more serious accidents will require a more detailed and time-consuming investigation involving a team of investigators, media coordinators and technical experts.

Investigate the event (исследуй проблему)

Physical Evidence

Before gathering information of any kind, the site (место происшествия) should be examined and details recorded as soon as possible after the accident.

• Secure the area (огородите место происшествия).

• Check items such as:

• position of injured (положение пострадавшего)

• housekeeping of area (поддержание порядка и чистоты)

• any visible Personal Protective Equipment (PPE)

• any tools that have been in use.

• Prepare and label sketches and photographs.

Documentary Evidence

• Relevant information can be found in:

• technical data sheets (таблицы технических данных)

• maintenance reports (отчеты о техобслуживании)

• safe-work procedures (процедуры безопасного производства работ)

• training reports (отчеты о повышении квалификации)

• risk assessment records (документация об оценке риска) etc.

Human Evidence

• Interviews with witnesses. Possible witnesses could include:

• persons who are directly involved in the event

• eyewitnesses (observers who saw the events immediately before, during or after)

• emergency response personnel (персонал для аварийного реагирования)

• other (port officials, company management personnel, equipment / vessel designers etc).

• Witnesses should be interviewed as soon as possible after the incident. If witnesses are left to talk among themselves, exact details of what they remember may change.

• Before the interview, it is useful to ask witnesses to:

• prepare a written statement describing events exactly as they remember them before, during and after the incident

• make a simple drawing of the accident scene showing the positions of all persons involved from the witness's point of view at that time.

Record and analyze the results (запиши и проанализируй результаты)

• Accidents / incidents almost never result from a single cause.

• Accidents often develop from a sequence of events.

• Events and conditions must be identified and examined in order to find the cause and prevent the accident from recurring.

Review the process (следи за поставарийной ситуацией)

Accident Investigation can only be fully effective if:

• action is taken to implement recommendations (выполнять рекомендации);

• the corrective action is monitored (слежение за исправительными действиями) and measured (их оценка);

• monitoring corrective action means documenting, tracking (учет) and validating (проверка правильности).

• training is often identified as a solution to preventing the recurrence of a problem. The short-term impact of training is positive; however, 'old habits' often resurface (возобновляться) and, if not addressed, lead to a continuous cycle (постоянная повторяемость) of incident-induced training (обучение действиям в аварийных ситуациях).