In 1987 a serious accident occurred when a British ferry capsized off Zeebrugge in Belgium with the loss of 197 lives. In the troubled aftermath, there was a call for the creation of an unbiased and independent investigative body.
This led to the establishment of the MAIB which has now served the British marine industry for nearly 20 years. Its sole purpose is to find and report causes and circumstances and make recommendations to avoid the recurrence of similar accidents.
Accidents Do Happen
It is a quiet day somewhere off the coast of Great Britain. On the bridge of a medium-sized ferry the calm is suddenly interrupted by shouts of distress followed by a thumping sound and the loud screech of metal. The unthinkable has suddenly become a reality: the ferry has been rammed by a bulk carrier leaving port.
The spine-chilling drama that is unfolding is a playback of sound, radar images and vessel data in the MAIB laboratories in Southampton. We are kindly - but firmly - made to understand that this lab is normally strictly out of bounds to unauthorised personnel due to the sensitivity of the data handled during ongoing investigations. No further information from this accident may therefore be disclosed...
“The introduction of the Voyage Data Recorder (VDR) has - when available - revolutionised our ability to dissect the chronology of accidents down to the minute, yes even seconds,” says the head of the MAIB, chief inspector Stephen Meyer. “We can now also combine these VDR recordings with other data through our recently developed technology to give us a comprehensive, objective picture. This - along with other information - then constitutes part of the evidence from which we may draw our final conclusions.”
Asking the Questions
“Our only objective is to investigate accidents to or on UK-flagged ships worldwide and ships under other flags in UK waters,” says Meyer. “I must emphasise that we do not point fingers, thereby apportioning blame or liability. Our task is only to determine and report circumstances and causes in order to increase marine safety by avoiding a recurrence of related incidents and accidents in the future. Our role is in many ways therefore also to serve as an educator.”
There are four basic questions which need answers when an accident has occurred:
■ What happened?
■ How did it happen?
■ Why did it happen?
■ What can be done to prevent it from happening again?
The focus is on systemic failures, and to answer these questions the MAIB has at its disposal an advanced technological toolbox. But first and foremost it has an experienced and professional staff of former Masters, Chief Engineers and Naval Architects. These have all undergone the requisite two-year major accident investigation training course and constitute four teams, each led by a principal inspector.
In addition, external consultancy services are called upon when needed to assist in specialist fields. These may include various technical experts not available in-house and the involvement of special test facilities. The MAIB has also developed what it terms Recommendation Meetings where it invites experts from the specific industry involved in an accident to deepen the understanding of the lessons to be learned and so help in the development of recommendations.
Accident Reporting and Investigation
All UK seafarers and vessel owners are required by law to report accidents and serious injuries to the MAIB within a defined time limit. “And our watch is a 24-hour around-the-clock one,” says Mr Meyer. “Accident evidence must be considered perishable and our obligation is therefore to evaluate the need to collect available data as quickly as possible, if need be in remote locations.”
On a yearly basis, around 1,800 incidents and accidents are reported to the MAIB. A significant number of these are classified as “straightforward” and may not need any other follow-up than a couple of phone calls. However, all reports are processed and entered in the reporting system as components in a statistical database dating back to 1991, to be used, for example, in trend analyses. In line with this, the MAIB encourages the reporting of hazardous incidents - or near misses - which may often teach lessons that are every bit as relevant as those arising from accidents.
When notified about more serious accidents, the inspectors collect evidence and a Preliminary Examination (PE) may be conducted. If the causes and circumstances relating to the accident found during the PE meet the criteria, a Full Investigation is performed through evidence recovery, interviews and the extensive collection of various other data. Finally a report is issued and made publicly available. A total of 70-80 accidents are investigated each year.
Often the true cause of an accident turns out to be very different from the convenient solution identified by people who are not accident investigators. Any leakage of initial accident data to external parties by the MAIB might therefore also lead to their misuse and misinterpretation by a variety of parties with financial and other interests, and is avoided at all costs. The data are therefore guarded as precious valuables and kept under wraps until the publication of the final MAIB accident investigation report with its conclusions.
A Full Investigation or PE is entirely independent of any enquiries made by the police or other authority collecting evidence for a possible prosecution. The MAIB accident investigation report is accordingly not written with liability in mind and is not intended to be used in court for the purpose of litigation.
Publications and Training
During investigation and analysis, the time may be spent interviewing a wide range of individuals and verifying evidence, in addition to examining suspect equipment and consulting with experts. Thus the publication of a full investigation report may in many cases take place seven months, or up to a year, after an accident.
The majority of these investigations lead to recommendations to prevent the occurrence of similar accidents. Since 2006, the MAIB has issued an annual report outlining the uptake of such safety recommendations.
A Safety Digest is published three times a year with a circulation of 9,000 and is freely distributed to any interested companies or institutions. This contains a collection of short reports and outlines the lessons learned from the examinations and investigations that have been carried out.
“We are very pleased to note that these have proven to be extremely popular reading,” says Meyer. “One thing is of course the often dramatic stories that are told. Another is that they allow us to achieve our objective, namely to teach the reader a lesson.” In accordance with the MAIB’s “no finger-pointing policy”, the stories told are often anonymised, for example by re-colouring the pictures of hulls and by the removal of names and logos. “However, we are aware that our efforts to attain anonymity often lead to intense discussions and have provided an entertaining pastime on board vessels.”
The knowledge gained by the MAIB during its 20 years of existence is now a well developed science and as such a sought after commodity. Says Meyer: “The number of organisations similar to ours is on the rise. A European Union directive demanding the formation of such national organisations is in the pipeline and is expected to be implemented by 2010. For a couple of years now, we have been conducting week-long courses to train personnel from, for example, China, South Africa and Iran as well as a number of European states.” These courses provide an introduction to how to gather evidence, how to conduct interviews and methodical analyses and how to interpret data.
“We have a good reputation and feel confident that our efforts are paying off. And we will remain committed to striving for an increasing level of safety in the marine industry in the interest of all parties,” concludes Mr Meyer.
Date: 2008-09-18