Casualty Investigation Code

What is the legal requirement of Casualty Investigation Code?
Following initiatives and regulations are related to the casualty investigation.
SOLAS: Flag State Administrations to conduct investigations into any casualty suffered by a ship of its flag, if an investigation may assist in identifying regulatory issues as a contributing factor
LOAD LINES, 1966: Flag States are required to inquire into certain marine casualties and marine incidents occurring on the high seas.
MARITIME LABOUR CONVENTION, 2006: Investigation of some serious marine casualties as well as setting out working conditions for seafarers. Recognizing the need for special protection for seafarers during an investigation.
IMO: Adopted, in December 2005, the “Guidelines on Fair Treatment of Seafarers in the Event of a Maritime Accident” through resolution A.987 (24).
Legal Committee: Adopted resolution LEG.3(91) on 27 April 2006 Guidelines on fair treatment of seafarers in the event of a maritime accident.
MSC at 84^th session: Adopted the Casualty Investigation Code by resolution MSC.255(84); and added a new regulation 6 in chapter XI-1 of the SOLAS Convention by resolution MSC.257(84), making the code mandatory. Code as well as new SOLAS regulation XI-1/6 took effect on 1 January 2010.
IMO ASSEMBLY: Resolution A.1056(27) adopted on 30 November 2011 was regarding promotion as widely as possible of the application of the 2006 guidelines on fair treatment of seafarers in the event of a maritime accident.

What regulations of SOLAS deal with this subject?
SOLAS regulation 6 of Chapter XI-1
Taking into account regulation I/21, each Administration shall conduct investigations of marine casualties and incidents, in accordance with the provisions of the present Convention, as supplemented by the provisions of the Code of the International Standards and Recommended Practices for a Safety Investigation into a Marine Casualty or Marine Incident (Casualty Investigation Code) adopted by resolution MSC.255(84), and:
.1 the provisions of parts I and II of the Casualty Investigation Code shall be fully complied with;
.2 the related guidance and explanatory material contained in part III of the Casualty Investigation Code should be taken into account to the greatest possible extent in order to achieve a more uniform implementation of the Casualty Investigation Code;

Both, Code as well as this regulation come into force 01.01.10
SOLAS Regulation 21 of chapter I
(a) Each Administration undertakes to conduct an investigation of any casualty occurring to any of its ships subject to the provisions of the present Convention when it judges that such an investigation may assist in determining what changes in the present Regulations might be desirable.”
(b) Each Contracting Government undertakes to supply the Organization with pertinent information concerning the findings of such investigations. No reports or recommendations of the Organization based upon such information shall disclose the identity or nationality of the ships concerned or in any manner fix or imply responsibility upon any ship or person.

What are India’s initiatives in response to the regulations in respect of casualty investigation?
In India investigations shall be conducted by Indian Maritime Administration, which is the competent authority. Casualty Investigation Reports for each year may be accessed online to assess how to prevent future accidents & if any regulations may be changed;

DG has provided ‘Standard Operating Procedure’ to be followed during Marine Casualty. It deals with various issues such as, ‘Flow of Information with Directorate General of Shipping during Marine Casualty’ and ‘Division of Responsibilities during Marine Casualty within DGS: DGCOMM CENTRE’.  Thus, the incharge of casualty investigation, with next in line in his absence, etc are stated. Crisis Management Team is a team formed at DGS on receipt of information of the Marine casualty. In this circular a table is provided which provides how to classify a casualty or incident. In this respect casualty circular 1of 2006 is very important. It says, ‘In a number of cases, reports into shipping casualties being forwarded to the Directorate, are found to be lacking in depth and quality in their contents. More so when reports are compiled by Port Officers of Minor Ports. The purpose of conducting investigations into such marine casualties thereby gets defeated’.

The purpose of the circular is to inform and educate the Preliminary Inquiry Officer of the needs and obligations that require to be fulfilled, by providing guidelines that shall enable the PIO to adopt a uniform approach when conducting a Preliminary Investigation into a Marine casualty.

Guidelines include:
1.  The objective of any shipping casualty investigation is to prevent similar casualties in the future. The investigation should identify the circumstances of the casualty and establish the causes and contributing factors by inferencing and analyzing data compiled during the investigation.
2.  The PIO shall conduct the inquiry in accordance with the relevant provisions contained in Part XII of the Merchant Shipping Act or as per the terms of reference assigned to him, by the Central Government.
3.  The Inquiry Report shall in all cases conform to the following format:
(i) A summary outlining the basic facts of the casualty and stating whether any death, injury or pollution occurred as a result;
(ii) The identity of the Flag State, Owners, Managers, company and classification society;
(iii) Details of the dimensions and engines of any ship involved, together with a description of crew, work routine and other relevant matters, such as time served on the ship.
(iv) A narrative detailing the circumstances of the casualty.
(v) Analysis and comment which should enable the report to reach logical conclusions or findings establishing all factors that contributed to the casualty.
(vi) A section or sections analyzing and commenting on the causal elements, including both mechanical and human factors, meeting the requirements of the IMO data base; and
(vii) Recommendations, where appropriate with a view to preventing similar casualties.

What is safety investigation code?
It is the code of international standards and recommended practices for a safety investigation into a marine casualty or marine incident. It has 3 parts. Part I (general)and part II (mandatory standards) are each mandatory. Part III is recommended practices.

What is contained in part II and III of code?
Part II Mandatory standards include:
Marine safety investigation Authority, Notification, Requirement to investigate very serious marine casualties ,Flag State ís agreement with another substantially interested State to conduct a marine safety investigation, Powers of an investigation, Parallel investigations, Co-operation, Investigation not to be subject to external direction, Obtaining evidence from seafarers, Draft marine safety investigation reports, Marine safety investigation reports

Part III Recommended practices include: Administrative responsibilities, Principles of investigation, Investigation of marine casualties (other than very serious casualties) and marine incidents, Factors that should be taken into account when seeking agreement under chapter 7 (Flag State ís agreement with another substantially interested State to conduct a marine safety investigation), Acts of unlawful interference, Notification to parties involved and commencement of an investigation, Co-ordinating an investigation Collection of evidence, Confidentiality of information, Protection for witnesses and involved parties, Draft and final report 20 Re-opening an investigation.

Part I

Q. What is the objective of the Casualty Investigation Code? M
The objective of this Code is to provide a common approach for States, in conducting marine safety investigations of marine casualties and incidents. Marine safety investigations do not seek to apportion blame or determine liability. Instead a marine safety investigation, as defined in this Code, is an investigation conducted with the objective of preventing marine casualties and marine incidents in the future. The Code envisages that this aim will be achieved through States:

1. applying consistent methodology and approach, to enable and encourage a broad ranging investigation, where necessary, in the interests of uncovering the causal factors and other safety risks; and
2. providing reports to the Organization to enable a wide dissemination of information to assist the international marine industry to address safety issues.

This Code recognizes that under the Organization’s instruments, each Flag State has a duty to conduct an investigation into any casualty occurring to any of its ships, when it judges that such an investigation:

• may assist in determining what changes in the present regulations may be desirable; or
• if such a casualty has produced a major deleterious effect upon the environment.

The Code also takes into account that a flag State shall cause an inquiry to be held, by or before a suitably qualified person or persons into certain marine casualties or marine incidents of navigation on the high seas. However, the Code also recognizes that where a marine casualty or marine incident occurs within the territory, including the territorial sea, of a State, that State has a right to investigate the cause of any such marine casualty or marine incident which might pose a risk to life or to the environment, involve the coastal State’s search and rescue authorities, or otherwise affect the coastal State.

Q. What is a marine casualty as per Casualty Investigation Code? M
Marine Casualty means an event, or a sequence of events, that has resulted in any of the following which has occurred directly in connection with the operations of a ship:

1. the death of, or serious injury to, a person;
2. the loss of a person from a ship;
3. the loss, presumed loss or abandonment of a ship;
4. material damage to a ship; MSC 84/3 ANNEX 4 Page 8;
5. the stranding or disabling of a ship, or the involvement of a ship in a collision;
6. material damage to marine infrastructure external to a ship, that could seriously endanger the safety of the ship, another ship or an individual; or
7. severe damage to the environment, or the potential for severe damage to the environment, brought about by the damage of a ship or ships.

However, a marine casualty does not include a deliberate act or omission, with the intention to cause harm to the safety of a ship, an individual or the environment.

Q. What is a marine incident as per Casualty Investigation Code? M
Marine Incident means an event, or sequence of events, other than a marine casualty, which has occurred directly in connection with the operations of a ship that endangered, or, if not corrected, would endanger the safety of the ship, its occupants or any other person or the environment. However, a marine incident does not include a deliberate act or omission, with the intention to cause harm to the safety of a ship, an individual or the environment.

Q. What is a marine safety investigation as per Casualty Investigation Code? M
Marine safety investigation means an investigation or inquiry (however referred to by a State), into a marine casualty or marine incident, conducted with the objective of preventing marine casualties and marine incidents in the future. The investigation includes the collection of, and analysis of, evidence, the identification of causal factors and the making of safety recommendations as necessary.

Q. What should a marine safety investigation report contain?  M
A marine safety investigation report should contain:

1. a summary outlining the basic facts of the marine casualty or marine incident and stating whether any deaths, injuries or pollution occurred as a result;
2. the identity of the flag State, owners, operators, the company as identified in the safety management certificate, and the classification society (subject to any national laws concerning privacy);
3. where relevant the details of the dimensions and engines of any ship involved, together with a description of the crew, work routine and other matters, such as time served on the ship;
4. a narrative detailing the circumstances of the marine casualty or marine incident;
5. analysis and comment on the causal factors including any mechanical, human and organizational factors;
6. a discussion of the marine safety investigation’s findings, including the identification of safety issues, and the marine safety investigation’s conclusions; and
7. where appropriate, recommendations with a view to preventing future marine casualties and marine incidents.

Q. What is a marine safety record as per Casualty Investigation Code? M
Marine Safety Record means the following types of records collected for a marine safety investigation:

1. statements taken for the purpose of a marine safety investigation;
2. all communications between persons pertaining to the operation of the ship;
3. all medical or private information regarding persons involved in the marine casualty or marine incident;
4. all records of the analysis of information or evidential material acquired in the course of a marine safety investigation;
5. information from the voyage data recorder.

Q. What is substantially interested State as per Casualty Investigation Code? M
Substantially interested State means a State:

1. which is the flag State of a ship involved in a marine casualty or marine incident; or
2. which is the coastal State involved in a marine casualty or marine incident; or
3. whose environment was severely or significantly damaged by a marine casualty (including the environment of its waters and territories recognized under international law); or
4. where the consequences of a marine casualty or marine incident caused, or threatened, serious harm to that State or to artificial islands, installations, or structures over which it is entitled to exercise jurisdiction; or
5. where, as a result of a marine casualty, nationals of that State lost their lives or received serious injuries; or
6. that has important information at its disposal that the marine safety investigating State(s) consider useful to the investigation; or
7. that for some other reason establishes an interest that is considered significant by the marine safety investigating State(s).

Part II

Q. What is the responsibility of a state in respect of its marine investigation authority? M
The Government of each State shall provide the Organization (IMO) with detailed contact information of the marine safety investigation Authority(ies) carrying out marine safety investigations within their State.

Q. What is the responsibility of the Flag State of ship involved in respect of notification? M
When a marine casualty occurs on the high seas or in an exclusive economic zone, the flag State of a ship, or ships, involved, shall notify other substantially interested States as soon as is reasonably practicable. When a marine casualty occurs within the territory, including the territorial sea, of a coastal State, the flag State, and the coastal State, shall notify each other and between them notify other substantially interested States as soon as is reasonably practicable. Notification shall not be delayed due to the lack of complete information.

Q. What should the notification contain and what is the prescribed format?  M
The notification shall contain as much of the following information as is readily available:

1. the name of the ship and its flag State;
2. the IMO ship identification number;
3. the nature of the marine casualty;
4. the location of the marine casualty;
5. time and date of the marine casualty;
6. the number of any seriously injured or killed persons;
7. consequences of the marine casualty to individuals, property and the environment; and
8. the identification of any other ship involved.

Q. What is the provision in respect of very serious marine casualty? M
A marine safety investigation shall be conducted into every very serious marine casualty. Subject to any agreement in accordance with chapter 7 (Flag State’s agreement with another substantially interested state to conduct a marine safety investigation), the flag State of a ship involved in a very serious marine casualty is responsible for ensuring that a marine safety investigation is conducted and completed in accordance with this Code.

Q. What is the provision regarding flag state’s agreement with another substantially interested state to conduct a marine safety investigation? M
Without limiting the rights of States to conduct their own separate marine safety investigation, where a marine casualty occurs within the territory, including territorial sea, of a State, the flag State(s) involved in the marine casualty and the coastal State shall consult to seek agreement on which State or States will be the marine safety investigating State(s) in accordance with a requirement, or a recommendation acted upon, to investigate under this Code.

Without limiting the rights of States to conduct their own separate marine safety investigation, if a marine casualty occurs on the high seas or in the exclusive economic zone of a State, and involves more than one flag State, then the States shall consult to seek agreement on which State or States will be the marine safety investigating State(s) in accordance with a requirement, or a recommendation acted upon, to investigate under this Code.

Q. What must the National laws provide in respect of power to investigate?  M
All States shall ensure that their national laws provide investigator(s) carrying out a marine safety investigation with the ability to board a ship, interview the Master and crew and any other person involved, and acquire evidential material for the purposes of a marine safety investigation.

Q. Can the parallel investigation be done by another substantially interested State? M
Where the marine safety investigating State(s) is conducting a marine safety investigation under this Code, nothing prejudices the right of another substantially interested State to conduct its own separate marine safety investigation.

While recognizing that the marine safety investigating State(s) shall be able to fulfill obligations under this Code, the marine safety investigating State(s) and any other substantially interested State conducting a marine safety investigation shall seek to co-ordinate the timing of their investigations, to avoid conflicting demands upon witnesses and access to evidence, where possible.

Q. While obtaining evidence from seafarers, what precautions should be taken by the investigators? M
Where a marine safety investigation requires a seafarer to provide evidence to it, the evidence shall be taken at the earliest practical opportunity. The seafarer shall be allowed to return to his/her ship, or be repatriated at the earliest possible opportunity. The seafarers human rights shall, at all times, be upheld.

The seafarer shall be informed of the nature and basis of the marine safety investigation. He shall also be informed, and allowed access to legal advice, regarding:

1. any potential risk that they may incriminate themselves in any proceedings subsequent to the marine safety investigation;
2. any right not to self-incriminate or to remain silent;
3. any protections afforded to the seafarer to prevent the evidence being used against them if they provide the evidence to the marine safety investigation.

Q. In which situations, an investigating State must/may not send draft marine safety investigation report to the substantially interested State? M
Whenever, it is requested, the marine safety investigating State(s) shall send a copy of a draft report to a substantially interested State to allow the substantially interested State to make comment on the draft report. This is done except for the situation is as in the following paragraph.

Marine safety investigating State(s) are only bound to comply with this paragraph where the substantially interested State receiving the report guarantees not to circulate, nor cause to circulate, publish or give access to the draft report, or any part thereof, without the express consent of the marine safety investigating State(s) or unless such reports or documents have already been published by the marine safety investigating State(s).

The marine safety investigating State(s) are also not bound to send a copy of a draft report to a substantially interested State where the marine safety investigating State(s) request that the substantially interested State receiving the report does not affirm that evidence included in the draft report will not be admitted in civil or criminal proceedings against a person who gave the evidence and the substantially interested State refuses to provide such an affirmation.

The marine safety investigating State(s) shall invite the substantially interested States to submit their comments on the draft report within 30 days or some other mutually agreed period.

Q. What is done with the final version of marine safety investigation report? M
The marine safety investigating State(s) shall submit the final version of a marine safety investigation report to the Organization (IMO) for every marine safety investigation conducted into a very serious marine casualty.  Where a marine safety investigation is conducted into a marine casualty or marine incident, other than a very serious marine casualty, and a marine safety investigation report is produced which contains information which may prevent or lessen the seriousness of marine casualties or marine incidents in the future, the final version shall be submitted to the Organization.

The marine safety investigation report referred in the paragraph above shall utilize all the information obtained during a marine safety investigation, taking into account its scope, required to ensure that all the relevant safety issues are included and understood so that safety action can be taken as necessary. The final marine safety investigation report shall be made available to the public and the shipping industry by the marine safety investigating State(s) Or the marine safety investigating State(s) shall undertake to assist the public and the shipping industry with details, necessary to access the report, where it is published by another State or the Organization.

PART III

Q. What facilities must be ensured by a State to assist functioning of investigation? R
States should ensure that marine safety investigating Authorities have available to them sufficient material and financial resources and suitably qualified personnel to enable them to facilitate the State’s obligations to undertake marine safety investigations into marine casualties and marine incidents.

Q. What are the basic principles of investigation? R
Independence: A marine safety investigation should be unbiased to ensure the free flow of information to it. In particular; the investigator must have financial independence from:

• the parties involved in the marine casualty or marine incident; and
• anyone who may make a decision to take administrative or disciplinary action against an individual or organization involved in a marine casualty or marine incident; and judicial proceedings. The investigator(s) carrying out a marine safety investigation should be free of interference.

Safety focused: It is not the objective of a marine safety investigation to determine liability, or apportion blame. However, the investigator(s) carrying out a marine safety investigation should not refrain from fully reporting on the causal factors because fault or liability may be inferred from the findings.

Co-operation: The investigating State(s) should seek to facilitate maximum co-operation between substantially interested States and other persons or organizations conducting an investigation into a marine casualty or marine incident.

Priority: A marine safety investigation should, as far as possible, be afforded the same priority as any other investigation, including investigations by a State for criminal purposes being conducted into the marine casualty or marine incident.

The evidence for which, ready access should be provided should include: survey and other records held by the Flag State, the owners, and classification societies; all recorded data, including voyage data recorders; and evidence that may be provided by government surveyors, coastguard officers, vessel traffic service operators, pilots or other marine personnel.

Q. How should the Master and others involved in a marine casualty be notified of the commencement of an investigation? R
When a marine safety investigation is commenced under this Code, the Master, the owner and agent of a ship involved in the marine casualty or marine incident being investigated, should be informed as soon as practicable of:

1. the marine casualty or marine incident under investigation;
2. the time and place at which the marine safety investigation will commence;
3. the name and contact details of the marine safety investigation Authority(ies);
4. the relevant details of the legislation under which the marine safety investigation is being conducted;
5. the rights and obligations of the parties subject to the marine safety investigation; and
6. the rights and obligations of the State or States conducting the marine safety investigation.

The above information can be transmitted electronically to the Master, the agent and the owner of the ship. A ship should not be delayed more than is absolutely necessary. The marine safety investigation should be commenced as soon as is reasonably practicable.

Q. What instruments must be considered for consistency during the coordination? R
It must be ensured that the methodology followed during the marine safety investigation: 

• is consistent with that recommended in resolution A.884(21), as amended;
• takes into account any recommendations or instruments published by the IMO or ILO, relevant to conducting a marine safety investigation; and
• takes into account the safety management procedures and the safety policy of the operator of a ship in terms of the ISM Code.

Q. Can a substantially interested State attend an investigation? What are the powers & responsibility in this respect? R
The marine safety investigating State(s) should allow a substantially interested State to participate in aspects of the marine safety investigation relevant to it, to the extent practicable. Participation should include allowing representatives of the substantially interested State to:

1. interview witnesses;
2. view and examine evidence and make copies of documents;
3. make submissions in respect of the evidence, comment on and have their views properly reflected in the final report; and
4. be provided with the draft and final reports relating to the marine safety investigation^*.

To the extent practical, substantially interested States should assist the marine safety investigating State(s) with access to relevant information for the marine safety investigation. To the extent practical, the investigator(s) carrying out a marine safety investigation should also be afforded access to Government surveyors, coastguard officers, ship traffic service operators, pilots and other marine personnel of a substantially interested State.

Q What is ‘right not to self incriminate’? What is the provision for protection for witnesses and involved parties? R
A person cannot be forced to give evidence to incriminate own self. If a person is required by law to provide evidence that may incriminate him, for the purposes of a marine safety investigation, the evidence should, so far as national laws allow, be prevented from admission into evidence in civil or criminal proceedings against the individual.

A person from whom evidence is sought should be informed about the nature and basis of the investigation. A person from whom evidence is sought should be informed, and allowed access to legal advice, regarding:

1. any potential risk that they may incriminate himself in any proceedings subsequent to the marine safety investigation;
2. any right not to self-incriminate or to remain silent;
3. any protections afforded to the person to prevent the evidence being used against him if he provides the evidence to the marine safety investigation.

Q. Can an interested party or a substantially interested State comment on the the investigation report? R
Where it is requested, and where practicable, the marine safety investigating State(s) should send a copy of a draft marine safety investigation report for comment to interested parties. However, this recommendation does not apply where there is no guarantee that the interested party will not circulate, nor cause to circulate, publish or give access to the draft marine safety investigation report, or any part thereof, without the express consent of the marine safety investigating State(s).

The marine safety investigating State(s) should allow the interested party 30 days or some other mutually agreed time to submit their comments on the marine safety investigation report. The marine safety investigating State(s) should consider the comments before preparing the final marine safety investigation report and where the acceptance or rejection of the comments will have direct impact on the interests of the interested party that submitted them, the marine safety investigating State(s) should notify the interested party of the manner in which the comments were addressed. If the marine safety investigating State(s) receives no comments after the 30 days or the mutually agreed period has expired, then it may proceed to finalize the marine safety investigation report.

Casualty Investigation by DG Shipping, a few examples

1. Casualty Circular No. 4 of 2003
Dated 28th July 2003
Sub: Capsizing of spilt Hopper Barge

1. NARRATION:-
1.1 One split hopper barge was employed for constructing a break-water at Dahej, India. This barge was loaded with rocks and towed / assisted by two tugs to the desired co-ordinates for off-loading. The towing vessel was registered in a foreign country and was manned by persons of different nationality. These persons, however, were certified by their Maritime administration under Near Coastal Voyages (NCV) system.

1.2 While en-route from her loading port and about four kilometers from break-water at Dahej base, the barge capsized. Both the crew members who were on board the barge were rescued and there was no loss of life. At the time of incident, the barge was loaded 80% of her capacity and was drawing 4.4 metres. On leaving for her destination to off-load, the barge was seen to be listing to port.

1.3 The probable cause of this accident appears to be ingress of water, which had gone unnoticed earlier and subsequently increased thereby minimizing the stability of the vessel. It appears that the barge while entering into and out from the harbour and while coming alongside may have suffered some damage on its side which initiated the ingress of water.

2. LESSONS LEARNT :-
2.1 There is an urgent need to bring about awareness for adequate co-ordination between shore and tug personnel who were responsible for towing the barge to the dumping side.
2.2 Vessel must be loaded at all times as per the requirements of approved ‘Trim & Stability Booklet’. This important statutory document must address generally all aspects of vessels loading conditions.

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