CODE FOR INVESTIGATION

OF MARINE CASUALTIES
AND INCIDENTS

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TRAINING DASAR-DASAR INVESTIGASI KECELAKAAN LAUT
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
Oleh:
CAPT. Rozaimi Jatim

Resolution849(20)
TheCodefortheInvestigationof
MarineCasualtiesandIncidents

United Nations Law of the Sea Convention

Article 2 - Legal Status of the territorial sea and the

air space over the territorial sea
Article 94 - Duties of the flag State
94 (7) Each State shall conduct
investigations into casualties or incidents
involving ships flying its flag, to be held
before a suitably qualified person.

International Convention for the Safety

of Life at Sea, 1974.
Regulation 21 - Casualties
(a) Each Administration undertakes to conduct
an investigation of any casualty occurring to any
of its ships subject to the provision of the present
Convention when it judges that such an
investigation may assist in determining what
changes in the present regulations might be
desirable.

OTHER INTERNATIONAL CONVENTIONS CASUALLTY INVESTIGATION PROVISIONS

Load Line Convention, 1966, Article 23
Standards of Training, Certification and
Watchkeeping for Seafarers, 10978/95, Article
I/4.1.3, Article I/5
Prevention of Pollution from Ships, 1973/78,
Article 12
Safety of Fishing Vessels, 1977, Article 7
ConsolidatedMaritimeLabourConvention

IMO Resolution A. 849 (20)

Code for the Investigation of Marine Casualties
and Incidents
as amended by

Resolution A. 884 (20)

The Code for the Investigation of

Marine Casualties and Incidents
The aim is to promote a common approach to the investigation
of marine casualties and incidents and to promote co-operation
between States, to:

to introduce best practice safety investigation

aid remedial action

promote uniform input to accident data base
create a uniform system which applies to seafarers
wherever they are in the world

The Code for the Investigation of Marine Casualties and

Incidents
The Code aims to achieve:
Separation of the safety investigation process from
disciplinary or criminal proceedings
Qualified indemnity in disciplinary and criminal proceedings
Confidentiality and anonymity
Rapid, transparent, impartial, objective and accurate reporting
A simple reporting format, which is followed by all States
Publication and wide dissemination of reports and findings
Consistent data input to IMO

Code for the Investigation of Marine Casualties and Incidents

1. Introduction
2. Objective of an investigation
3. Application

Appendix 1
Guidelines to assist
investigators

4. Definitions
5. Conduct of an investigation
6. Responsibility for investigations
A.21 Res.884
7. Lead State responsibilities
Guidelines for the
8. Consultation
investigation of human
factors in marine
9. Co-operation
casualties and incidents
10. Disclosure of records
11. Personnel and material resources
12. Issuing the report and submission to IMO
13. Re-opening of investigations
14. Content of reports
15. Contact between Administrations

Code for the Investigation of Marine Casualties and Incidents

1.

Introduction

1.1

Calls up the obligations of flag States under UNCLOS,

art.94(7) and coastal States jurisdiction under art. 2

1.2

States the aim is to create a uniform approach to

investigations and promote cooperation between States.

1.3

Lists some basic principles of the code

1.4

Recognises other forms of investigation, but states that

accident investigations should be separate from other
forms of inquiry.

Code for the Investigation of Marine Casualties and Incidents

2.

Objective

To prevent similar casualties

To identify circumstances and establish causes

It is not to apportion blame or liability

The investigation should not refrain from fully

reporting the causes because fault or liability may be
inferred

Code for the Investigation of Marine Casualties and Incidents

3.

Application

This Code applies, as far as national law allows, to the

investigation of marine casualties and incidents where
either one or more interested States have a substantial
interest in a marine casualty involving a ship under their
jurisdiction.

Code for the Investigation of Marine Casualties and Incidents

4.

Definitions
4.1

Marine casualty

4.2

Very serious casualty

4.3

Serious casualty

4.4

Marine incident

4.5

Causes

4.6

Marine casualty or incident investigation

4.7

Marine casualty investigator

4.8

Serious injury

4.9

Ship

4.10

Lead investigating State

4.11

Substantially interested State

Code for the Investigation of Marine Casualties and Incidents

5.

Conduct of marine casualty investigations

5.1

Thorough and without bias. Encourages co-operation.

Given same priority as other inquiries.
Free access to
information. Use of VDRs. Govt to cooperate.
IMO/ILO guidelines. Reports should be made public.

5.2

Substantially interested States to have standing

5.3

State investigation should start as soon as possible with

any Substantially interested State allowed to join
subsequently

Code for the Investigation of Marine Casualties and Incidents

6.

Responsibility for investigating

6.1

Flag States should investigate all serious and very serious

casualties.

6.2

In coastal State jurisdiction States should mutually agree

on lead State.

6.3

In event of collision on high seas two flags and other

interested States should co-operate.

6.4

By participating flag State fulfills its UNCLOS

obligations under art 94 (7).

6.5

Investigations to start as soon as possible,, other

States should join as convenient.

Code for the Investigation of Marine Casualties and Incidents

7.

Responsibility of lead investigating State

.1

Develop strategy in consultation with other states

.2

provide investigator/in charge/co-ordinator.

.3

establish parameters based on municipal law.

.4

custodian of records/evidence.

.5

prepare report in consultation with other States

.6

co-ordinate with other investigating agencies (e.g. police),

.7

provide logistical support.

.8

liaise with other agencies

Code for the Investigation of Marine Casualties and Incidents

8.

Consultation

8.1

Coastal State to inform flag State of casualty and action

being taken.

8.2

Inform other substantially interested States, through

Consular representatives.

8.3

Nothing should prejudice the right of any State with a

jurisdiction to conduct a separate investigation. But
parties should cooperate to avoid conflicting demands
upon witnesses etc.

Code for the Investigation of Marine Casualties and Incidents

9.

Co-operation

9.1

Each State may question witnesses, examine evidence,

produce witnesses or evidence, make submissions and
transcripts, statements, etc.

9.2

States are encouraged to participate to maximum extent

9.3

Flag States should facilitate access to ships crew.

Code for the Investigation of Marine Casualties and Incidents

10. Disclosure of records

The following should not be disclosed:

Records of interview,

voice transmissions,

medical or private information,

opinions expressed during the investigation

Such records should only be included in the report when

pertinent to the analysis of the casualty or incident.

Code for the Investigation of Marine Casualties and Incidents

11.

Personnel and material resources

Governments should take all necessary steps to ensure that

they have available sufficient means and suitably qualified
personnel and material resources to enable them to
undertake casualty investigations.

Code for the Investigation of Marine Casualties and Incidents

12 Issue of marine casualty reports and

submissions to IMO
Makes provision for interested party (including substantially
interested States) comment on final draft report.
Reports should be completed as quickly as possible and
published.
Any State may write and submit a dissenting report
Interim recommendations on urgent safety action may be made to
the appropriate authority.

Code for the Investigation of Marine Casualties and Incidents

13

Re-opening of investigation

If new evidence comes to hand, the evidence should be

assessed and, referred to the other States participating
in the original investigation. The investigation should
be re-opened if necessary.

Code for the Investigation of Marine Casualties and Incidents

14. Contents of report

A summary
Details of flag State, owners, managers, company, class etc
Details of ship, crew, work routine, trade etc.
A narrative detailing the circumstances of the casualty.
Analysis and comment.
Comment on the causal elements to meet requirement of IMO
database.
Where appropriate, recommendations.

Code for the Investigation of Marine Casualties and Incidents

15. Contact between Administrations

To facilitate implementation of this Code, States should
inform the Organization of the responsible authorities
within their Governments that may be contacted regarding
co-operation in casualty investigation.

Code for the Investigation of Marine Casualties and Incidents

Appendix
Guidelines to assist investigators in the Implementation of the code
1.
1.1
1.2
1.3
1,4
1.5
1.6
1.7
1.8
1.9
1.10

General information
Ships particulars
Documents to be produced
Voyage particulars
Details of personnel
Sea state, weather, tide etc
Particulars of incident
Post incident action
Authentication of documents
Engine room orders
External information

2.
2.1
2.2
2.3
2.4
2.5

Specific information in the event of:

Fire/explosion
Collision - each ship
Grounding/stranding
Foundering
Pollution incidents

3.

Securing physical evidence

4.

Voyage data recorders

5.

Other sources of information

Human activity data form (96 hour history)

Code for the Investigation of Marine Casualties and Incidents

Appendix 2
Guidelines for the investigation of human factors in marine casualties and
incidents
1.

Introduction

2.

Investigation procedures
and techniques

2.1

A systematic approach

2.2
2.2.1
2.22
2.2.3
2.2.4
2.2.5
2.2.6
2.2.7
2.2.6

General Timing of the investigation

The occurrence site
Witness information
Background information
The investigation sequence
Fact-finding
Conducting interviews
Selection of interviewees

2.3
2.3.1
2.3.2
2.3.3
2.3.4
2.3.5
2.3.6

Topics to be covered
People factors
Organization on board
Working and living conditions
Ship factors
Shore side management
External influences and environment

2.4

Analysis

2.5

Safety action

3.

Reporting procedures

4.

Qualifications and training of

investigators

Code for the Investigation of Marine Casualties and Incidents

Appendix 2
Guidelines for the investigation of human factors in marine
casualties and incidents

Appendix 1 - IMO/ILO process for investigating human factors

.1
Collect occurrence data;
.2
determine occurrence sequence;
.3
identify unsafe acts/decisions and unsafe conditions;
For each unsafe act/decision,
.4
identify the error type or violation;
.5
identify underlying factors; and
.6
identify potenetial safety problems and develop safety actions.

Code for the Investigation of Marine Casualties and Incidents

Appendix 2
Guidelines for the investigation of human factors in marine
casualties and incidents
Appendix 2
Areas of human factor inquiry
Shipboard issues Safety policy
Activities prior to incident
Duties at time of accident
Behaviour at time of accident
Training/experience/certification etc
Physical condition
psychological/emotional/etc
workload/complexity of task
Work/rest/recreation pattern
Interpersonal relationships
Living conditions/environment

Manning levels
Masters standing orders
level of automation/equipment reliability
Ship design, motion, cargo characteristics
Shore-side management
Scheduling/rosters
Manning levels
Watchkeeping practices
Assignment of duties
Shore/ship/shore communications & support
Voyage planning
Welfare - recreation - contracts-- agreements

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