interpreters and the clarity with which they are explained down to the
last detail, the more technical and adjusted to reality our report will be. How many times
the issued report does not have sufficient objetive data and depends on possibilities and
on what is subjective!.
Based on what has been previously mentioned, results impossible, with
the precariousness of the current procedures for collecting data and the sparingness of
records available, to obtain detailed conclusions of any of the meaningful aspects of the
accident due to fire, therefore there is the urgent need of an exhaustive updating of the
current system, of the present regulation and the way of completing accident reports
including the most details that happened in the event and even more, those which provide
the observation, analysis and investigation that any event must go through.
The data provided by the group of causes related to the human factor
reaffirm the criterion of the huge influence exercised on the materialization of the
accident, especially in those cases that can theoretically be dealt with in the preventive
aspects, such as the modification of attitude (lack of care) through preparation and
training, and the internal organization (improper maintenance and insufficient safety)
through procedure guides, signaling and control of operations.
Therefore, the design of a new normalized offical form for accident
reports does not provide a direct result of the incident, but facilitates to the
investigator a good amount of knowledge to be treated conveniently, with the objective of
obtaining reasonable conclusions from the real causes that were present and determinating
factors of the origing and gravity of the accident, with which, the necessary adjustments
of preventive character in the present positions (regulations, training contents,
modification of requirements for equipment, etc.) could be accomplished so that the
mercantile fleet could take advantage of them.
The availability of an exhaustive tree diagram with the causes, as
complete as possible, facilitates the design of training policies trying to encompass the
wide spectrum of knowledge, basically in general safety but also in the areas of
maintenance, design, management organization and equipment. All this with an evident
improvement for crew members, their commands and the aspects related to maritime and port
organizations.
In the same way, the maritime authorities with responsibility in the
inspections of the Port State Control will be able to point their objectives towards the
actual aspects causing the accidents that they are trying to avoid, being necessary for
this, to offer a special training to the inspectors who have to carry them out.
With both aspects covered, the internal and external ones, the ship
safety and the objectives of sea transport are guaranteed by a superior level of
efficiency and optimization.
I firmly believe, that training programs should be designed and,
therefore, include the fruits obtained from the specific investigation of accidents, when
these have been analyzed under the approach of prevention and not with the inverse
position.
