1.4 Analyses of marine casualties and incidents that have occurred over the past 30 years have prompted the international maritime community, and the various safety regimes concerned, to evolve from an approach which focuses on technical requirements for ship design and equipment to one which seeks to recognize and more fully address the role of human factors in maritime safety within the entire marine industry. These general analyses have indicated that given the involvement of the human in all aspects of marine endeavours, including design, manufacture, management, operations and maintenance, almost all marine casualties and incidents involve human factors.
1.5 One way the maritime community has sought to address the contribution of the human factor to marine casualties and incidents has been to emphasize the proper training and certification of ships' crews. It has become increasingly clear, however, that training is only one aspect of the human factor. There are other factors which contribute to marine casualties and incidents which must be understood, investigated and addressed. The following are examples of these factors relevant to the maritime industry: communication, competence, culture, experience, fatigue, health, situational awareness, stress and working conditions.
1.6 Human factors which contribute to marine casualties and incidents may be broadly defined as the acts or omissions, intentional or otherwise, which adversely affect the proper functioning of particular system, or the successful performance of a particular task. Understanding human factors thus requires a study and analysis of the, design of the equipment, the interaction of the human operator with the equipment and the procedures followed by crew and management.
1.7 It has been recognized that there is a critical need for guidance for accident investigators which will help them to identify specific human factors which have contributed to marine casualties and incidents. There is also a need to provide practical information on techniques and procedures for the systematic collection and analysis of information on human factors during investigations. These Guidelines seek to fulfil those needs. They include a list of topics which should be considered by investigators, and procedures for recording and reporting the results.
1.8 These Guidelines should result in an increased awareness by all involved in the marine industry of the role human factors play in marine casualties and incidents. This awareness should lead to proactive measures by the maritime community which in turn should result in the saving of lives, ships, cargo and the protection of the marine environment, improvements to the lives of marine personnel, and more efficient and safer shipping operations.
1.9 These Guidelines apply, as far as national laws allow, to the investigation of marine casualties or incidents in which either one or more States have a substantial interest because the casualty or incident involves a ship under or within their jurisdiction.
2 INVESTIGATION PROCEDURES AND TECHNIQUES
2.1 A systematic approach
2.1.1 The following is a process that provides a step-by-step systematic approach for use in the investigation of human factors. The process is an integration and adaptation of a number of established human factor frameworks. The process can be applied to any type of marine casualty or incident and consists of the following steps:
.1 collect occurrence data;
