2.2.5 The investigation sequence
2.2.5.1 The method for fact-finding while conducting an investigation includes, but is not necessarily limited to, the following activities:
- inspecting the location;
gathering or recording physical evidence;
- interviewing witnesses taking into account cultural and language differences (on-site and external);
- reviewing of documents, procedures and records;
- conducting specialised studies (as required);
- identifying conflicts in evidence;
- identifying missing information; and
- recording additional factors and possible underlying causes.
2.2.5.2 Following the fact-finding a typical marine casualty or incident investigation includes analysis of the facts, conclusions and safety recommendations.
2.2.6 Fact-finding
2.2.6.1 The objective of this stage of the investigation is to collect as many facts as possible which may help understanding of the incident and the events surrounding it. The scope of any investigation can be divided into five areas:
- people;
- environment;
- equipment;
- procedures; and
- organization.
2.2.6.2 Conditions, actions or omissions for each of these may be identified, which could be factors contributing to the incident or to subsequent injury, damage or loss.
2.2.6.3 During the initial stages of every investigation, investigators should aim to gather and record all the facts which may be of interest in determining causes. Investigators should be aware of the danger of reaching conclusions too early, thereby failing to keep an open mind and to consider the full range of possibilities. With this in mind, it is recommended that the fact-finding stage of the investigation process itself be kept separate from the complete analysis of the collected evidence leading to conclusions and recommendations, and that a structured methodology be adopted to ensure the effectiveness of that analysis. The analysis may well help to identify missing pieces of evidence, or different lines of enquiry that may otherwise have gone undetected.
