MAIB MARINE GUIDANCE NOTE MGN 115 (M+F)

Accident Reporting and Investigation

Summary

Introduction

1. The Marine Accident Investigation Branch (MAIB) is responsible for the investigation of all types of marine accidents, both to ships and to those on board. The MAIB is a separate branch within the Department of the Environment, Transport and the Regions (DETR) and is not part of the Maritime and Coastguard Agency. The MAIB's head, the Chief Inspector of Marine Accidents, reports direct to the Secretary of State on accident investigation. He and his professional staff who are drawn from the nautical, marine engineer, naval architect and fishing disciplines, are appointed under the Merchant Shipping Act 1995 by the Secretary of State. An administrative staff deals with records, data analysis and publications and provides general support.

2. The MAIB's fundamental purpose in investigating an accident under the Regulations is to determine its circumstances and the causes with the aim of improving the safety of life at sea and the avoidance of accidents in the future. It is not the purpose to apportion liability, nor, except so far as is necessary to achieve the fundamental purpose, to apportion blame. The MAIB is not an enforcement or prosecuting agency.

3. Procedures are mainly governed by the Merchant Shipping Act 1995, and by regulations. The Merchant Shipping (Accident Reporting and Investigation) Regulations 1999 (SI No. 2567), which replace the Accident Reporting and Investigation Regulations of 1994, come into force on 12 October 1999. They define the accidents to which they apply; set out the purpose of investigation; and make provisions for the ordering and conduct of investigations. The Regulations apply generally to all ships, including fishing vessels and (except as indicated below) to pleasure vessels.
　
They also set out requirements for reporting accidents (which includes major injuries) and serious injuries. They do not cover formal investigations or other public inquiries, the rules for which are a separate matter.

4. Annex 1 defines major and serious types of injury. Reports of minor incidents that posed no danger are not required. Nor are reports of injuries to shore-based workers in a United Kingdom port or shipyard; such injuries should be reported by the employer to the Health and Safety Executive (HSE) as should reports of other accidents occurring in a United Kingdom shipyard.
　
The Regulations also allow for the investigation of “hazardous incidents” - broadly any unspecified events which might have led to an accident - though they do not require such incidents to be reported.

Reporting

5. Accidents must be reported initially within 24 hours and should contain the information noted in Annex 2 section 3(1). Serious injuries must be reported within 14 days.
　
Reports should be sent by the quickest means available, including telephone, facsimile, telex or e-mail, to the MAIB. The reporting requirements apply to merchant ships, fishing vessels, and vessels in commercial use for sport or pleasure.
　
Accidents on or to pleasure craft used only for recreation and not for commercial gain are not required to be reported.

6. The Regulations require masters and skippers to ensure that the circumstances of every accident are examined. Where a ship carries a safety officer, the investigation which he or she is required to carry out by the Merchant Shipping and Fishing Vessel (Health and Safety at Work) Regulations 1997 (SI 1997 No. 2962) will meet this requirement. A report on the findings must be sent to the Chief Inspector, if requested. The MAIB Incident Report Form (IRF) has been introduced to facilitate this and can be used to amplify the initial report of any accident; it can also be used for serious injuries. Annex 2 section 3(2) contains advice on the information which is needed.

7. Although there is no requirement to report hazardous incidents, owners, masters, skippers and others are strongly urged to do so voluntarily since useful lessons can always be learned. Examples are navigational or engineering incidents causing hazard, failure of procedures in shipboard operations, material defects, fatigue and human failures. The critical question in deciding whether or not to report an incident is whether it had the potential to lead to an accident. These reports should also be sent using an IRF, or if preferred, in narrative form. Many incidents occur which, due to timely action, do not cause injury or damage but have the potential to be hazardous.

8. In making reports, whether on an IRF or in narrative, particular attention is requested to the content of the descriptive text. Lessons can be learned from the positive as well as negative aspects. Details of actions taken to minimise the effects of the accident or, in the case of a hazardous incident, to prevent it developing into an accident, are particularly helpful. A description of actions taken, or a recommendation, to prevent a recurrence are also of value. Much is gained from the information provided by those most intimately concerned in the event when it occurred.

9. Annex 2 includes a summary of reporting procedures and details of the MAIB's address and contact numbers.

Investigations

10. An accident or serious injury may be investigated by the MAIB if it involves a United Kingdom ship or any other ship in UK waters, or if the Branch agrees to a request to undertake an investigation on behalf of another flag state. Hazardous incidents may also be investigated.

11. Whether an MAIB investigation is carried out, and its extent, depends upon the circumstances. In some cases the ship's own investigation will be sufficient but the MAIB may seek further details if necessary. The Regulations require owners, masters and others to provide any such information when requested.

12. Should the MAIB decide to start an investigation, the master or owner will be notified within 28 days of the receipt of the initial report. If, however, any additional information has been requested, then the notification will be provided within 28 days of that information having been received by the MAIB.

13. The MAIB may investigate any accident. This may involve inspectors visiting the ship concerned and any connected organisation or authority. The owner and master should ensure that all charts, log books, voyage data and other records, electronic and magnetic recording and video tapes and all documents which might reasonably be considered pertinent to a reportable accident are kept. No alterations should be made to recordings or entries, and any equipment associated or involved in an accident should, as far as practicable, remain undisturbed, until

14. Where an inspector is appointed to carry out an investigation his powers are extensive, and are set out in detail in Section 259 of the Merchant Shipping Act 1995. Subject to these powers the Inspector has wide discretion as to how he carries out his investigation. If at all possible most of it will take place on board the ship concerned. He may wish to visit the owners or ship managers. An inspector may also prohibit, pending investigation, access or interference with anything involved in an accident.

15. The Inspector can require any person whom he considers is likely to be able to assist his investigation to attend before him, answer questions, and sign a declaration of the truth of his answers. A person being interviewed by an inspector has the right to be accompanied by any third person of his choice, for example a friend, a union representative, or a solicitor. No one else may be present except with the agreement of the Inspector. The interview is essentially a matter between the Inspector and the witness, and the third person must not interfere with the questioning though he may make representations on behalf of the witness.

MAIB Reports of Investigations

16. If an accident or other incident is investigated, the Inspector will make a report which may or may not contain recommendations. Any recommendations made will be forwarded to those considered best fitted to implement them.
　
The report will be made publicly available in such a manner as the Chief Inspector thinks best. A number of options are available to him including publishing it as priced publication, releasing it to anyone who asks for it, including the media (for which a small administrative charge may be made), placing it on the internet, or summarising the key features and lessons learned in the MAIB's periodic Safety Digest, which is distributed free of charge.
　
Provision is made for anyone criticised in the report to see the draft and to comment on it before it is finalised and made publicly available. The Chief Inspector is obliged to consider any comments received.

Penalties

17. Finally, the Regulations lay down penalties for breaches of the requirements. These offences include a failure to report an accident or serious injury; not providing information as required; falsely claiming to have additional information or new evidence; and failure to preserve evidence. Penalties for obstructing an Inspector or otherwise impeding his investigation are laid down in Section 260 of the Merchant Shipping Act 1995.

ACCIDENTS AND MAJOR & SERIOUS INJURIES

1. An accident means any contingency caused by an event on board a ship or involving a ship when:

2. Major injury is a defined accident and occurs when there is:

3. Serious injury means any injury, other than a major injury, to a person employed or carried in a ship which occurs on board or during access which results in incapacity for more than three consecutive days excluding the day of the accident, or as a result of which the person concerned is put ashore and the ship sails without that person, unless the incapacity is known or advised to be of three consecutive days or less, excluding the day of the accident.

REPORTING PROCEDURES

1. Summary (Regulation 5)

2. The MAIB's address is:

3. Information needed in Reports

4. IRFs are available on the MAIB's website on the Internet.