SHIP MANAGEMENT MANUAL Ch. 9 REPORTING / ANALYSIS Rev. No. 5 Date 28-Oct-16 Page 1 of 19 REPORTING 9.1. VESSEL GENERAL REPORTING Refer to SMM Chapter 19 Communication for routine reporting. As guidance to Masters for easy reference following matrix gives an overview of the communication that a Master is required to perform with the office. For the better understanding the process of office communication is also provided against every process by the Master. Reporting Matrix Activity Master’s Communication Responsibility Office Communication Responsibility Communication Drill Upon Joining vessel Master shall call Emergency contact numbers of the company within 10 days of taking over command. Emergency Communication test to be reported / acknowledged. Routine Communication Master and CE shall call vessel’s Superintendent once in a week. In addition to above Weekly/ Monthly / Quarterly/ Annual Reports are to be communicated to office as per Index of forms Superintendent to follow up matters raised during the call through SMMS / Ship palm Office review of reports to be sent to vessel. Regulatory Reporting of Oil Spill and Pollution Report as per procedures in SOPEP / SMPEP and / or VRP (in US waters) in consultation with office. Activate response on board vessel / Company as per procedures in the Vessel Response Plan / SOPEP/ SMPEP. Liaise with Spill response Organization and coastal state authorities. Accident / Injury Reports (Contingency Manual, Chapter 2, Section 2.4.6 and 2.6) Refer to Contingency Manual Ch. 2 Appendix-1 for initial notification requirement. In case of serious incident - Call on 24 Hrs Emergency Contact Number. {Refer to Contingency Manual section 2.3.1 and Initial Notification form(Chapter 2 Appendix 1)} Drug & Alcohol testing for the personnel involved must be done and reported within 2 hours of the incident. Record sequence of events Duty Superintendent to notify Head of Ship Management Team and Crisis Manager. Crisis Manager To analyze Emergency Classification {Refer contingency Manual Chapter 1, section 1.5} Activate Crisis Management Team (CMT) and Media Management team as required. Uncontrolled when Printed
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SHIP MANAGEMENT MANUAL
Ch. 9 REPORTING / ANALYSIS
Rev. No. 5
Date 28-Oct-16
Page 1 of 19
REPORTING
9.1. VESSEL GENERAL REPORTING
Refer to SMM Chapter 19 Communication for routine reporting. As guidance to Masters for easy
reference following matrix gives an overview of the communication that a Master is required to
perform with the office. For the better understanding the process of office communication is also
provided against every process by the Master.
Reporting Matrix
Activity Master’s Communication Responsibility Office Communication Responsibility
Communication Drill Upon Joining vessel Master shall call Emergency contact numbers of the company within 10 days of taking over command.
Emergency Communication test to be reported / acknowledged.
Routine Communication
Master and CE shall call vessel’s Superintendent once in a week. In addition to above Weekly/ Monthly / Quarterly/ Annual Reports are to be communicated to office as per Index of forms
Superintendent to follow up matters raised during the call through SMMS / Ship palm Office review of reports to be sent to vessel.
Regulatory Reporting of Oil Spill and Pollution
Report as per procedures in SOPEP / SMPEP and / or VRP (in US waters) in consultation with office.
Activate response on board vessel / Company as per procedures in the Vessel Response Plan / SOPEP/ SMPEP. Liaise with Spill response Organization and coastal state authorities.
Refer to Contingency Manual Ch. 2 Appendix-1 for initial notification requirement. In case of serious incident - Call on 24 Hrs Emergency Contact Number. {Refer to Contingency Manual section 2.3.1 and Initial Notification form(Chapter 2 Appendix 1)} Drug & Alcohol testing for the personnel involved must be done and reported within 2 hours of the incident. Record sequence of events
Duty Superintendent to notify Head of Ship Management Team and Crisis Manager. Crisis Manager To analyze Emergency Classification {Refer contingency Manual Chapter 1, section 1.5} Activate Crisis Management Team (CMT) and Media Management team as required.
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{Refer Contingency Manual Chapter 02, Table 2-2, Contingency Plan Log.} Interaction with Media {Refer contingency Manual Chapter 4}
Continuously Update CMT on further developments. The update interval must not exceed 6 hours.
To monitor the progress of activity and provided suggestions/ assistance, as this might help the Vessel in tackling the emergency more efficiently.
Reports to PSC and Flag State as per advice from Office. Flag state Accident notification Forms to be used.
Advise vessel with Flag state reports and reports to Coastal state authorities.
Send Incident (Accident / Injury) report thru the ship palm if available or using the prescribed formsoon after resumption of normal operation but not later than 72 hours in any case. The initial report has to be made within the 24 Hours of occurrence.
Incident to be analyzed and all stake holders updated accordingly.
Near Miss Reports As early as practicable but not later than 72 hours of occurrence
Near Miss to be analyzed and reportcompleted. To be sent to all vessels
as part of safety bulletin for learning.
PSC/FSC inspection PSC/FSC inspection
Inform Vessel’s Superintendent as soon as PSC/ FSC boards vessel.
Superintendent to inform SMT and CMSTeam to ensure support is available.
Send a copy of the PSC report to Office immediately after the inspection. Code 17 Deficiencies. Inform office of Immediate Corrective actions for rectifying all code-17 deficiencies. Close out all Code 17 deficiencies with PSCO Other Code Deficiencies Inform PSCO when the deficiencies are rectified. Confirm Closure.
Assist to rectify all code 17 deficiencies before vessel sails from port.
Detention Inform Vessel Superintendent / Fleet Manager immediately if a detainable deficiency is noted.
Mobilize SMT&CMS Team SMTTeam to verify the regulation
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PSC/FSC inspection
Consult with PSCO the measures to be taken to rectify the deficiency and for revocation of detention. Ensure the PSCO/ PSC Office contact details are noted down for follow up. Inform Superintendent the scope of work to be done to rectify the detainable deficiency. Liaise with agent and local ship chandler for any work shop assistance or stores that may be required to rectify the detainable deficiency.
relating to the detainable deficiency. Inform Owners. Contact Classification society for occasional survey to verify the corrective actions for the detainable deficiency. Liaise with Agent and PSC Office to secure release from detention. Liaise with Flag State – provide details of Immediate corrective action being taken to close out the issue.
Corrective Action Plan Corrective action report to be sent to Office within a week.
Review Master’s CAP, and finalize. In case of Detention, submit the Corrective Action Plan to Flag State. Report to Class/ Oil majors/ Owners as appropriate. Report to Right Ship for all BC PSC inspections.
Class Survey Follow up with TechnicalSuperintendent on Survey status of the vessel. Liaise with TechnicalSuperintendent for preparation for the survey.
Liaise with Classification Society to arrange surveys as per survey status. TechnicalSuperintendent to inform survey plan to vessel. To provide Vessel with class specific requirements/Checklist for vessel to prepare
On completion, email to be sent to office with relevant reports provided by the Class inspector.
Attachments to be verified to ensure all in order
Corrective action report to be sent to Office within one week for observation or Condition Of Class (COC) set out by the Class Surveyor.
To verify corrective action plan, and to follow through with vessel to rectify observation or Condition of Class
On rectification of observations and/or COC, same to be reported to office.
Submit closure report to class. Liaise with Class to delete the COC or the note set out.
External Audits / Inspection (SMM
Follow up with SMT Division to arrange audit/Inspection on board vessel.
Liaise with Classification Society/Oil Major to arrange Audits/Inspection as
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Ch12) per vessel’s audit calendar/Inspection Plan.
Report to office the status of Non Conformities / observations / Finding set out during past internal and external audits/inspections on board vessel.
Ensure that all open Non conformities/findings are appropriately closed prior to arranging audit on board.
Liaise with Office on preparation for the audit/inspection.
Verify preparation of vessel for the planned audit/inspection.
Audit/inspection report to be sent to Office on completion of the audit.
Audit/inspection report to be verified
Corrective action report to be sent to Office within one week for observation or Non Conformity (NC)/findings set out by the Class Surveyor/Inspector.
Submit Corrective Action Plan to Class/Oil Majors.
Report to Office on completion of Corrective action plan for NC/ Observations. Retain records of NC Closure in Audit file for verification at next audit.
Report closure of NC to Class. Keep records at office for verification during DOC audit of the office.
Hull/Machinery Defect Reporting
Report to be completed and sent to Office thru defect reporting in ship palm or HMX report in the prescribed formatif ship palm is not available.
Verify the extent of defect to machinery/ Hull. To Communicate with Makers and arrange for any necessary Shore assistance.
Relevant requisition to be raised as required, in consultation with office.
To advise any further requisitions to be raised To follow through with any additional shore assistance required
To follow through with Office, with the progress of preparation for Shore assistance and any preparation required onboard prior arrival of shore assistance.
To advise Vessel on any preparations required prior arrival of shore assistance onboard
On rectification of defects, relevant reports received from shore technicians to be sent to office and confirm closure of defect.
To verify Shore technicians report and follow through with Vessel to ensure closure of defect
Navigation / Radio Equipment defects
Inform Superintendent by phone immediately. Follow up thru defect reporting in ship palm or HMX report in the prescribed
Liaise with Maker of equipment for trouble shooting instructions. Seek dispensation from Flag state if equipment is listed in statutory
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formatif ship palm is not available, with details of make/ model of the equipment. Verify Past service reports for similar trouble reports. Report to Port Authority / Flag State as per advice from Office.
certificate.
Defects of Critical Equipment
Report to be completed and sent to Office thru defect reporting in ship palm or HMX report in the prescribed format if ship palm is not available. Raise requisition for spares.
Verify the extent of defect to equipment. Verify the extent of defect to machinery/ Hull. Consult makers and arrange for any necessary Shore assistance.
Safety related deficiency that can cause a PSC detention
Report any defect to safety equipment immediately to company. Log down the deficiency in Defects register / PMS software.
Provide necessary stores to rectify the deficiency. Arrange for shore assistance if necessary. Report to Flag state and seek dispensation if appropriate.
Stevedore Damage reporting (Hull/Cargo)
Stevedore damage report and / or Charterer’s Stevedore damage report to be filled out (Third Party damage report). This report to be acknowledged by the stevedores and forwarded to office Liaise with Charterers / Agents / stevedores for repair plans – if same being done at port. Liaise with local Classification society office if class attendance is required. Obtain approval from Office and local port authority if repairs require Hot work. Continuously update Office on progress of repairs, but in any case not exceeding 6Hrs. Follow up with complete statement of facts on completion of repairs.
Inform Owners. Liaise with charterers / agents if local workshop has to be arranged for repairs. Call Class attendance if damage affects sea worthiness of the vessel. To communicate with the relevant agents to provide necessary permits, like attendance of required personnel, permits for work shop including Hot work and material procurement
Crew Dismissal Recommendation for dismissal to be made with details of incident/ events necessitating this action. Relevant entries in the Official Log Book
Verify the facts and documentation is adequately done to confirm dismissal of the crew member. Arrange for Dispensation from flag
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and statements from the crew member and supervising officer to be sent to Manning div. Liaise with Manning division for relief arrangements and settlement of wages. Liaise with manning div on the complaint procedures and advise crew to report to office.
state if reliever cannot be placed on board. Advise Master on settlement of wages and relief arrangements. Advise Master on complaint procedures and the date the dismissed crew member should report to office. Report to Flag state.
Communication with Charterer
All communication with charterers must be copied to Synergy. Routine Communication Routine reports to be made as per voyage instructions in the Charter party Notice of Readiness should be sent as per Voyage Instruction Discharge of cargo on LOI terms to be confirmed from owners, before accepting Charterer’s instructions. Cargo Operation Plans Cargo stowage plan and operation sequence plan to be confirmed with Marine Superintendentwhen sending to charterers. Off Hire Any cargo/ vessel stoppage incident that entails off-hire of the vessel should be reported to Synergy immediately by Phone and followed by email with relevant details and action plan to minimize Off-hire period. Continuously update Office on stoppage, but in any case not exceeding 6Hrs. Statement of Facts to be reported to Charterers after confirming the statement with Synergy. Prepare incident report within 72 Hrs of the incident and send to Office
Verify the reports are as per Voyage instructions/ charter party. Liaise with owners on acceptance of LOI. Verify the stowage / cargo quantity is as per Voyage instruction. Inform Owners about the incident and follow up with updates on measures being taken to minimize Off-hire period To inform all concerned departments in order to ensure Verify SOF and confirm with owners before advising vessel to send the statement to charterers.
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9.2. OTHER IMPORTANT REPORTING:
9.2.1. Regulatory Reporting of vessel damage, death, Injury, Serious illness of personnel, Casualties
All regulatory reports including flag state, on vessel damages, death, injury, serious illness shall be
reported by the vessel, in consultation with office. Detailed reporting procedures are available in
contingency Manual.
9.2.2. Deficiencies pointed out by PSC / FSC and similar other authorities.
Deficiencies notified to vessel by authorities such as Classification Society surveyors, Port State
Control inspectors, Vetting inspectors, Flag State authority, charterers, Terminal inspectors etc. shall
be notified to the company. A corrective action plan shall be agreed upon with the company. The
vessel superintendent shall monitor such deficiency and close out as agreed. The company shall
communicate to the authority that have raised the deficiency and ensure close out.
Requirements for reporting to flag state:
All PSC inspection results shall be reported immediately to relevant division of flag state.
Masters shall send the PSC inspection report to office and Ops & Tech Team will send the
report to flag state.
The action taken to correct the deficiency identified by PSC shall be sent to flag state as soon
as possible by SMT (in the format required by flag state).
The action taken to correct the deficiency identified during flag state annual safety inspections
shall be sent to flag state within 30 days of the inspection date. Report shall be sent by SMT
in the format required by flag state.
Any failure of equipment that may affect safe navigation and further closure of the defect shall
be reported to the concerned flag state.
Occurrences of occupational accidents, injuries and diseases on board ships shall be reported
promptly. Additional reporting shall be done if the accident, injury or disease renders the crew unfit for
work for more than 3 consecutive days or hospitalized for at least 24 hours.
9.2.3. Urgent notification to the fleet
Head of CMS team shall ensure that the fleet is rapidly notified of the following through bulletins:
Urgent safety related information
Urgent Security related information
The Company must make arrangements to receive and review security related information and
disseminate appropriate data to vessels and other parties. Up-to-date security information relating
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to a trading area should be passed to the vessel in good time prior to her entering or transiting the
area. Security information may be obtained by the Company using the following sources:
International and national agencies
Military authorities
Local agent
Specialist consultants
Industry bodies
Any violation of regulations
Any major incident
Any near miss of high potential.
Other important information on safe / unsafe practices, Near misses from the fleet as well as from the
industry and information on new regulations will be notified to the fleet through quarterly brochures.
9.3. INCIDENT REPORTING & INVESTIGATION PROCEDURE
9.3.1. Purpose
The purpose of this procedure is to ensure that a formalized system exists for reporting of the
incidents (includes near misses), investigation of incidents, for carrying out an analysis of the
incidents, for implementing corrective actions and for sharing the lessons learnt from the incident /
near miss with all concerned by sending broadcasts.
Incident investigation has the primary purpose of preventing further incidents by identifying the causes
and lessons learnt to allow safeguards to be put in place to prevent recurrence.
9.3.2. Scope
This procedure applies to
- Any casualty, accident or serious incident involving a vessel managed by Synergy.
- All incidents involving any person on articles of agreement on Synergy managed vessel
whether onboard, ashore or accessing the vessel
- Incident involving any contractor including shipyard workers, visitor or Office personnel while
on board or accessing the vessel.
Near Miss reporting is an integral part of an incident reporting system. Not all near misses will require
full investigation and thus a system for capturing these unsafe acts and conditions should be
available.
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9.3.3. Responsibility
The Master is responsible for the timely reporting of all incidents and near misses to the office and for
the onboard investigation of the incident.
The respective Marine Manager or his designate shall analyze the severity and nature of the incident
reported by the vessel and reviews the corrective measures arising out of the incident. He shall
determine if immediate information needs to be sent to the fleet.
Marine Superintendent will be responsible for collection of information and preparation of the incident
report bulletin.
If evidence shows that the incident has either occurred due to or resulted in a breach of regulatory
requirements, the DPA is required to report it to the appropriate authorities.
The respective Marine Manager or his designate is responsible for monitoring the effective disposition
of the nonconformance as a consequence of the incident or near miss.
9.3.4. Definitions
Please see the Acronyms / Abbreviations and Definitions listed in the starting of the manual.
9.3.5. Forms for Reporting
All incidents shall be reported to the office in the appropriate manner. The report shall be completed
and sent thru the ship palm or using the prescribed format if ship palm is not available.
Near Miss report – shall be used for reporting Near misses
Accident / Damage report - shall be used for reporting accidents onboard.
Injury report - shall be used for reporting injuries
9.3.6. Classification of Incidents
The following table details the consequences and categories against which the potential of an incident
should be measured are defined. (Also refer Consequence table on Chapter 08, Risk Assessment for
understanding of category)
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Incident
Category
Personal
Injury
Property Damage Environmental Release Near Miss
Catastrophic
(Extremely
Harmful)
Fatality,
PTD,
Loss of vessel or total
loss amounting over
1,000,000 USD
Major Spill >=10 bbls into sea or
uncontrolled gas release >10
tonnes or volumetric equivalent
Critical
(Severe
Harm)
Ill health
leading to
permanent
disability,
PPD,
Major damage, Yard
repair required.
(Damages loss
amounting to 500,000
usd and over but less
than 1,000,000 USD)
Oil spill into sea < 10 barrel
Oil spill contained on deck >
10bbls
Regionalenvironmental impact,
likely to receive citation / fine
and could jeopardize the
reputation of the company
Catastrophic
Potential – Near
Miss
Marginal
(Moderate
Harm)
LWC, RWC,
MTC,
Vessel disabled or
expenses amounting
to USD 10,000 but
less than USD
500,000.
Oil spill contained on deck
> 1barrel < 10 barrel
Critical Potential
– Near Miss
Minor First Aid
Case
Minor Damage,
Repairable on board
Oil Spill contained on deck < 1
bbl.Environmental impact not
existent
Marginal
Potential– Near
Miss
9.3.7. Initial Reporting
The initial response to an accident or near miss should be made by the appropriate means depending
upon the category of the incident. In all cases, an initial notification by email or phone should be made
to the Superintendent. This should be done as soon as practicable after the occurrence of the incident
or near miss and should contain as much information as is available through a preliminary
investigation, with the added comment that a report will follow after carrying out a thorough
investigation.
For initial reporting of defects related to hull, machinery and equipment, defect report has to be raised
in the ship palm. Where shippalm is not available HMX reports need to be raised. For HMX reports of
category Substantial and Intolerable, in addition damage reports would have to be raised in
consultation with Technical Superintendent.
At any case, the Master shall complete and send appropriate Incident Report to office in no later
than72 hours after the incident. If the Master is unable to complete the incident report within the time
limit, he shall request extension from the respective Marine Manager.
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The Marine Manager or DPA shall assess the incident for the need of statutory or legal requirements
to the authorities. He shall provide necessary direction and guidelines to the superintendent and / or
vessel for reporting the incident to the appropriate authorities within the required deadline.
9.3.8. Incident Investigation Training and Team
9.3.8.1. Investigation Training for Office Staff
Investigation shall always be headed only by suitably qualified investigator.
At office, as far as possible, the staff that form part of the investigation team shall be duly trained in
Incident Investigation methodology. At least one senior staff should be trained by the External agency
who developed the incident investigation model or by a suitable Classification Society. He in turn,
may, train the other superintendents and the vessel staff. Trained superintendents should be given
opportunity to participate in the investigation if relevant to the skill before expected to lead an
investigation.
The Incident Investigation training shall be refreshed at a period not more than 5 years.
9.3.8.2. Investigation Training for Ship Staff
Training shall be provided to the senior officers onboard on incident investigation methods.
This may be done in shore based seminars, specific training by office or onboard training session.
Pre joining briefing may also be effectively utilized to carry out incident investigation course for
seafarers
Company shall ensure that at any time, atleast two seafarers onboard should have been trained in
Incident Investigation.
Refresher course for Incident investigation shall be provided for the team at a period not more than 5
years.
9.3.8.3. Incident Investigation Team Office and Shore:
Incident investigation team onboard shall consist of Master, Chief Officer (Safety Officer), Chief
Engineer and Second Engineer. Master shall lead the on board investigation team and if the Master is
directly connected with the incident, the Chief Engineer or Safety Officer shall lead the team.
Marine Manager shall head the investigation team ashore, except for minor category.
Constitution of the office team for the category shall be as follows.
“Catastrophic” – Head of Ship Management Team, Head of CMS, Head of Technical Team,
Marine Manager, DPA & All superintendents as required.
External consultants / experts and representations from owners as required.
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“Critical”- Head of CMS &Head of Technical Team, Marine Manager, DPA and one
Superintendent.
“Marginal” – Marine Manager, DPA, One Marine Superintendent and one Technical
superintendent.
Minor – Marine Superintendent and / or Technical Superintendent.
Marine Manager shall ensure that the person leading the investigation is not connected with the
incident.
9.3.9. Incident Categorization
In deciding the category of an incident the “Potential” as well as the “Actual” consequence must be
taken into account. Personal injury should be the first consequence to be evaluated and this will take
precedence over the other types of loss or damage.
In order to be able to address each incident with the correct level and speed of response the decision
on the category must be made within 24 hours of the incident.
9.3.10. Stages of Incident Investigation
The first stage in investigation involves establishing factual information. This requires recording and
observation of all activities at the time and scene of the incident.
Once the incident is under control, the Master and onboard investigation team shall carry out a
methodical investigation of the incident to determine the causes and the appropriate corrective
measures to prevent recurrence.
The investigation will require the observation and collection of all relevant information, which may
include but is not limited to:
Photographs
Sketches
Statements from persons involved in the incident and any witnesses
Operational records
Logbooks
Checklists
Permits
Maintenance records
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Test records
Certificates
Data printouts
Record of rest hours
The second stage is to analyze the facts and make a judgment on the direct, indirect and root
causes.
Incident investigation process shall primarily follow Loss causation model (identifying direct causes,
indirect causes and root causes) with the help of events and Conditional factor charting or events and
causal factor charting, human factor analysis and barrier analysis. Taproot model may alternatively be
used in cases that indicate long pre- existing conditions with a potential to evolve as a causal factor.
However Depending on incident the head of investigation team in consultation with the Head of CMS
shall decide on the various tools to be adopted as relevant to the incident and investigation process.
The gathered evidence and the facts of the incident should lead to the determination of direct, indirect
and root causes and thereafter, to the derivation of corrective measures to prevent recurrence.
If necessary an Event and Causal Charting should be done to depict the events in logical sequence
and to analyze the event by identifying various unsafe conditions and unsafe acts that existed /
contributed to the event.
The identification of causes follows a process of asking a series of "why did it happen" questions.
The first ‘why’ or on occasion, 'how' question will provide the direct cause(s). The direct causes
may be an “unsafe act” or a normal act carried out an “unsafe condition” or the combination of
both.
The second 'why' question seeks to understand why the direct cause(s) happened. The answers
will provide the indirect cause(s). Usually these are the job and personal factors that exist.
In the final stage, questioning why the indirect cause(s) occurred will lead to the root cause(s),
which are always non-compliances with procedures / rules / regulations / industry best practice /
proper design standards or at times, lack of a procedure / regulation / knowledge / training etc.
A near miss of serious nature will be managed similar to an accident in the identification of causes
and corrective measures.
The third stage is to recommend actions to ensure, so far as possible, that the incident will not or is
less likely to happen again. Each of the identified root causes should now be used to develop an
appropriate corrective measure that will address the lapse and prevent its recurrence.
All incidents involving the ship / shore interface shall, whenever possible be investigated by both
parties involved. Whenever this is considered impracticable, the minimum action required subject to
the draft copy of completed investigation report shall be made available to the other party.
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9.3.11. Incident Investigation Report
The investigation report should be completed as soon as possible with all the facts and relevant
information. Statements from participants and witnesses should be used to establish the facts. Drug &
Alcohol testing for the personnel involved is to be done within 2 hours of the incident.
Every possible effort shall be taken to ensure the report is full of facts as this report assists to identify
the root causes and thereby efficient corrective action. Ops and Tech team will review the report sent
by the Master and the investigation team. The time duration allowed for the completion of the
investigation shall be reviewed until all issues are addressed and resolved. The final report is
completed as soon as practicable. However, the report shall be completed within 90 days from the
date of the accident unless a different time scale has been decided by the investigation team. The
Incident Investigation report should include the time scale & the person responsible for closing out the
proposed Corrective/Preventive Action.
The investigation report is to state the following at the bottom of the report:
Report should not be written with litigation in mind and, shall be inadmissible in any judicial
proceedings whose purpose, or one of whose purposes is to attribute or apportion liability or blame.
Master will be responsible for implementing the corrective action onboard.
All extension shall be approved by the Head of Ship Management Team.
9.3.12. Review
The report sent by the vessel shall be reviewed by the office investigation team to confirm that the
incident has been adequately investigated, analyzed, categorized and sound recommendations made.
The office team shall ensure that the investigation has fully explored the possible causes and
identified appropriate actions to prevent recurrence. The office analysis of the incident report shall be
recorded in the “Analysis of the incident reporting by office”.
It is important that suggested corrective action, should be such that, it does not generate a new
hazard in the system. Hence, if necessary, a risk assessment shall be carried out prior implementing
the suggested corrective action.
The findings and the conclusions from the investigation shall be circulated to the fleet. Masters shall
discuss the bulletins with all crew so that similar incidents are prevented.
Where appropriate, Head of Ship Management Team shall share the investigation results and the
lessons learnt with other authorities such as class, oil major vetting departments, charterers, industry
groups, equipment manufacturers, and various customers to avoid similar incidents on other vessels.
9.3.13. Action Plan and Follow up
The Ops & Tech team is responsible for ensuring the corrective actions are documented, tracked and
closed out.
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9.3.14. Trend Analysis
The incidents shall be reviewed in the management review to identify the trends. Suitable action plan
shall be derived to avoid / minimize the losses in future.
While conducting risk evaluation in relation to management of occupational safety and health shall
refer to appropriate statistical information from the ships and from general statistics provided by the
Flag state.
9.3.15. Near Miss:
While the Near Miss reporting is an integral part of Incident reporting system, not all near misses will
require full investigation. The near misses which have high potential for learning or for loss control
shall be investigated. The near misses which record just the unsafe acts or conditions need not be
investigated but they shall be captured in the system for trend analysis. Marine Manager will decide
whether a full investigation is necessary or not.
Near Miss report may be completed anonymously by the vessel.
Near miss reports shall be reviewed for the presence of potential danger and the lessons to learn.
The review of Incident analysis shall be sent to the vessels as lesson learnt.
