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Maritime Investigation Reports Involving Man-Over-Board (MOB) Casualties: A Methodology for Evaluation Process Vol: 5 No: 2 (2019) 141-170.

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Flag states must issue their maritime investigation reports in accordance with the International Maritime Organization (IMO) circulars with the inclusion of 'lessons learned' items from recorded accidents or incidents. To identify the root cause of an event, there must be enough detail of information about the investigated event presented in reports. The information included in reports may help identifying the procedural deficiencies or technical challenges. Considering the Man-OverBoard (MOB) events as a sub group of maritime accident investigations, authors systematically reviewed over 100 reports containing MOB events in this study. In this study, reports are reviewed and major differences in formats as well as level and type of information are recorded. A systematic methodology for reviewing and reporting the overall information retrieved from maritime accident reports is presented. To cover all information from reviewed reports, 113 information items are identified. An associated standard form is developed for use in extracting information from all investigation reports. Enabling the data collected systematically from reports, issued by the world maritime accident reporting states and agencies, and successively populated into a database for overall analysis, this form is called "Maritime MOB Events Investigation Form (MEI Form)". This paper presents the content of the MEI Form and demonstrates the methodology of use for retrieving, formatting and analyzing the information from the MOB investigation reports using case examples. 142 ÖZET Bayrak devletleri, deniz kazaları inceleme raporlarını Uluslararası Denizcilik Örgütü (IMO) genelgelerine uygun olarak ve kaza veya olaylardan öğrenilen dersleri içerecek şekilde yayınlamak zorundadırlar. Bir olayın kök sebebinin tanımlamak için ve bu nedenle raporlardan "Çıkartılan Dersler" dâhil edebilmesi için, sunulan raporlarda araştırılan olay ile ilgili yeterli bilgi detayı olması gereklidir. Raporlarda yer alan bilgiler olay esnasında yapılan işlemlerdeki eksikliklerin veya oluşan teknik zorlukların belirlenmesine yardımcı olabilir. Bu çalışmada, Denize Adam Düşmesi (DAD) olayları deniz kazaları araştırmasının bir alt grubu olarak değerlendirilmiş ve DAD olaylarını içeren 100'den fazla rapor sistematik olarak gözden geçirilmiştir. İncelenen raporlarda, format ve bilgilerin yanı sıra bilgi içeriklerinde de önemli farklılıkların olduğunu tespit edilmiştir. Bu çalışmada, deniz kazaları raporlarından elde edilen genel bilgilerin gözden geçirilmesi ve raporlanması için sistematik bir yöntem sunulmuştur. İncelenen raporlardaki tüm bilgileri kapsayacak şekilde 113 bilgi maddesi tanımlanmıştır. Tüm araştırma raporlarından bilgi çıkarmada kullanmak amacıyla bir standart form oluşturulmuştur. Dünyada deniz kazalarını rapor eden devletler ve ajanslar tarafından yayınlanan ve genel analiz için bir veri tabanına yerleştirilen raporlardan sistematik olarak toplanan verilerin sağlanması için kullanılacak olan bu form "Denizcilik DAD Olayları İnceleme Formu (DAD Form veya MEI Form)" olarak adlandırılmıştır. Bu çalışmada DAD Formunun içeriği tanımlanmış, oluşturulan bu formlar kullanılarak araştırma raporlarından bilgi derlenmesi, formatlanması ve analiz edilmesi amacıyla olay örnekleri ile birlikte sistematik kaza inceleme yöntemi gösterilmiştir.
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141
Research Article
Turkish Journal of Maritime and Marine Sciences Volume: 5 Issue: 2 (2019) 141-170
Maritime Investigation Reports Involving Man-Over-Board (MOB)
Casualties: A Methodology for Evaluation Process
Denize Adam Düşme (DAD) Kazaları İçeren Deniz Kazası İnceleme Raporları:
Bir Değerlendirme İşlem Yöntemi
Türk Denizcilik ve Deniz Bilimleri Dergisi Cilt: 5 Sayı: 2 (2019) 141-170
Orhan GONEL1,*, İsmail CİCEK1
1Postane Mahallesi, Manastır Yolu Caddesi, 1, 34940, Tuzla, İstanbul, TÜRKİYE
ABSTRACT
Flag states must issue their maritime
investigation reports in accordance with the
International Maritime Organization (IMO)
circulars with the inclusion of ‘lessons
learned’ items from recorded accidents or
incidents. To identify the root cause of an
event, there must be enough detail of
information about the investigated event
presented in reports. The information
included in reports may help identifying the
procedural deficiencies or technical
challenges. Considering the Man-Over-
Board (MOB) events as a sub group of
maritime accident investigations, authors
systematically reviewed over 100 reports
containing MOB events in this study.
In this study, reports are reviewed and major
differences in formats as well as level and
type of information are recorded. A
systematic methodology for reviewing and
reporting the overall information retrieved
from maritime accident reports is presented.
To cover all information from reviewed
reports, 113 information items are identified.
An associated standard form is developed for
use in extracting information from all
investigation reports. Enabling the data
collected systematically from reports, issued
by the world maritime accident reporting
states and agencies, and successively
populated into a database for overall
analysis, this form is called “Maritime MOB
Events Investigation Form (MEI Form)”.
This paper presents the content of the MEI
Form and demonstrates the methodology of
use for retrieving, formatting and analyzing
the information from the MOB investigation
reports using case examples.
Keywords: Maritime Accident
Investigation, Casualty Investigation Code,
Man Over Board (MOB), Lessons Learned,
Database, Data Format, Report Forms.
Article Info
Received: 04 November 2019
Revised: 11 December 2019
Accepted: 16 December 2019
*Corresponding Author
E-mail:
gonelo@itu.edu.tr
Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
142
ÖZET
Bayrak devletleri, deniz kazaları inceleme raporlarını Uluslararası Denizcilik Örgütü
(IMO) genelgelerine uygun olarak ve kaza veya olaylardan öğrenilen dersleri içerecek
şekilde yayınlamak zorundadırlar. Bir olayın kök sebebinin tanımlamak için ve bu
nedenle raporlardan "Çıkartılan Dersler" dâhil edebilmesi için, sunulan raporlarda
araştırılan olay ile ilgili yeterli bilgi detayı olması gereklidir. Raporlarda yer alan bilgiler
olay esnasında yapılan işlemlerdeki eksikliklerin veya oluşan teknik zorlukların
belirlenmesine yardımcı olabilir. Bu çalışmada, Denize Adam Düşmesi (DAD) olayları
deniz kazaları araştırmasının bir alt grubu olarak değerlendirilmiş ve DAD olaylarını
içeren 100'den fazla rapor sistematik olarak gözden geçirilmiştir. İncelenen raporlarda,
format ve bilgilerin yanı sıra bilgi içeriklerinde de önemli farklılıkların olduğunu tespit
edilmiştir.
Bu çalışmada, deniz kazaları raporlarından elde edilen genel bilgilerin gözden geçirilmesi
ve raporlanması için sistematik bir yöntem sunulmuştur. İncelenen raporlardaki tüm
bilgileri kapsayacak şekilde 113 bilgi maddesi tanımlanmıştır. Tüm araştırma
raporlarından bilgi çıkarmada kullanmak amacıyla bir standart form oluşturulmuştur.
Dünyada deniz kazalarını rapor eden devletler ve ajanslar tarafından yayınlanan ve genel
analiz için bir veri tabanına yerleştirilen raporlardan sistematik olarak toplanan verilerin
sağlanması için kullanılacak olan bu form “Denizcilik DAD Olayları İnceleme Formu
(DAD Form veya MEI Form)” olarak adlandırılmıştır. Bu çalışmada DAD Formunun
içeriği tanımlanmış, oluşturulan bu formlar kullanılarak araştırma raporlarından bilgi
derlenmesi, formatlanması ve analiz edilmesi amacıyla olay örnekleri ile birlikte
sistematik kaza inceleme yöntemi gösterilmiştir.
Anahtar sözcükler: Deniz kazaları İnceleme, Kaza İnceleme Yönetmeliği, Denize Adam
Düşmesi, Öğrenilen Dersler, Veri Formatlanması, Rapor Formatı.
1. INTRODUCTION
International conventions, such as the Safety
of Life at Sea (SOLAS) (URL-1, 2019), the
Maritime Pollution Act (MARPOL) (URL-
2, 2019) and the Load Line Convention
(Contracting Governments, 1966), introduce
liability and responsibility of casualty
investigations assumed by the flag states.
Therefore, flag states must prepare accident
or incident reports and share findings as
mandated by these international
agreements. An international convention
(United Nations, 1982) clearly states that
flag states are required to carry out an
inquiry for the ships sailing under their flag
at open seas. The IMO adopted the Casualty
Investigation Code (CI Code) (IMO MSC,
2008a) in the year 2008 in order to set an
international standard for conducting the
safety investigations and reporting. This
code brings liability to very serious marine
casualties. While MSC brings responsibility
for the investigation of very serious marine
casualties, the Maritime Labor Convention
(MLC) additionally introduces flag states to
investigate serious marine casualties (ILO,
2006). In order to classify a marine casualty
as ‘very serious marine casualty’, the
incident must involve; ‘the total loss of the
ship or death or severe damage to the
environment (URL-3, 2019).
CI Code also clearly states that the objective
of a marine safety investigation is
‘preventing marine casualties and marine
incidents in the future’ (IMO MSC, 2008b).
Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
143
It also states the inclusion of ‘the
identification of causal factors and the
making of safety recommendations’ as
necessary and yet ‘the reports must be
provided to the Organization to enable wide
dissemination of information to assist the
international marine industry to address
safety issues’ (IMO MSC, 2008a).
A marine safety investigation report is
written as a result of a marine safety
investigation that must contain certain
information, such as basic facts about the
casualty or incident, relevant details about
the ship, and narrative detailing of the
incident or marine accident (IMO MSC,
2008a). Casualty investigation reports
including such information are submitted to
the IMO Secretariat by the member flag
states. IMO has a designated group called
Correspondence Group on Casualty
Analysis and this group reviews the
submitted reports according to the
guidelines included in a document called
Casualty Analysis Procedure (URL-4,
2019). This group drives important
information from casualty investigation
reports, such as the analysis and lessons
learned information, which is published for
the maritime community. In this study we
studied the investigation reports and
identified several inconsistencies in
presentation of the data as well as missing
information.
In current practice, MSC recommends root-
cause analysis performed in the
investigations; however, there is no
guideline provided. In literature, according
to comparison criteria (Gano, 2007), an
effective Root Cause Analysis process
compares the six generalized criteria. There
are several methods for analyzing the root
causes of an accident/incident. Arslan
(2011), listed main root cause analysis
methods (Arslan, 2011) for chemical tanker
management as; FTA (fault tree analysis),
ETA (event tree analysis), FMEA (Failure
Mode and Effect Analysis), What/If
Method, HAZOP (Hazard and Operability
Analysis) and SWOT-AHP. According to a
study, there are 20 different accident
analysis methods; however, the most
commonly used ones are fault tree analysis
and Pareto analysis.
Kececi (2015) developed and presented
criteria, with 18 items, as conditions for
appropriate application of the root cause
analysis of marine accidents. Akyuz and
Celik (2014a) proposed an investigation
model to apply to marine accidents that may
help identify and reduce human errors in
marine accidents (Akyuz and Celik, 2014b).
Their study included a man overboard
situation during a lifeboat drill, chosen as a
novel case for their model demonstration.
So far, there are no proposals in literature
for the standardization of the investigation
forms to use or process the current data
other than what is laid out by current
procedures issued by the IMO. Current IMO
procedures seem to be generic, which is
causing inconsistencies in formats between
reports. Additionally, inconsistencies in
reports result in a big yet unstructured data
being used by the maritime agencies as well
as academia. Some of the other studies about
marine casualty investigation and CI Code
focus on limited aspects of casualty
investigation and proposal for use in local
regions (Lim, 2010). Schröder- Hinrichs
(2011) studies Accident investigation
reporting deficiencies related only to
organizational factors limited only with
machinery space fires and explosions
(Schröder-Hinrichs, 2011). Some of these
studies are centered on general casualty
investigation for a specific event, however,
these studies are not focused on the use of
the IMO casualty investigation code. For
example, Moradi et al. (2014) proposes a
fuzzy model for Iranian marine casualty
management and Fukuoka (2016) studied
the relationship between latent conditions
and the characteristics of holes in marine
accidents based on the Swiss cheese model.
Another perspective of maritime casualty
reporting is the data being publicly available
and structured such that agencies of
academia may digitally retrieve and conduct
analysis. The methodology introduced in
this paper provides a methodology of
Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
144
structuring the data and sharing the
information using a proposed form for
enabling automated processes for analysis.
With this approach, lessons learned based
on statistics from the world’s reported MOB
events may easier be driven. Therefore, this
methodology may be viewed as the first step
definition and guidance for automating the
lessons learned process for better
understanding the areas for procedural
improvements or introducing new
techniques and technologies.
The most important outcome of maritime
accident reports is the lessons learned and
sharing this outcome with maritime user’s
community and technology developers.
Weber et al. (2000), defines tasks in lessons
learned process as; collecting, validating,
storing, disseminating, and reuse. Weber et
al. (2000) lists various methods of lessons
learnt systems and proposes a system called
‘Active Lessons Delivery System (ALDS)’
(Weber et al., 2000). Such studies point out
that there is a wide range of lessons learned
processes and procedures. However, for
driving lessons learned information from
marine casualty investigations, specific
procedures and processes are yet to be
described.
The outcome of this study is the proposed
use of the form, MEI Form, which is
specific to the MOB event reports. It may be
viewed as guidance for automating the
information acquisition and formatting the
reports for driving a more structures process
for driving lessons learned from MOB
cases. World maritime investigation
agencies can also use the proposed MEI
Form as guidance in standardizing their data
collection process.
2. CURRENT METHODOLOGY
EMPLOYED IN MARITIME
ACCIDENT REPORTING
2.1. Process for Maritime Accident
Investigation Reporting Involving MOB
Events
According to IMO Maritime Safety
Committee Regulation (IMO MSC, 2008a),
a marine safety investigation report is
written as a result of a marine safety
investigation which must contain the
following specific information:
a summary outlining the basic facts of
the marine casualty or marine incident
and stating whether any deaths, injuries
or pollution occurred as a result
the identity of the flag State, owners,
operators, the company as identified in
the safety management certificate, and
the classification society (subject to any
national laws concerning privacy)
where relevant the details of the
dimensions and engines of any ship
involved, together with a description of
the crew, work routine and other
matters, such as time served on the ship;
a narrative detailing the circumstances
of the marine casualty or marine
incident;
analysis and comment on the causal
factors including any mechanical,
human and organizational factors;
a discussion of the marine safety
investigation’s findings, including the
identification of safety issues, and the
marine safety investigation’s
conclusions; and
where appropriate, recommendations
with a view to preventing future marine
casualties and marine incidents.
For further review and analysis of these
reports focusing on events involving
casualties, these reports are reviewed by
various different groups of the IMO
according to the guidelines included in a
document called Casualty Analysis
Procedure. Figure 1 shows the details of this
process. In this process, IMO Casualty
Analysis Working Group (CAWG) drives
out the following information from casualty
investigation reports (URL-4, 2019):
the analysis of casualty report
draft lessons learned for presentation to
seafarers;
potential safety issues, when
appropriate; and
draft safety recommendations, when
appropriate.
Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
145
Figure 1. Graphic Representation of a Typical Flow of Casualty Information (URL-4,
2019) (redrawn for clarity).
2.2. Investigation of Current Maritime
Safety Reports
Authors accessed to IMO’s public database,
called Global Integrated Shipping
Information System (GISIS) (URL-5, 2019),
and studied the current maritime safety
reports and relevant publications. Until
31.12.2018, there have been 3876 recorded
incidents categorized as ‘very serious’ in the
IMO database with 1603 of these incidents
having maritime safety reports. Table 1
shows the number of reports submitted to
IMO by some of the Flag States and
populated on the IMO website. The
countries with the highest submission
records are also shown. Table 1 includes
both “total number of ‘very serious
incidents’” and “with public investigation
form”, respectively, reported to IMO for the
ships under Flag of the mentioned state. As
these are involving ships with the respective
Flag State, some of these investigation
reports might be a submission by other
countries.
So far, authors found 24 ‘Lessons Learned’
documents in different formats published by
IMO in English (URL-6, 2019), 13 of which
is found published in French (URL-7, 2019)
and 15 of which is in Spanish (URL-8,
2019). However, up to date, there are 3100
reports are submitted in the GISIS website
(URL-5, 2019) This may be an indicator for
that the GISIS website could announce not
many lessons learned items, using the
current process.
For better understanding the content of
current submitted reports with MOB
involvement, authors studied and evaluated
more than 50 reports and selected seven
reports randomly among the collected
reports, Table A.1 (Appendix A) lists the
specifics about these reports and Table 2
presents an overview of these reports, as a
case study and presentation. The first 7 rows
in Table 2 include the information required
by CI Code (IMO MSC, 2008b), listed in the
previous section, and the next four rows
provide the total number of information
available in the pertaining report, shown in
the next seven respective columns. Some of
the reports included very little information,
as specified in the CI Code and listed in
Table 2; therefore, those reports were
purposely discarded for use in this study for
presentation. Table 2 gives some ideas about
total pages, what type of information
included and the total number of words used
in the reports, yet it does not provide enough
detail for what specific information and how
much detail is provided. This and several
Casualt y
Investiga tion
Reports
Summary of
Investigation
Reports s ubmitted
by Administrators
Potential Safety
Safety
Recommendation
Lessons Learned for
Presentation to
Seafarers from
Review of Reports
Issue
Potential Safety Issue
with background
information
GISIS Casualty
Database
Draft Safety
Recommendation
Supported by a Risk
Assessment
Safety Issues to be
developed by WG
Sub-committee
Casualt y Analysi s
Working Group
Casualt y Analysi s
Correspon dance
Group
IMO
Committees and
Sub-Committees
IMO Committees
and Sub-
Committees
Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
146
other issues noted when reviewing these
reports are, for example:
Report No 5 provides four
recommendations while Report No 7
provides only one.
All recommendations were for
different targets. For example, one
recommendation was for ‘the
Ministry of Health Care Services’
while several recommendations
were reminding notes on ‘Code of
Practice on Safety Standards for
Class II Vessels.
CI Code clearly states that, an
investigation report must contain,
‘where relevant the details of the
dimensions and engines of any kind
of ship involved.’ One report
provides detailed information about
the relevant engine details whereas
another report gives only engine
power and one other includes no
engine information.
Additionally, the format of the
content between the reports is
inconsistent; yet there is no tool to
identify this observation by
measurable methods.
The total number of pages used in
several reports is a few pages, i.e.
only 4 in one report, while some
other reports are more than 30 pages.
There are some reports with one or
several missing information areas.
For example, there is information in
all of them about the narrative;
however, specifying seven items in
the contents does not indicate what
detailed level of information exists.
Below is a summary of learnings that we
obtained as the outcome of this study:
i. CI Code requirement gives a general
idea about what must be the contents
of an investigation report; however,
it does not specify how the detailed
contents should be. This may be
because the investigation reports, in
practice, are about specific subjects,
such as ship accident and personal
injury during work.
ii. CI Code’s content recommendation
is not specific for the MOB events.
However, when a specific MOB
event is studied from investigation
reports, some specific information
could be very important for
understanding the procedures,
techniques, and the root causes. In
other words, these information are
essential to include to identify
tangible lessons learned items.
iii. For populating the report information
such that those can be crosschecked
through analysis tools from
databases, the MOB reports should
be structured accordingly, allowing
the reports to have consistent
formats. It would also allow
statistical analysis of reports.
Table 1. Number of Investigation Reports Submitted to IMO by Major Flag States.
Italy
Belgium
France
Japan
Turkey
Tunisia
US
Norway
Egypt
Brazil
Total very serious incidents
35
13
141
223
187
1
294
209
31
32
With public investigation form
6
4
71
50
14
0
13
18
5
8
Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
147
Table 2. Review Results of Several Accident Investigation Reports According to
Requirements of RESOLUTION MSC.255(84).
Report Number
1
2
3
4
5
6
7
Summary
-
-
Identities
Details
-
-
Narrative
Casual Factors
Discussions
-
Recommendations
-
-
Total Pages
8
8
4
17
35
33
11
Total Pages Without
Cover Page
8
4
4
14
31
31
11
Total Number of Words
(estimate)
3806
1738
1317
2433
12305
10468
4221
Percent Field Complete
(estimate)
85,70%
85,70%
42%
100%
85,70%
100%
100%
3. INVESTIGATION OF MOB EVENTS
FOR DEVELOPING THE MEI FORM
We studied the factors affecting a MOB
event to start driving the required
information that should be presented in
investigation reports involving MOB events.
Section 3.1 presents these factors with
several examples from the studied reports.
3.1. Important Factors in a MOB Event
Detailed information is needed to
understand all details associated with a
MOB event. Initially, we made the
following considerations to understand what
areas of information should be included in
the reports:
What information is already requested
by IMO
The information areas missing in the
reports for extracting lessons learned
information
Factors affecting the event is being
initiated
Factors affecting the development of the
process negative or positively
Techniques used during the response
action
Factors affecting the end result, which is
casualties survival or ending with
minimal health risks
Information to derive should be standard
such that it can be extracted and inserted
into a database with appropriate tags.
Examples below provide an understanding
of what detail level of information needs to
be included in the reports.
Example 1: During cargo operation at port,
a deck rating fell overboard resulting in a
fatality on vessel Joanna (UK Inv., 2011).
Even though there was an alcohol policy, the
analysis of postmortem blood revealed that
Stanislaw had a blood alcohol concentration
of 93mg/100ml. There was a procedure but
it was not applied properly. The casualty
was not using proper safety equipment and
there were no proper safety equipment
onboard. From this event, the following
questions were driven and added on the MEI
form:
Alcohol / Drug Influence; ‘Describes the
alcohol or drug influence of the casualty
at the time of the event.’
Working as per the safety rules; ‘Was
the work being performed as per the
safety rules and instructions?’
Workplace conditions as per the safety
rules; ‘Was the work conditions set as
per the rules and safety instructions’
Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
148
Example 2: Response actions and times are
very critical when removing the casualty
from the water. According to the report of
MOB event onboard Hyundai Dangjin
(Appendix A, Report No. 2), the casualty
was alive when seen and became not
meanwhile there was a removal procedure
continuing. To understand the details of why
the casualty could not survive, sea
temperature and time of removal of the
casualty from the water must be known, yet
this information is not found in this report.
3.2. Factors Considered for Developing
the Contents of the Proposed MEI Form
MOB event starts with the time of a person
falling overboard and ends when the MOB
response operation is terminated. There are
many factors affecting a MOB event, for
example, “how it occurred”, “how it
developed”, “how it was responded”, and
“how it was terminated”. To understand
what specific details are associated, we
reviewed over 100 reports and focused on the
details of the information. Starting with the
seven content items provided in CI Code,
we studied over 100 reports and labelled
information items with a unique code. There
became 113 information fields identified in
this study with unique codes assigned for
each information item, as presented in
section 4.
Using the evaluation of the reviewed reports
as well as listed aforementioned factors,
which are specific to MOB event
information in reports, all information that
can be found in reports was categorized as
follows:
Vessel Information
Navigation Conditions
Information about the
Casualty/Casualties
Meteorological Conditions
Work Type and Conditions
Managerial/Procedural Conditions
Start of the Event and Initial Timings
Response Times and Actions
Search and Rescue (SAR) Operation
Health Status of the Casualty
Type of Recommendations
Breakdown of the above categories yielded
in 113 information items with unique codes,
shown in the sections of the MEI form,
presented in sections below.
4. PROPOSED FORM
This section describes the contents of the
MEI Form, proposed to use by Maritime
Investigators when the investigation
involves a Man-Over-Board (MOB)
casualty. There is a group of 11 sub-
categories with 113 form items under all
categories in the proposed MEI Form. Each
item has a unique identifier, named as ‘Field
Code’, for future use in electronic form
submissions into a database. The user could
search the MEI Reports Database with the
Field Code of the specific item and do
analysis for one item or do a more complex
analysis with correlation study.
Note: For the tables presented in this section,
from table 3 to table 12, ‘NA’ means ‘Not
Applicable’ and ‘NI’ means ‘Not Indicated’
in the report.
4.1. Vessel Information
This field group is to drive information from
a report about the vessel, associated with the
MOB event at the time of the event
occurring. Table 3 shows the detailed
contents of the Vessel Information to
retrieve from reports with short descriptions
for guidance.
4.2. Navigation Conditions
This field group is for extracting the
navigation conditions under which the ship
is navigating on the sea and /or what
operations it is performing during the MOB
event. Table 4 indicates the detailed contents
of the ‘Navigation Conditions' category of
information to retrieve from reports.
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149
Table 3. Proposed MEI Form: ‘Vessel Information’ Section.
Field
Code
Field Name
Short Description /Guide
V01
Event number
Event investigation number, which is an identifier for the MOB
event.
V02
Vessel name
Name of the ship recorded during the MOB event investigation.
V03
Flag
Registered flag of the vessel.
V04
Vessel type
For example, cargo ship, passenger ship, research ship, military
ship, etc.
V04.1
Vessel
sub
category
G04.1 is a sub-category for the vessel type. For example, crude oil
tanker, container, and bulk carrier fall under cargo
ship sub
-
category.
V05
Age group
The age group of the ship’s age. Age intervals mainly are as follows:
0
-3, 4-6, 7-10, 11-15, 16-20, 21-30, 31+, or ‘NI’.
If the report does not specify, the difference between the MOB
event date and ship’s construction date is used.
V05.1
Exact age
Construction year of the vessel.
V06
Tonnage group
Gross Tonnage of the vessel, which specifies the predetermined
tonnage range of gross tonnage of the ship. Tonnage intervals are:
0
-49, 50-99, 100-299, 300-499, 500-999, 1000-1999, 2000-
2999, 3000-4999, 5000-9999, 10000-49999, and 50000+.
V06.1
Tonnage (GRT)
The exact value of the gross tonnage recorded in the ship’s registry.
V07
Length group
The following interval of the registered full length (LOA) of the
vessel, in meters: 0-11, 12-19, 20-49, 50-99, 100-199, or 200+.
V07.1
Vessel length
The registered full length (LOA) of the vessel in meters.
V08
Vessel
classification
The classification organization of the ship.
V09
Number
of
personnel
The number of personnel listed in the ship’s log at the time of the
MOB event. At ports or during anchorage, registered personnel or
passenger’s being out of the ship does not chang
e this number.
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150
Table 4. Proposed MEI Form: ‘Navigation Conditions’ Section.
Field
Code
Field Name
Short Description /Guide
N01
Navigation status
Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’ as an answer for the
following question: ‘Was the ship in navigation during the
MOB event?’
N02
Operational state
The operational status of the ship during the accident. Enter
Navigation, Port, Anchorage, Drift, Shipyard, In-
Maneuver, Other, or ‘NI’.
N03
Was the on-duty
officer
alone?
Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’. Note: Need to fill this
item if S03 is one of the following choices: Navigation,
anchorage, drift, In-Maneuver, or Other (the ship has
way?). Otherwise, enter ‘NA’.
N04
Who has the
command-in-
charge?
Indicates which one of the personnel had the responsibility of
the ship at the time of MOB event: ‘Watch keeping Officer’,
‘Ship’s Captain’, ‘Pilot’, ‘No Command’.
Note: Need to fill this item if S03 is one of the following:
Navigation, anchorage, drift, In-Maneuver, or Other (the
ship has way?). Otherwise, enter ‘NA’.
N05
Distance to the
nearest
land
The distance, in nautical miles, to the nearest land part at
the time of the event.
N06
Location
Preferably the latitude and longitude of the ship’s location.
If exact location is not available in the report, geographic
name of the location is used.
N07
Ship’s draft (m)
Draft of the vessel, in meters.
N08
Ship’s speed (knots)
Ship speed, in nautical miles (knots). Enter:
Ship speed value in knots, if the ship in navigation or
“0” is the ship is anchored or at port
4.3. Casualty Status/Information
This section provides a piece of general
information about the person(s) involved in
the MOB event according to the studied
report. It also helps to understand whether a
person was under the influence of alcohol or
drug recorded at the time of the event. Table
5 gives detailed information about casualty
and his familiarization to ship.
4.4. Meteorological Conditions
This section of the form is to extract the
environmental, especially meteorological
conditions during the MOB event. Table 6
shows very detailed information about the
meteorological conditions such as wind,
visibility, rain, etc.
4.5. Work Type and Conditions
This section of the form is to extract the
information about the work type and
conditions during the MOB event. Table 7
describes if work type and place are
compatible with safety rules.
4.6. Managerial/Procedural Conditions
This section of the form is to extract the
documentation and process-related
managerial/procedural conditions of the
vessel, indicated in the event report. Table 8
gives very detailed information about
managerial procedures and by examining
this table, the root cause can be
distinguished.
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151
Table 5. Proposed MEI Form: ‘Information about the Casualty/Casualties’ Section.
Field Code
Field Name
Short Description /Guide
C01
Rank
Enter the rank or status of the casualty on-board ship.
Captain, Deck Officer, Passenger, Other Service Personnel
are some examples. “Integrated Rating”
classification can
be entered if the casualty’s position is identified as both
deck and engine personnel.
C02
Nationality
Nationality of the casualty.
C03
Age
Age of the casualty.
C04
Overall on-board
work experience
Work experience of the casualty in years.
C05
Work duration (on-
board Ship)
Work duration on-board the current ship of the casualty,
in months.
C06
Alcohol/drug
Influence
Describes the alcohol or drug influence of the casualty at
the time of event. Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’.
Table 6. Proposed MEI Form: ‘Meteorological Conditions’ Section.
Field
Code
Field Name
Short Description /Guide
M01
Adverse weather
Information to drive the weather conditions having any adverse
effects on the MOB event. Information to consider in general
are the effect of
wind, sea waves, current, visibility,
and
temperature. Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’.
M02.1
Wind speed
Wind speed in ‘beafort scale’.
M02.2
Wind direction
Wind direction in angle, as true direction.
M03
Sea scale
Sea Scale indicating the condition of sea waves, entered in
‘beafort scale’.
M04.1
Sea current speed
Enter sea current speed in knots.
M04.2
Sea current direction
Direction of the sea current’s angle, as true direction.
M05
Rain
Indicates the existence of rain or snow conditions during the
event. Information to include rain, snow, slow rain, no rain,
etc.
M06
Visibility
Indicates the visibility recorded at the time of the event. The
information is entered as per the visibility scale from 0 to 8
or
‘NI’ is entered. If the reports states ‘normal visibility’, enter
‘6’ for a neutral visibility level.
M07
Sea temperature
Sea temperature in Celsius (°C).
M08
Air temperature
Air temperature, in Celsius (°C).
M09
Sea depth
Sea depth in meters.
M10
Darkness
Indicate the weather being ‘dark’ or ‘not dark’.
M11
Lightning conditions
Lightning conditions, recorded at the time of the event. Enter
as
follows:
Yes: Enough light conditions No: Lightning is not enough
M12
Day/night
Enter ‘Day-time’ or ‘Night-time’ if additionally indicated in
the report.
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152
Table 7. Proposed MEI Form: ‘Work Type and Conditions’ Section.
Field
Code
Field Name
Short Description /Guide
W01
Relevance to work
Information to drive whether the event was work related. Yes:
Work related event
No: Not a work related event
During transportation: Both for passengers and for employees
during their transportation to/from work.
Enter ‘NI’ if no information found in the report.
W02
Working as per the
safety rules
Was the work being performed as per the safety rules and
instructions? Fill this section
with a ‘Yes’, ‘no’, or ‘NI.
Example: The answer is ‘No’ when not wearing a life jacket
where a person ‘must’ wear, at the time of the event.
W03
Workplace conditions
as per the safety rules
Select ‘Yes’, ‘No, ‘NA or ‘NI as answer to the following q:
“Was the work conditions set as per the rules and safety
instructions?”.
Example: The answer is ‘No’ when there is no life jacket
available where there ‘must’ be, at the time of the event.
W04
Wearing a life jacket
Was the casualty wearing a life jacket (or personal floatation
aid), as recorded at the time of the event? Select ‘Yes’, ‘No’,
‘NA’ or ‘NI’.
W05
Alone
Information to understand if there was a secondary person
(other than the casualty) witnessing the event. Select ‘Yes’,
‘No’, ‘NA’ or ‘NI’.
Table 8. Proposed MEI Form: ‘Managerial/Procedural Conditions’ Section.
Field
Code
Field Name/Short
Description
Guide
P01
Applicable checklist
Is there a document requirement (checklist or form) before
the work of which the event occurred? For example, a
checklist must be filled at each time a work
will be at the
overboard. Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’.
P01.1
Checklist filled
If P01 cell is filled with a ‘Yes’, then this section is filled.
Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’.
P01.2
Checklist filled properly
If P01.1 cell is filled with a ‘Yes’, then this section is
filled. Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’ depending on
the
checklist or form fulfilled properly as per the instructions.
P02
Applicable general
work
procedures
This section is to understand whether the safety
instructions or procedures were described per the safety
manuals. Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’.
P02.1
General work
procedures implemented
properly?
Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’. Note 1: If the result of
the section P02 is a ‘yes’, then this section is to fill.
Note 2: If the result of the section P02 is other than a
‘yes’, ‘NA’ is to enter in this field.
P03
Fatigue condition
This section is to extract information from the report for
that there could be a fatigue situation involved with the
casualty. Select a Standard Answer.
P04
Implementation of
MOB drills
Was the MOB drills were carried out in required periods?
Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’.
P05
Was there a SAR
Procedure?
Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’.
P05.1
SAR
Procedure
implemented appropriately?
Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’. Fill this section only if
the result of the section P05 is a ‘yes’. Or, fill with ‘NA’.
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153
4.7. Start of the Event and Initial Timings
This section of the form is aimed to extract
information about the MOB Event’s Time
and Initiation from the event report. In other
parts of this study, this time is mentioned as
T0. All other times are given as time passed
from this moment. Table 9 gives
information related to key elements and
timings of the accident.
4.8. Response Times and Actions
This section of the form is prepared to
extract information about the initial
practices implemented for preventing a
casualty or further damage. Table 10 gives
information both if specific initial response
actions were carried out and their timings if
they were carried out.
4.9. Search and Rescue (SAR) Operation
This section of the form is targeted to drive
information about the rescue operation, as
indicated in the event report. Table 11 gives
information about both search and rescue
actions and their timings.
4.10. Health Status of the Casualty
This section of the form (Table 12) is to
extract information about the health status of
the casualty. Note that the investigator
should fill all sections of the MEI Form
separately for each casualty. Table 12 gives
detailed information related to the health
status of casualty.
4.11. Type (Category) of
Recommendation
This section of the form is generated to
extract recommendations properly from
reports. Recommendations are categorized
as ‘Human’, ‘Management’, and
‘Equipment’. The form shown in Table 13 is
used for extracting the recommendations
with categorizations.
Table 9. Proposed MEI Form: ‘Start of the Event and Initial Timings’ Section.
Field
Code
Field Name/Short
Description
Guide
M01
Date
Date of the MOB event.
M01.1
Time
Time recorded for the man become overboard. Time format
in formats, such as ZT, GMT or national time formats are all
acceptable.
M02
Action causing the
MOB event
The action casualty was performing when the MOB event
occurred. Some examples:
‘Rigging pilot ladder’, ‘engaging
in fishing’, ‘slipping’, ‘hit by waves’, ‘extreme wind’,
‘intentional’.
M03
From where?
Information about from which part of the vessel, the casualty
fall overboard. The following are the choices to enter:
‘Forecastle’, ‘Starboard bow’, ‘Starboard’, ‘Starboard
quarter’,
‘Aft deck’, ‘Port quarter’, ‘Port’, ‘Port Bow’,
‘Other’, or ‘No information’.
M04
Immediate/late
awareness
Was the MOB event seen immediately by another person?
Fill this section with an answer, namely, ‘yes’, ‘no’, or ‘NI’.
M05
Latency
Minutes passed between MOB and the time that a person
became aware of the situation.
M06
Assumed
overboard
There are cases where man-over-board event is not witnessed
but assumed with an investigation. Was the MOB event had to
be the assumed? Select ‘Yes’, ‘No’, ‘NA’ or
‘NI’.
M06.1
Decision duration
Minutes passed between the time of the actual event and the
time the MOB event had to be assumed. Enter ‘NA’ if M06
is
other than a ‘yes’.
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154
Table 10. Proposed MEI Form: ‘Response Times and Actions’ Section.
Field
Code
Field Name/
Short
Description
Guide
T01
Event notification to
the bridge
When MOB event actual time is considered to be t0, enter the
duration, in minutes, passed between t0 and the time of the event
notified to the bridge (when in navigation) or cargo
control
station (during loading/unloading).
T02.1
Alarm
Enter the duration, in minutes, passed between t0 and the time
of alarm.
T02.2
Announcement
Enter the duration, in minutes, between t0 and the time of
internal announcement.
T02.3
Whistle
Enter the duration, in minutes, between t0 and the time of
whistle.
T03
Buoy
Enter the duration, in minutes, between t0 and the time of
throwing the buoy.
T04
Maneuvering
Enter the duration, in minutes, between t0 and the time of the
start of
maneuvering
. For search and rescue events, generally
‘Williams Turn’ method is implemented. If the ship is not in
navigation, enter ‘NA’.
T05
Captain
Enter the duration, in minutes, between t0 and the time of the
ship’s captain gaining control over the situation.
T06
GPS MOB
Enter the duration, in minutes, between t0 and the GPS MOB
system’s activation time.
T07.1
Notification to close by
ships
Enter the duration, in minutes, between t0 and the time of the
notification broadcast to close by ships.
Note: If the notification to the SAR stations performed with a
VHF type general announcement, this could also be considered
as the announcement to the close by ships.
T07.2
Notification to SAR
stations?
Enter the duration, in minutes, between t0 and the time of the
notification broadcast to the Shore or SAR stations.
T07.3
Other notifications
Enter the duration, in minutes, between t0 and the time of the
notification to other organizations, such as ship operating
company.
T08
Rescue boat is ready
Enter the duration, in minutes, between t0 and the time of the
Rescue Boat is ready.
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155
Table 11. Proposed MEI Form: ‘Search and Rescue (SAR) Operation’ Section.
Field
Code
Field Name/Short
Description
Guide
R01
Rescue boat
Was there a rescue boat utilized in the MOB event?
Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’.
R02
Timing of rescue boat
in water
Duration, in minutes, between t0 and the time of the rescue
boat placed in water.
R03
Other ships
Was there other ships involving with the rescue operation?
Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’.
R04
Timing of other ships
Duration, in minutes, between t0 and the time of the other
ships joined in the rescue operation.
Note 1: If there are more than one ship joined to the
operation, the duration is for the first ship involved
Note 2: If R03 is ‘no’, fill this with ‘NA’.
R05
SAR ships
Was there SAR ships joined into the SAR operation?
SAR ships are boats designed to operate only for SAR
operations. Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’.
R06
Timing of SAR boats
Duration, in minutes, between t0 and the time of the SAR
Boat joined in the SAR
operation.
Note 1: If R05 is ‘no’, fill this with ‘NA’.
R07
Air operation
Was there Air Vehicles joined into the SAR operation?
Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’.
R08
Timing
of Air
operation
Duration, in minutes, between t0 and the time of the Air
Vehicle(s) joined in the SAR operation.
Note 1: If R07 is ‘no’, fill this with ‘NA’.
Note 2: If there are more than one air vehicle, enter the
duration for the first air vehicle.
R09
Shore assistance
Was there shore personnel or teams (such as ambulance and
medical teams) joined into the SAR operation? Select ‘Yes’,
‘No’, ‘NA’ or ‘NI’. Note: Enter ‘NA’ if the ship is
not in
port.
R10
Timing of shore
assistance
Duration, in minutes, between t0 and the time of the Shore
Assistance started in SAR
operation.
Note 1: If R09 is ‘no’, fill this with ‘NA’.
Note 2: If there are more than one team or person, enter the
duration for the first team joined into the SAR operation.
R11
Casualty removed
from the water
Was the casualty removed from water (regardless of
survival status)? Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’.
R12
Removed by
Enter the team or personnel removed the casualty from
water. Fill this item if R11 is ‘yes’ or fill with ‘NA’.
R13
Timing of removal
Duration, in minutes, between t0 and the time of the
casualty was removed.
Note: Fill this item if R11 is ‘yes’ or fill with ‘NA’.
R14
Cancellation of the SAR
operation
Enter the reason which cancelled the SAR operation other
than ‘removal’ of the casualty from water. Examples are:
S
hore authorities command/order
Ship decision
Heavy weather conditions Other
No info
R15
Duration, cancellation of
the SAR operation
Duration, in minutes, between the start and cancellation
time of the SAR operation.
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156
Field
Code
Field Name/Short
Description
Guide
R16
Limited Sighting of the
Casualty in Water
Was there eye watch of the casualty, after the MOB,
meanwhile the casualty in the water, for a limited time?
Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’.
R17
Duration, limited sighting
of
the casualty in the
water
Duration, in minutes, of the casualty was under eye watch.
Enter a value if R16 is a ‘yes’ or enter ‘NA’.
R18
Uninterrupted sighting of
the
casualty in water
Was there a continuous eye watch of the casualty until the
end of the MOB operation? Select ‘Yes’, ‘No’, ‘NA’ or
‘NI’.
Table 12. Proposed MEI Form: ‘Health Status of the Casualty’ Section.
Field
Code
Field
Name/Short
Description
Guide
H01
Death
Enter the status of the casualty (Did the casualty die?).
Fill this section with: ‘yes: Death’, ‘no’, ‘NA’, or ‘NI’.
H01.1
Witnessing death
Was the death identified through a medical check, such as
controlling the pulse or with a similar method?
Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’.
H01.2
Decision for death
Was the death of the casualty the result of a decision,
considering the conditions, such as seawater temperature,
waves, during the operation?
Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’. Note: If the casualty could
not be found, as per the
report, select ‘Decision for
Death’.
H01.3
Timing of death
Was the death before or after the end of SAR operation? Fill
this section with a ‘before’, ‘after’, ‘missing/assumed
death’, ‘NA’, or ‘NI’.
H02
Cause of death
Fill this section if H01 is a ‘yes’ or, enter ‘NA’. Some
examples to enter are ‘hypothermia’, ‘cardiac arrest’, ‘head
injury’, ‘drowning’.
H03
Duration until death
Duration, in minutes, between t0 and the time of death. Fill
this section with a ‘yes’, ‘no’, ‘NA’, or ‘NI’.
Note 1: If
the report does not include this information, use
the information in the death announcement.
Note
2: If the casualty could not be found or not taken from
the sea, enter ‘not clear’.
H04
Rescue to death timing
Duration, in minutes, between the time of rescue and time of
casualty’s death.
Note
1: Fill this section only if both H01 and R11 are ‘yes’.
Note 2: If the report does not include this information, use
the information from the death announcement.
H05
First aid
Was there a first aid needed? Select ‘Yes’, ‘No’, ‘NA’ or
‘NI’.
H05.1
Duration MOB to first aid
Duration, in minutes, passed between the MOB and first aid
given.
Note 1: Fill this section only if H05 is ‘yes’ or enter ‘NA’.
H05.2
Duration rescue to first aid
Duration, in minutes, passed between the times of rescue of
the casualty to the first aid started.
Note 1: Fill this section only if both H05 and R11 are ‘yes’
or enter ‘NA’.
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157
Field
Code
Field Name/Short
Description
Guide
H06
First Aid at or by the
medical
facility (Shore
side)
Was there a first aid performed by the medical care
personnel (shore based), i.e. at an ambulance, hospital or at
a health
center? Select ‘Yes’, ‘No’, ‘NA’ or ‘NI’.
H06.1
Duration, time passed until
first aid given by at or by an
established medical facility
(shore side)
Duration, in minutes, passed between MOB time and time of
first aid given by shore side medical care personnel. Enter
‘NA’ if H06 is not a ‘yes’.
Table 13. Proposed MEI Form: ‘Type of Recommendation’ Section.
Field
Code
Field
Name/Short
Description
Guide
L01
Existence of
Recommendation
Fill this section with a ‘yes’ or ‘no’.
L02
Number of
Recommendation
Enter the number of recommendations indicated.
L03
Recommendation Cat I
Enter ‘yes’ if there is a recommendation in ‘Human’
category
Enter ‘no’ if there is no such recommendation.
‘Yes’ would indicate at least one recommendation is
made in this category.
L03.1
Content of Rec Cat I
Enter all recommendations as indicated in the report in
‘Human’ Category’.
L04
Recommendation Cat II
Enter ‘yes’ if there is a recommendation in
‘Management’ category
Enter ‘no’ if there is no such recommendation.
‘Yes’ would indicate at least one
recommendation is
made in this category.
L04.1
Content of Rec Cat II
Enter all recommendations as indicated in the report in
‘Management’ Category.
L05
Recommendation Cat II
Enter ‘yes’ if there is a recommendation in
‘Equipment’ category
Enter
‘no’ if there is no such recommendation.
‘Yes’ would indicate at least one recommendation is
made in this category.
L05.1
Content of Rec Cat II
Enter all recommendations as indicated in the report in
‘Equipment’ Category.
5. BENEFITS OF USING THE MEI
FORM
Appendix A shows the use of the MEI Form
for extracting information from three different
Investigation Reports. List of these three
reports are as follows:
We noted benefits while implementing the
MEI Form for these reports. This section
summarizes the benefits of using the MEI
Form with standard content and format,
allowing the data from MOB investigations
populated in a database, called the MEI
database.
We were able to populate information from
over 50 investigation reports with MOB
events and derived many results. This paper’s
focus is to describe the MEI Form and discuss
Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
158
the benefits; therefore, some of the benefits
observed during this analysis and research
study are reported and discussed in sections
below. Further discussion on the analysis
results will be issue of another report paper.
5.1. Obtaining Statistical Data
Using standard fields in digital forms
populated in a database, statistical data can
easily and accurately be driven. As an
example, according to data provided by the
Boat Owners Association of the United States
Reports, U.S. boating MOB events between
2003 and 2007 (Edmonston, 2012):
In deaths from MOB events occurring
during day times, the rate of the casualties’
being under the influence of alcohol was
27 percent. Whereas, the same rate was
found as 50 percent at night times.
90 percent of events occurred in low
weather conditions with wave height is
less than one feet.
24 percent of the deaths were at night and
76 percent were during the day.
Academia and industrial researchers can
easily generate similar statistical results using
the data from a global perspective.
Additionally, several parameters between the
information across all reports could be
analyzed for more elaborated statistical
evaluations.
5.2. Providing Useful Data for Obtaining
Lessons Learned
Very few of the current reports provide some
lessons learned information which IMO Sub-
committees are then can review and evaluate.
However, the statistical results using the data
can provide direct information as ‘lessons
learned’. For example:
Alcohol has a very high (27 percent at day
time, 50 percent at night time) in MOB
casualties in boating events
Influence of alcohol in MOB casualties at
night time is nearly twice (1,852 times) a
day.
A great percentage (90 percent) of events
occur in favorable weather conditions
(wave height being less than 1 feet).
As well as providing useful data for obtaining
lessons learned, standardized and digitized
forms provide exact numbers and data instead
of generic numbers.
5.3. Better Understanding of the Root
Cause
In the MOB event of Graig Rotterdam,
casualty fell overboard when cargo at deck
collapsed. There was an applicable checklist
titled; ‘Refer to Log & Timber Cargo
Operations Checklist’. The checklist was
filled by the chief officer and verified by the
master but no control measures were taken
and the requirements of the checklist were
matched. When the information is extracted
from this report using the MEI Form, P01,
P01.1, and P01.2 are the applicable fields and
while extracting the information, the process
is shown in Figure 2. To better understand this
process, below mentioned three questions are
taken from the proposed MEI form:
P01 Applicable checklist; was there a
document requirement (checklist or form)
before the work of which the event
occurred?
P01.1 Checklist filled; if P01 cell is filled
with a ‘Yes’, then this section is filled with
a ‘yes’, ‘no’, ‘NA’, or ‘NI’
P01.2 Checklist filled properly; if P01.1
cell is filled with a ‘Yes’, then this section
is filled. Fill this section with a ‘yes’, ‘no’,
‘NA’, or ‘NI’ depending on the checklist
or form fulfilled properly as per the
instructions.
Answers of these three questions are enough to
distinguish that the root cause of this event is a
human factor or managerial issue.
Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
159
Figure 2. Methodology Applied for Extracting the Data related to Checklists
5.4. Correlation between Relevant
Parameters in a Report
From data mentioned above ‘Obtaining
Statistical Data’ title, 24 percent of the deaths
were at night time and 76 percent were during
the day time. In order to drive this sort of
information and to find out the factors
affecting the event, many questions are
required to be asked and analyzed for
relevance to see if the relationship is
coincidental or actual.
Using the MEI Form data applied to 50 MOB
event reports, the following statistical results
were obtained: 36.7 percent of the casualties
were alone and 63.3 percent of the casualties
were not alone at the time of the MOB event.
In the MEI Form, P03 under
‘Managerial/Procedural Conditions’, fatigue
condition is specifically indicated. According
to this, in 85 percent of the events, fatigue was
not an issue.
5.5. Automating the Lessons Learned
Process
Although the MEI Form does not directly
cover a ‘Lessons Learned’ section, the
relational topics to ‘Lessons Learned can
easily be generalized and information
extracted from the reports via categorizations.
Designing a database architecture considering
the categories of the lessons learned could
improve the current Lessons Learned process
of the IMO, shown in Figure 1. The use of the
MEI Form and process described in this paper
helps bring lessons learned from five studies
that could be performed on the reports
populated in the MEI Database (Figure 3).
Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
160
Figure 3. Methodology of MOB Reports Data Retrieval, Formatting, and Analysis
Process.
6. CONCLUSIONS
More than 50 reports, involving MOB
accident data, were reviewed. Reviewed
reports indicated major differences in formats
as well as in the level and type of information.
A structured methodology was developed and
presented for reviewing and retrieving the
data systematically from MOB event reports.
As part of this process, a standard form, called
the MEI Form, is introduced. The MEI Form,
with 113 information items, is presented with
how to retrieve the information as a standard
process. Several case examples are presented
to demonstrate the standard use of the MEI
Form including how to format, populate, and
analyze the data.
Having the data investigated using the MEI
Form showed a structured methodology for
populating all MOB related maritime
accidents digitally with a unique format. We
propose the use this methodology to maritime
investigating agencies in order to utilize the
MEI Form. With this manner, structured data
can be compared and consistently analyzed,
which enables to drive measurable and usable
“lessons learned” information and
“recommendations”. Data can be populated
into the IMO websites for community use.
Case examples also demonstrated how to
perform the root cause analysis as well as how
to retrieve the “lessons learned” items using
the proposed methodology.
The use of the MEI Form for obtaining the
statistical analysis results may be automated
and the results may directly help areas to
identify as for the improvements in, for
example:
MOB procedures
Innovative technologies to utilize for
detecting the event, preventing it from
happening, or minimizing the risk level to
the casualty before, during or after the
MOB event respectively
Analyzing one or several parameters for
allowing lessons learned information
gathered from analysis results
Casualty Investigation Code, which is
adopted to set international standard for
conducting the safety investigations and
reporting is;
Very generic
Does not offer use of a specific method for
analyzing root cause
Does not guide key elements to be
included
Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
161
As a result of preparing these forms with the
guidance of this generic code, serious
inconsistences is observed in reports
published by different agencies. To avoid
these inconsistences, code must include;
A specific approved method for analyzing
root cause
Minimum information required to drive
root cause and lessons learnt.
Format of investigation report
Information required to acquire statistical
data to analyze maritime accidents.
Benefits of using a common form when
investigating maritime accidents and
publishing these investigation reports are;
Preparing a digital database instead
Obtaining cross-check data between
different factors
Obtaining serious data to create
simulations
If a digital database is prepared and enough
data is collected, simulation scenarios may be
established. As an example; a survivability
simulation of a casualty that is immersed in
cold water can be prepared if enough cross-
check data is acquired. From such simulations
very important data can be acquired to
improve response methods. The data
collection and data analysis are important
issues for future research on MOB casualties.
In future investigations, it might be possible to
use big scale data sets. Therefore, a further
study with more focus on big data analysis for
MOB casualties is therefore suggested.
7. REFERENCES
URL-1, IMO-SOLAS regulation I/21. IMO Casualties
Page, (2019). Accessed Date: 17/03/2019,
http://www.imo.org/en/OurWork/MSAS/Casualties/Pa
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URL-2, Maritime Pollution Act (MARPOL). IMO
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ges/Default.aspx.
Contracting Governments, (1966). International
Convention on Load Lines (LL Convention). Article
23, London.
United Nations, (1982). Convention on the Law of the
Sea (UNCLOS). Article 94, Jamaica.
IMO MSC, (2008a). IMO Maritime Safety Committee,
84th session, pp. resolution MSC.255(84), revoking
resolutions A.849(20) and A.884(21).
ILO, (2006). International Labour Conference
Maritime Labour Convention, Regulation 5.1.6
Marine casualties.
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Organization, (2019). Accessed Date: 12/03/2019,
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IMO MSC, (2008b). Code of International Standards
and Recommended Practices for a Safety Investigation
into a Marine Casualty or Marine Incident (Casualty
Investigation Code), Resolution MSC.255 (84).
URL-4, IMO FSI Casualty Analysis Procedure (CAP),
(2019). Accessed Date: 15/03/2019,
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LYSIS%20PROCEDURE.pdf.
Gano, D.L. (2007). Comparison of common root cause
analysis tools and methods. Apollo Root Cause
Analysis-A new way of thinking. Apollonian Publ.
Arslan, O., Güler, N., (2011). Kimyasal tanker
işletmeciliği için stratejik yönetim modellemesi. ITU
Dergisi, 10.
Kececi, T., Bayraktar, D., Arslan, O., (2015). A ship
officer performance evaluation model using fuzzy-
AHP. Journal of Shipping and Ocean Engineering 5:
26-43.
Akyuz, E., Celik, M., (2014a). Utilization of cognitive
map in modelling human error in marine accident
analysis and prevention. Safety science 70: 19-28.
Akyuz, E., Celik, M., (2014b). A hybrid decision-
making approach to measure effectiveness of safety
management system implementations on-board ships,
Safety Science 68: 169-179.
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Lim, C.H., (2010). A Study on the Introduction of IMO
Casualty Investigation Code and Marine Safety
Investigation System in Korea. Journal of the Korean
Society of Marine Environment & Safety 16: 57-63.
Schröder-Hinrichs, J.U., Baldauf, M., Ghirxi, K.T.,
(2011). Accident investigation reporting deficiencies
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43: 1187-1196.
Moradi, A., Etebarian, A., Shirvani, A., Soltani, I.,
(2014). Development of a fuzzy model for Iranian
marine casualties management. Journal of Fuzzy Set
Valued Analysis 1: 1-17.
Fukuoka, K., Furusho, M., (2016). Relationship
between latent conditions and the characteristics of
holes in marine accidents based on the Swiss cheese
model. World Maritime University Journal of Maritime
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Weber, R., Aha, D.W., Muñoz-Ávila, H., Breslow, L.
A., 2000. An intelligent lessons learned process.
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https://gisis.imo.org/Public/MCI/Search.aspx.
URL-6, Our Work: Lessons learned English, (2019).
Accessed Date: 12/03/2019,
http://www.imo.org/en/OurWork/MSAS/Casualties/Pa
ges/Lessons- learned.aspx.
URL-7, Our Work: Lessons Learned French, (2019).
Accessed Date: 12/03/2019,
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Alongside in Glasgow, Scotland, Rpt No 8/2011, 13
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Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
163
APPENDIX A: Investigation Reports
Table A.1. Reports Selected for Reviewing their Contents as per the Requirements of
RESOLUTION MSC.255(84).
#
Ship Name
Publishing
Agency
Flag State
Report Name
Report Date
1
Forth
Guardsman
MAIB Marine
Accident
Investigation Branch
UK
Fatal injuries to a crewman during
mooring operations on FORTH
GUARDSMAN
South of Jura
September
2011
2
Hyundai
Dangjin
Australian Transport
Safety
Bureau
Australia
Man overboard fatality from
Hyundai Dangjin
19 January 2016
3
Federal
Champlain
The Transportation
Safety Board of
Canada
Canada
Marine Transportation Safety
Investigation
Report M17C0292
06 September
2018
4
Kwong Fei
38
Marine Accident
i
nvestigation Section
Hong Kong
Report of investigation into the
fatal accident of a sailor fell
overboard a local dumb lighter
“Kwong Fei 38” and drowned in
the waters east of Round Island on
13 January
2017
20 July 2018
5
Ribeye 785
Accident
Investigation Board
Norway
REPORT ON MARINE
ACCIDENT
RIB, FALL OVER
BOARD
IN OLDEN 22 JULY
2015
March 2017
6
Skawlink III and
Nord
Gardenia
The Danish Maritime
Accident
Investigation
Board
Denmark
2017SKAWLINK III and NORD
GARDENIA
Fall
overboard on 29
September 2016
11 May 2017
7
MV MSC
Ravenna
Marine Safety
Investigation
Unit
Malta
MV MSC RAVENNA Fatal fall
overboard of a crew
member in
the
port of M’Xlokk
22 June 2017
June 2018
Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
164
APPENDIX B: Case Studies for Use of the MEI Form
This appendix show these of the MEI Form with three example reports as shown in Table
B.1 to Table B.12. The report examples shown in Table B.1 to B.12 are the first three
reports shown in Table A.1 in respective order.
Table B.1. Vessel Information
Code Field Name Report 1 Report 2 Report 3
V01 Event Number
1 2 3
V02 Vessel Name Forth Guardsman
Hyundai Dangjin
Federal
Champlain
V03 Flag British Liberia Marshall Islands
V04 Vessel Type
Commercial
(Other)
Cargo Ship Cargo Ship
V04.1 Sub Category Landing craft NI Bulk Carrier
V05 Age Group 21-30 0-3 NI
V05.1 Exact Age 28
3
NI
V06 Tonnage Group 500-999 50000+ NI
V06.1 Tonnage (GRT) 654 132587 NI
V07 Length Group 20-49 200+ NI
V07.1 Vessel Length 48.46 329.95 NI
V08 Vessel Classification None
Nippon Kaiji
Kyokai
NI
V09 Number of Personnel
6
NI NI
Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
165
Table B.2. Navigation Conditions
Code Field Name Report 1 Report 2 Report 3
N01 Navigation Status No No No
N02 Operational State In-Maneuver Port Port
N03
Was Duty Officer
Alone?
No NA NA
N04
Who has the Command-
in-Charge?
Ship’s Captain NA NA
N05 Distance to Nearest Land
0
0
0
N06 Location
55°47.4’N
006°01.3W
20° 35.33’ S
117° 10.50’ E
Thunder Bay
Terminals
N07 Ship’s Draft (m) NI NI 8,08
N08 Ship’s Speed (knots)
0
0
0
Table B.3. Casualty Status / Information
Code Field Name Report 1 Report 2 Report 3
C01 Rank Deck Rating Deck Officer Deck Officer
C02 Nationality Polish NI NI
C03 Age 47 NI NI
C04
Overall Work Experience
(On- board)
NI NI NI
C05
Work Duration (On-
board Ship)
18 months NI NI
C06 Alcohol / Drug Influence NI NI NI
Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
166
Table B.4. Meteorological Conditions
Code
Field Name
Report 1
Report 2
Report 3
M01 Adverse Weather Yes Yes Yes
M02.1 Wind Speed 6 (Beaufort) 3-4 (Beaufort)
0
M02.2 Wind Direction NNE NI Calm
M03 Sea Scale 3.Nis NI
0
M04.1 Sea Current Speed NI NI NI
M04.2 Sea Current Direction NI NI NI
M05 Rain No NI No
M06 Visibility NI NI
6
M07 Sea Temperature
8
22 -2
M08 Air Temperature NI NI -12,1
M09 Sea Depth NI NI NI
M10 Darkness Yes NI NI
M11 Lightning Conditions Yes NI NI
M12 Day/Night Night NI NI
Table B.5. Work Type and Conditions
Code Field Name Report 1 Report 2 Report 3
W01 Relevance to Work Yes Yes Yes
W02
Working as per the safety
rules
No No NI
W03
Workplace conditions as
per the safety rules
No Yes NI
W04 Wearing a Life Jacket No Yes No
W05 Alone No No No
Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
167
Table B.6. Managerial/Procedural Conditions
Code Field Name Report 1 Report 2 Report 3
P01
Applicable checklist
Yes
No
NI
P01.1
Checklist filled
Yes
NA
NA
P01.2
Checklist filled properly
No
NA
NA
P02
Applicable general work
procedures
No
No
NI
P02.1
General work procedures
implemented properly
NA
NA
NA
P03
Fatigue condition
NI
NI
NI
P04
Implementation of MOB
drills
NI
NI
NI
P05
Was there a SAR
Procedure?
NI
NI
NI
P05.1
SAR Procedure
implemented
appropriately?
NA
NA
NA
Table B.7. Start of the Event
Code Field Name Report 1 Report 2 Report 3
M01 Date 13.03.2011 10.07.2015 8.12.2017
M01.1 Time 1912 458 1950-2008
M02
Action causing the MOB
event
Impact of rope
Reading Draft
Marks
Reading Draft
Marks
M03 From Where Starboard Bow Port Port
M04
Immediate/Late
Awareness
Yes Yes Yes
M05 Latency NA NA NA
M06 Assumed Over Board No No No
M06.1 Decision Duration NA NA NA
Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
168
Table B.8. Response Times and Actions
Code Field Name Report 1 Report 2 Report 3
T01
Event Notification to the
Bridge
1-2
1
0
T02.1 Alarm 1-2 14 1-18
T02.2 Announcement 1-2 14-22 2-20
T02.3 Whistle No No No
T03 Buoy 1-2
1
0
T04 Maneuvering No NA NA
T05 Captain
0
2-4
0
T06 GPS MOB NA NA NA
T07.1
Notification to Close by
ships
2
No No
T07.2
Notification to SAR
Stations?
No No No
T07.3 Other Notifications No 22-42 6-37
T08 Rescue Boat is Ready 4-9 No 6-24
Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
169
Table B.9. Search and Rescue (SAR) Operation
Code Field Name Report 1 Report 2 Report 3
R01 Rescue Boat No No Yes
R02
Timing of Rescue Boat
In Water
NA NA 6-24
R03 Other Ships Yes No Yes
R04 Timing of Other Ships 11-20 NA 6-37
R05 SAR Ships Yes No No
R06 Timing of SAR Boats NI NA NA
R07 Air Operation Evet No No
R08 Timing of Air Operation 49-72 NA NA
R09 Shore Assistance No Yes No
R10
Timing of Shore
Assistance
NA 22 NA
R11
Casualty Removed from
the Water
Yes Yes Yes
R12 Removed by
Ship's crew and
other ship crew
Ship crew Other ship crew
R13 Timing of Removal 11-20 14-22 8-37
R14
Cancellation of the SAR
operation
NA NA NA
R15
Duration, Cancellation of
the SAR operation
NA NA NA
R16
Limited Sighting of the
Casualty in Water
No
No NI
R17
Duration, Limited
sighting of the casualty
in the Water
NA NA NA
R18
Uninterrupted Sighting
of the Casualty In Water
Yes Yes NI
Gonel and Cicek, Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170
170
Table B.10. Health Status of the Casualty
Code Field Name Report 1 Report 2 Report 3
H01 Death Yes Yes No
H01.1 Witnessing death Yes Yes NA
H01.2 Decision for death No No NA
H01.3 Timing of Death After Later NA
H02 Cause of Death Trauma (chest) NI NA
H03 Duration until Death 120 67 NA
H04 Rescue to Death Timing 100-109 45-53 NA
H05 First Aid Yes Yes NI
H05.1
Duration MOB to First
Aid
1.Eyl 14-22 NA
H05.2
Duration Rescue to First
Aid
Kas.20 1.Ağu NA
H06
First Aid at or by the
Medical Facility (Shore
Side)
Yes No Yes
H06.1
Duration, time passed
until First Aid given by
at or by the Medical
Facility (Shore Side)
72-120 NA 19-37
Table B.11. Type of Recommendation
Code Field Name Report 1 Report 2 Report 3
L01
Existence of
Recommendation
No No No
L02
Number of
Recommendation
0 0 0
L03 Recommendation Cat I No No No
L03.1 Content of Rec Cat I NA NA NA
L04 Recommendation Cat II No No No
L04.1 Content of Rec Cat II NA NA NA
L05 Recommendation Cat II No No No
L05.1 Content of Rec Cat II NA NA NA
... • MOB Event Investigation (MEI) Report Format: This part of the study was completed by the authors and already published (Gonel, O., Cicek, I., 2019). This subsection summarizes the format for using in this article (Section 2.1). ...
... Therefore, flag states must prepare accident or incident reports and share findings as mandated by these international agreements. The United Nations convention (United Nations, 1982) clearly states that flag states are required to carry out an inquiry for the ships sailing under their flag in open seas (Gonel, O., Cicek, I., 2019). ...
... Refer to this paper for the detail description of the associated parameters as well as the details of the methodology. In summary, the 113 parameters were grouped in the following 11 categories used in this article (Gonel, O., Cicek, I., 2019). ...
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The marine safety investigation inquires and concludes the facts and causes of the marine casualties and incidents with the objective of preventing similar roses in the future. Thus, IMO and most states adopt and revise marine safety related conventions and national laws based on the results of marine safety investigation. In particular, IMO recently adopts mandatory IMO Casualty Investigation Code to identify the precise cause of rose with states' cooperation, to report the result of investigation, and to establish new international safety standard helping prevention of similar cases based on the report. The Judgement of the Korean Maritime Safety Tribunal system based on the 'Act on the investigation of and inquiry into marine accidents' is used for the purpose of marine safety investigation in Korea to prove cause of marine accident and to improve marine safety. Therefore, this study examines the Code and compares the Code with the Act to reflect the contents of provisions in the Code into the Act. The study would also be the basic references in relation to revising of marine safety investigation system in Korea Specially, the contents in relation to the independence of investigation authority and mandatory counselling system, and guarantee of seafarers human rights to ensure fairness of investigation would be included.
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Careful accident investigation provides opportunities to review safety arrangements in socio-technical systems. There is consensus that human intervention is involved in the majority of accidents. Ever cautious of the consequences attributed to such a claim vis-à-vis the apportionment of blame, several authors have highlighted the importance of investigating organizational factors in this respect. Specific regulations to limit what were perceived as unsuitable organizational influences in shipping operations were adopted by the International Maritime Organization (IMO). Guidance is provided for the investigation of human and organizational factors involved in maritime accidents. This paper presents a review of 41 accident investigation reports related to machinery space fires and explosions. The objective was to find out if organizational factors are identified during maritime accident investigations. An adapted version of the Human Factor Analysis and Classification System (HFACS) with minor modifications related to machinery space features was used for this review. The results of the review show that organizational factors were not identified by maritime accident investigators to the extent expected had the IMO guidelines been observed. Instead, contributing factors at the lower end of organizational echelons are over-represented.
Fatal Man Overboard from Joanna
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Sobering MOB Facts, Boat Owners Association of the United States, Boat US Magazine
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Edmonston, C., (2012). Sobering MOB Facts, Boat Owners Association of the United States, Boat US Magazine. October-November 2012, pp. 62, Alexandria, USA.