American Marine
Insurance Forum
LCDR Bill Grossman
Chief, Investigations Division
(718) 354-4240
CG Investigative Process & analysis
Generate Timeline:
Collect Facts
Determine Sequence of
Facts
Conclusions &
Recommendations
Classify Facts:
Action
Condition
Event
Conduct Causal
Analysis
*Initiating Event
Subsequent(s)
*First unwanted
event or negative
outcome in a timeline.
Id unsafe LUC
conduct Human Error
Analysis
Mis-Action or decision
taken in the presence
of a hazard.
Violation Analysis
Misconduct
Violation Law or
Regulation
Negligence
Incompetence
Drug Use
Introduction
The Secretary shall prescribe regulations for the
immediate investigation of marine casualties
under 46 U.S. Code or decide as closely as
possible:
• The cause of the casualty, including the cause
of any death;
Introduction
• Whether an act of misconduct, incompetence,
negligence, unskillfulness, or willful violation
of federal law committed by any licensed
individual (including an officer, employee or
member of the Coast Guard), may have
contributed to the cause of the casualty.
Introduction
• Whether there is need for new laws or
regulations, or amendment or repeal of
existing laws or regulations, to prevent the
recurrence of the casualty.
What is a Marine Casualty??
Examples:
• Collision, Allision, Groundings, Stranding
• Fires, Explosions
• Failure or occurrences (regardless of cause) which impair
ANY aspect of a vessels operation, components or cargo
• Any damage affecting or impairing seaworthiness of a vessel
• Any fall overboard, injury, or loss of life
• Any injury or loss of life while diving from a vessel using
underwater breathing apparatus
Determining Cause
Generating a Timeline
The most basic element of conducting a
marine investigation is telling the story of
what happened. During the initial stages of
every investigation, marine investigators
should gather and record all the facts that
may assist in determining causes.
Classification of Information
• Classification
– Factual information that is gathered will be
classified into three category types
• Actions (things people do)
• Events (that happen to people & things)
• Condition (existing circumstances)
Analyzing Cause
• Identify the Initiating Event – The first
unwanted or negative outcome in the timeline
• Identify Active Failures – Unsafe acts and
decisions committed in the presence of a hazard
SHEL Model
• Using the SHEL Model
H
– The scope of any investigation may
be divided into four areas:
• Software: The information and
support systems guiding people
• Hardware: The vessels,
facilities, machinery, cargo,
equipment, and materiel people
work with
• Environment: The internal and
marine environment in which
people work
• Liveware: The people
themselves
S
L
L
E
How Systems Operate
• Model of Production
–
–
–
–
–
Organization
Workplace
Pre-Conditions
Production/Line Workers
Defenses
How Systems Fail
• Two Categories: Active Failures & Latent
Unsafe Conditions (LUC)
– Active Failures are unsafe acts or decisions committed
in the presence of a hazard (condition)
– LUCs are hazardous conditions in the system that lie
dormant, only becoming dangerous with an unsafe act or
decision
How Systems Fail
Marine Transportation
System
• ID foreseeable threats
• Create defenses
• Minimize negative
outcomes
Model of Human Performance
• Dr. Rasmussen identified three levels of
human performance: (SRK)
– Skill-Based Performance (SB)
– Rule-Based Performance (RB)
– Knowledge-Based Performance (KB)
Dr. Reason GEMS MODEL
BASIC
ERROR
TYPES
SLIP
UNINTENDED ACTION
(Execution Error)
Skilled Based Attention
Failures
Intrusions
Omissions
Reversal
Misordering
Mistiming
Skilled Based
Memory Failures
LAPSE
Unsafe Act
or
Decision
MISTAKE
Omitting planned items
Place-Losing
Forgetting Intentions
Rule Based Mistakes
(Learned)
Misapplication of a good rule,
Application of a bad rule
Heursitc
Bais
INTENDED ACTION
(Planning Error)
Knowledge Based Mistakes
(Experience)
Many variable forms
VIOLATION
Routine Violations
Exceptional Violations
Acts of Sabotage
Safety Recommendations
• Propose corrective actions for identified
latent unsafe conditions or other unwanted
outcomes
• May be made to address any latent unsafe
condition identified during an incident
investigation
Safety Alerts
• Quickly advises the public of
conditions that, if left
unaddressed, pose an
immediate treat to safety.
– Propose voluntary actions for
elimination or mitigation of
those threats
In Conclusion
• The ultimate goal of the USCG following a
marine casualty is PREVENTION!
• Through the notification process we will
determine the level of investigative effort
that is required and if preventive measures
can/should be implemented.
Questions?