Investigation Procedures

Decision Guidelines for Accident/Incident Categorisation

The ATSB is resourced each year to undertake a finite number of marine investigations. It is acknowledged, however, that an occurrence with a large number of passenger fatalities or which results in major pollution of the Great Barrier Reef or other sensitive area would represent a major accident that may require supplementary funding.

In categorising marine transport safety matters and selecting which of those the ATSB should investigate, the decision-makers must consider:

1. The potential safety value that may be gained by conducting an investigation;
2. Obligations under international conventions;
3. Recommendations stemming from IMO Assembly resolutions and Committee circulars;
4. The public profile of the occurrence;
5. Whether the occurrence is part of an identifiable trend;
6. The extent of resources available and projected to be available in the event of conflicting priorities and the extent of any investigation backlog;
7. Any risks associated with not investigating; and
8. The requirement under s21(2) of the TSI Act for the Executive Director to publish reasons (justification) for discontinuing an investigation where an investigation has already commenced.

The following broad hierarchy should also be taken into account when making the decision to initiate and categorise an investigation:

1. On-board fatalities and/or serious passenger injuries;
2. The pollution of environmentally sensitive areas;
3. Ships subject to significant structural damage;
4. Occurrences which disrupt, or have the potential to disrupt, major port operations; and
5. Occurrences that do not involve any of the above, but where the requirements of the International Safety Management Code may reasonably be anticipated to have been breached.

The decision to investigate will also have regard as to whether, in the absence of an ATSB investigation, a credible safety investigation by another organisation is likely.

In view of these considerations, initiation of a formal ATSB investigation can only be made at or above Team Leader level after discussion and agreement with the Deputy Director and/or Director and Executive Director. Each investigation will be categorised on a scale of 1 5 (see below).

Following the initial assessment of a marine transport safety matter a decision will be made whether or not to conduct a field investigation. Unless otherwise agreed by the Executive Director, all occurrences will initially be categorised at level 4. Subsequently an investigation may be upgraded or downgraded. The decision to upgrade (and commit extra resources) or to downgrade must be made at Deputy Director level or above after discussion with the Director and/or Executive Director. Any decision to discontinue an investigation must be endorsed by the Executive Director.

In assessing initial and developing action on any marine investigation due regard shall be had to the IMO requirements relating to reports on marine casualties and incidents, MSC Circ.953/MEPC Circ 372. This circular outlines the IMO reporting requirements, based on very serious, serious and less serious casualties and incidents.

For the purpose of reporting information to the Organisation, ship casualties are classified as "very serious casualties", "serious casualties", "less serious casualties" and "marine incidents". Administrations are requested to submit data for all "very serious casualties" and "serious casualties"1.

Where there are important lessons to be learned from "serious casualties", "less serious casualties" and "marine incidents", full investigation reports should be submitted along with the additional information indicated in annex 3.

Level 1

• An accident involving one or more ships resulting in large scale fatalities.

Level 2

• An accident involving major pollution of an area of recognised environmental sensitivity such as the Great Barrier Reef.
• The total loss of an Australian ship with loss of life.
• An accident involving multiple fatalities.

Level 3

• An accident involving one or more vessels involving a fatality or serious injury.
• An accident involving one or more vessels that resulted in pollution of the marine environment or potential pollution of an area of particular environmental sensitivity.
• A failure of a structural member of a ship so as to render the ship unseaworthy.
• The loss, presumed loss, or abandonment of a ship.
• A collision between two ships so that the watertight integrity of one or both vessels is compromised.
• Fire aboard a ship that compromises the seaworthiness of a ship.
• The failure of the main engine, steering gear, or electrical generating system that renders the ship disabled, requiring external assistance to bring the ship to a place of safety.

Level 4

• Collision of a ship with another ship or fishing vessel where the damage to either vessel is significant. An accident involving one or more vessels without fatalities or serious injuries and without substantial property damage where investigation is likely to contribute to mitigating future accidents.
• A ship stranding or grounding.
• Fire aboard ship where the seaworthiness of the ship is not affected
• Contact damage with a navigation aid or port infrastructure.
• Loss of stability such that the ship and its crew are imperilled.
• A ship or other vessel involved in a near collision, near stranding.
• A serious breach of the ISM Code.

When a decision has been made to investigate, marine investigations are initially categorised as Category 4. Following any filed investigation, the level of investigation will be assessed for the relative benefits to the maritime community and the general public. Any decision to upgrade or downgrade will be made on the recommendation of the Deputy Director in consultation with the Director and/or the Executive Director.

Level 5

• An accident or serious incident where another competent body will be conducting an investigation and available resources do not warrant an ATSB investigation.
• An accident involving one or more vessels without fatalities or significant pollution, where the potential safety lessons do not, after initial review, justify the commitment of investigative resources within available funds. Data will be filed for statistical purposes.
• An accident involving contact with navigational or port infrastructure, where the seaworthiness of the ship is not compromised.
• An accident or serious incident involving a minor breach of the ISM Code.

1 "Very serious casualties" are casualties to ships which involve total loss of the ship, loss of life, or severe pollution, the definition of which, as agreed by the Marine Environment Protection Committee at its thirty seventh session (MEPC 37/22, paragraph 5.8), is as follows:

"Severe pollution" is a case of pollution which, as evaluated by the coastal State(s) affected or the flag State, as appropriate, produces a major deleterious effect upon the environment, or which would have produced such an effect without preventive action.

"Serious casualties" are casualties to ships which do not qualify as "very serious casualties" and which involve a fire, explosion, collision, grounding, contact, heavy weather damage, ice damage, hull cracking, or suspected hull defect, etc., resulting in:
- immobilization of main engines, extensive accommodation damage, severe structural damage, such as penetration of the hull under water, etc., rendering the ship unfit to proceed*, or
- pollution (regardless of quantity); and/or
- a breakdown necessitating towage or shore assistance.

"Less serious casualties" are casualties to ships which do not qualify as "very serious casualties" or "serious casualties" and for the purpose of recording useful information also include "marine incidents" which themselves include "hazardous incidents" and "near misses".

2 The ship is in a condition, which does not correspond substantially with the applicable conventions, presenting a danger to the ship and the persons on board or an unreasonable threat of harm to the marine environment.