Annex Code for the Investigation of Marine Casualties and Incidents
1 Introduction1.1 This Code recognizes that under IMO conventions each flag State
has a duty to conduct an investigation into any casualty occurring to
any of its ships when it judges that such an investigation may assist in
determining what changes in the present regulations may be desirable or
if such a casualty has produced a major deleterious effect upon the
environment. The Code also takes into account that under the provisions
of UNCLOS article 94, a flag State shall cause an inquiry to be held, by
or before a suitably qualified person or persons into certain casualties
or incidents of navigation on the high seas. However, the Code also
recognises that where a casualty occurs within the territorial sea or
internal waters of a State, that State has a right, under UNCLOS
article 2, to investigate the cause of any such casualty which might pose
a risk to life or to the environment, involve the coastal State's search
and rescue authorities, or otherwise affect the coastal State.1.2 The aim of this Code is to promote a common approach to the safety
investigation of marine casualties and incidents, and also to promote
co-operation between States in identifying the contributing factors
leading to marine casualties. The result of this common approach and
co-operation will be to aid remedial action and to enhance the safety of
seafarers and passengers and the protection of the marine environment.
In achieving these aims, this Code recognizes the need for mutual
respect for national rules and practices and puts particular emphasis
upon co-operation.1.3 By introducing a common approach to marine casualty investigations
and the reporting on such casualties, the international maritime
community may be better informed about the factors which lead up to and
cause, or contribute to, marine casualties. This may be facilitated by: .1 Clearly defining the purpose of marine casualty investigation and
the guiding principles for its conduct. .2 Defining a framework for consultation and co-operation between
substantially interested States. .3 Recognizing that the free flow of information will be promoted if
individuals who are attempting to assist the investigation may be
offered a degree of immunity, both from self-incrimination and
from any ensuing risk to their livelihood. .4 Establishing a common format for reports to facilitate publication
and sharing of the lessons to be learned.1.4 It is not the purpose of the Code to preclude any other form of
investigation, whether for civil, criminal, administrative, or any other
form of action, but to create a marine casualty investigation process
the aim of which is to establish the circumstances relevant to the
casualty, to establish the causal factors, to publicise the causes of
the casualty and to make appropriate safety recommendations. Ideally,
marine casualty investigation should be separate from, and independent
of, any other form of investigation.2 ObjectiveThe objective of any marine casualty investigation is to prevent similar
casualties in the future. Investigations identify the circumstances of
the casualty under investigation and establish the causes and
contributing factors, by gathering and analysing information and drawing
conclusions. Ideally, it is not the purpose of such investigations to
determine liability, or apportion blame. However, the investigating
authority should not refrain from fully reporting the causes because
fault or liability may be inferred from the findings.3 ApplicationThis Code applies, as far as national laws allow, to the investigation
of marine casualties or incidents where either one or more interested
States have a substantial interest in a marine casualty involving a ship
under their jurisdiction.4 DefinitionsFor the purpose of this Code:4.1 "Marine casualty" means an event that has resulted in any of the
following: .1 the death of, or serious injury to, a person that is caused by, or
in connection with, the operations of a ship; or .2 the loss of a person from a ship that is caused by, or in
connection with, the operations of a ship; or .3 the loss, presumed loss or abandonment of a ship; or .4 material damage to a ship; or .5 the stranding or disabling of a ship, or the involvement of a ship
in a collision; or .6 material damage being caused by, or in connection with, the
operation of a ship; or .7 damage to the environment brought about by the damage of a ship or
ships being caused by, or in connection with, the operations of a
ship or ships.4.2 "Very serious casualty" means a casualty to a ship which involves
the total loss of the ship, loss of life or severe pollution.4.3 "Serious casualty" means a casualty which does not qualify as a
very serious casualty and which involves: .1 a fire, explosion, grounding, contact, heavy weather damage, ice
damage, hull cracking or suspected hull defect, etc., resulting
in; .2 structural damage rendering the ship unseaworthy, such as
penetration of the hull underwater, immobilization of main
engines, extensive accommodation damage etc.; or .3 pollution (regardless of quantity); and/or .4 a breakdown necessitating towage or shore assistance.4.4 "Marine incident" means an occurrence or event being caused by, or
in connection with, the operations of a ship by which the ship or any
person is imperilled, or as a result of which serious damage to the ship
or structure or the environment might be caused.4.5 "Causes" means actions, omissions, events, existing or
pre-existing conditions or a combination thereof, which led to the
casualty or incident.4.6 "Marine casualty or incident safety investigation" means a process
held either in public or in camera conducted for the purpose of casualty
prevention which includes the gathering and analysis of information, the
drawing of conclusions, including the identification of the
circumstances and the determination of causes and contributing factors
and, when appropriate, the making of safety recommendations.4.7 "Marine casualty investigator" means a person or persons qualified
and appointed to investigate a casualty, or incident, under procedures
laid down in national legislation for the furtherance of marine safety
and protection of the marine environment.4.8 "Serious injury" means an injury which is sustained by a person in
a casualty resulting in incapacitation for more than 72 hours commencing
within seven days from the date of injury.4.9 "Ship" means any kind of vessel which is used in navigation by
water.4.10 "Lead investigating State" means the State that takes
responsibility for the conduct of the investigation as mutually agreed
between the substantially interested States.4.11 "Substantially interested State" means a State: .1 which is the flag State of a ship that is the subject of an
investigation; or .2 in whose internal waters or territorial sea a marine casualty has
occurred; or .3 where a marine casualty caused, or threatened, serious harm to the
environment of that State, or within those areas over which the
State is entitled to exercise jurisdiction as recognised under
international law; or .4 where the consequences of a marine casualty caused, or threatened,
serious harm to that State or to artificial islands,
installations, or structures over which it is entitled to exercise
jurisdiction; or .5 where, as a result of a casualty, nationals of that State lost
their lives or received serious injuries; or .6 that has at its disposal important information that may be of use
to the investigation; or .7 that for some other reason establishes an interest that is
considered significant by the lead investigating State.5 Conduct of marine casualty investigations5.1 Where an investigation is to be conducted, the following should be
taken into consideration: .1 Thorough and unbiased marine casualty investigations are the most
effective way of establishing the circumstances and causes of a
casualty. .2 Only through co-operation between States with a substantial
interest can a full analysis be made of a marine casualty. .3 Marine casualty investigations should be given the same priority
as criminal or other investigations held to determine
responsibility or blame. .4 Marine casualty investigators should have ready access to relevant
safety information including survey records held by the flag
State, the owners, and classification societies. Access to
information should not be barred by reason of competing
investigations. .5 Effective use should be made of all recorded data, including
voyage data recorders (VDR), if fitted, in the investigation of a
marine casualty or marine incident wherever it occurred. The State
conducting the investigation should arrange for the read-out of
the VDR. .6 Marine casualty investigators should be afforded access to
Government surveyors, coastguard officers, vessel traffic service
operators, pilots or other marine personnel of the respective
States. .7 The investigation should take into account any recommendations or
instruments published by IMO or ILO, in particular those relating
to the human factor, and any other recommendations or instruments
adopted by other relevant international organizations. .8 Reports of investigations are most effective when released to the
shipping industry and public.5.2 In accordance with 9, other substantially interested States should
be invited to be represented during any such investigation and should be
admitted as a party in the proceedings and have equal standing, rights
and access to evidence as the State conducting the investigation.5.3 Recognizing that any vessel involved in a casualty may continue in
service and that a ship should not be delayed more than is absolutely
necessary, the State conducting the investigation should start the
investigation as soon as practicable, without delaying the ship
unreasonably. Other substantially interested States may, by mutual
agreement, join the investigation either immediately or at a later
stage.6 Responsibility for investigating casualties and incidents6.1 Flag States are encouraged to ensure that investigations are
carried out into all casualties occurring to its ships. All cases of
serious and very serious casualties should be investigated.6.2 Where a marine casualty or incident occurs within the territorial
sea of a State, the flag and coastal States recognizing the obligations
of that State to its citizens and the legal status of the territorial
sea under the provisions of UNCLOS and also recognising the duties
placed on a flag State, the flag and coastal States should co-operate to
the maximum extent possible, and mutually agree which State should take
the role of lead investigating State.6.3 Where a marine casualty or incident occurs on the high seas, a
flag State should carry out an investigation into a casualty to, or on,
any of its ships. If that casualty is a collision involving a ship of
another flag State, then the States should consult with each other and
agree which will be the lead investigating State and determine the best
means of co-operation under this Code. In line with 9.1, if another
State is a substantially interested State by virtue of the nationality
of the ship's crew, passengers or other persons, or the location of the
casualty, that State or States should be invited to take part in the
investigation.6.4 By fully participating in an investigation conducted by another
substantially interested State, the flag State shall be considered as
fulfilling its obligations under UNCLOS article 94, section 7.6.5 An investigation should be started as soon as practicable after
the casualty occurs. Substantially interested States should, by mutual
agreement, be allowed to join an investigation conducted by another
substantially interested State at any stage of the investigation.7 Responsibilities of the lead investigating State The lead investigating State should be responsible for: .1 developing a common strategy for investigating the casualty in
liaison with substantially interested States; .2 providing the investigator in charge and co-ordinating the
investigation; .3 establishing the investigation parameters based on the laws of the
investigating State and ensuring that the investigation respects
those laws; .4 being the custodian of records of interviews and other evidence
gathered by the investigation; .5 preparing the report of the investigation, and obtaining and
reflecting the views of the substantially interested States; .6 co-ordinating, when applicable, with other agencies conducting
other investigations; .7 providing reasonable logistical support; and for .8 liaison with agencies, organizations and individuals not part of
the investigating team.8 Consultation8.1 Notwithstanding the obligation placed on the master or owners of a
ship to inform its flag State authority of any casualty occurring to the
ship, where a casualty or incident occurs in the internal waters or
territorial sea of another State, the coastal State should notify, with
a minimum of delay, the flag State or States of the circumstances and
what, if any, action is proposed by the coastal State.8.2 Following a casualty, the investigating State should inform the
other substantially interested States, either through the Consular
Office in that State or by contacting the relevant authorities listed in
MSC/Circ.781/MEPC.6/Circ.2. That State and the other substantially
interested States should consult, at the earliest opportunity, on the
conduct of the investigation and to determine details of co-operation.8.3 Nothing should prejudice the right of any State to conduct its own
separate investigation into a marine casualty occurring within its
jurisdiction according to its own legislation. Ideally, if more than one
State desires to conduct an investigation of its own, the procedures
recommended by this Code should be followed, and those States should
co-ordinate the timing of such investigations to avoid conflicting
demands upon witnesses and access to evidence.9 Co-operation9.1 Where two or more States have agreed to co-operate and have agreed
the procedures for a marine casualty investigation, the State conducting
the investigation should invite representatives of other substantially
interested States to take part in the investigation and, consistent with
the purpose of this Code, allow such representatives to: .1 question witnesses; .2 view and examine evidence and take copies of documentation; .3 produce witnesses or other evidence; .4 make submissions in respect of the evidence, comment on and have
their views properly reflected in the final report; and .5 be provided with transcripts, statements and the final report
relating to the investigation.9.2 States are encouraged to provide for maximum participation in the
investigation by all States with a substantial interest in the marine
casualty.9.3 The flag State of a ship involved in a marine casualty should help
to facilitate the availability of the crew to the investigation and
encourage the crew to co-operate with the State conducting the
investigation.10 Disclosure of records10.1 The State conducting the investigation of a casualty or incident,
wherever it has occurred, should not make the following records,
obtained during the conduct of the investigation, available for purposes
other than casualty investigation, unless the appropriate authority for
the administration of justice in that State determines that their
disclosure outweighs any possible adverse domestic and international
impact on that or any future investigation, and the State providing the
information authorizes its release: .1 all statements taken from persons by the investigating authorities
in the course of the investigation; .2 all communications between persons having been involved in the
operation of the ship; .3 medical or private information regarding persons involved in the
casualty or incident; .4 opinions expressed during the conduct of the investigation.10.2 These records should be included in the final report, or its
appendices, "only" when pertinent to the analysis of the casualty or
incident. Parts of the record not pertinent, and not included in the
final report, should not be disclosed.11 Personnel and material resources Governments should take all necessary steps to ensure that they have
available sufficient means and suitably qualified personnel and material
resources to enable them to undertake casualty investigations.12 Issue of marine casualty reports and submission to IMO12.1 The lead investigating State should send a copy of the draft of
the final report to all substantially interested States, inviting their
significant and substantiated comments on the report as soon as
possible. If the lead investigating State receives comments within
thirty days, or within some mutually agreed period, it should either
amend the draft final report to include the substance of the comments,
or append the comments to the final report. If the lead investigating
State receives no comments after the mutually agreed period has expired,
it should send the final report to the Organization in accordance with
applicable requirements and cause the report to be published.12.2 By fully participating in an investigation conducted by another
substantially interested State that will be reporting to IMO, the flag
State shall be considered as fulfilling its obligations under IMO
conventions.12.3 Reports, or relevant parts of reports, into the circumstances and
causes of a marine casualty should be completed as quickly as
practicable, and be made available to the public and the shipping
industry in order to enhance safety of life at sea and protection of the
marine environment through improved awareness of the factors which
combine to cause marine casualties.12.4 Where a substantially interested State disagrees with whole or
part of the report referred to in 12.1 above, it may submit its own
report to the Organization.12.5 The investigating State, upon determining that urgent safety
action is needed, may initiate interim recommendations to the
appropriate authority.13 Re-opening of investigations When new evidence relating to any casualty is presented, it should be
fully assessed and referred to other substantially interested States for
appropriate input. In the case of new evidence which may materially
alter the determination of the circumstances under which the marine
casualty occurred, and may materially alter the findings in relation to
its cause or any consequential recommendations, States should reconsider
their findings.14 Contents of reports14.1 To facilitate the flow of information from casualty
investigations, each report should conform to the basic format outlined
in 14.2 below.14.2 Reports should include, wherever possible: .1 a summary outlining the basic facts of the casualty and stating
whether any deaths, injuries or pollution occurred as a result; .2 the identity of the flag State, owners, managers, company and
classification society; .3 details of the dimensions and engines of any ship involved,
together with a description of the crew, work routine and other
relevant matters, such as time served on the ship; .4 a narrative detailing the circumstances of the casualty; .5 analysis and comment which should enable the report to reach
logical conclusions, or findings, establishing all the factors
that contributed to the casualty; .6 a section, or sections, analysing and commenting on the causal
elements, including both mechanical and human factors, meeting the
requirements of the IMO casualty data base; and .7 where appropriate, recommendations with a view to preventing
similar casualties.15 Contact between Administrations To facilitate implementation of this Code, States should inform the
Organization of the responsible authorities within their Governments
that may be contacted regarding cooperation in casualty investigations.