Maritime accident investigation and risk assessment data with the review of Costa Concordia case Capt. Davor Vidan (Pomorski Fakultet Split) ((!mail" davor.vidan#pomorstvo.hr) davor.vidan#pomorstvo.hr)
ABSTRACT
$he use of risk assessment re%uires availa&ilit' of maritime accidents reports data &ut also *ear!Miss cases and +est (Safe) Practices solutions in order to properl' identif' the risks assess their pro&a&ilit' and conse%uences and determine safeguards. $he amount and the %ualit' of the data availa&le should &e improved &' implementing the ,ust Culture and -pen industr' in the maritime world in order to share information a&out all such cases that have happened around the world. $he sie of ships toda' makes the accident conse%uences untolera&le due to high num&er of possi&le casualties and high costs of salvage if salvage is possi&le at all and clean!up operations as more and more ships has to &e demolished on the site of the accident due to their sies. $herefore $heref ore it is of great importance importance to improve improve the error prevention prevention and one of the &est availa&le availa&le sources are the data that should &e collected and made availa&le &' sharing reports not onl' a&out accidents &ut also a&out *ear!Miss cases and +est Practices solutions.
KEY WORDS
Maritime /c /ccident 00nnvestigation
1isk aasssessment.
*ear!Miss.
1. INTRODUCTION
0M- adopted amendments2 to S-3/S Chapter 40!2 MSC 56th. session in Ma' 7885 in force from 2 ,anuar' 7828 making mandator' parts 0 and and 00 of th thee new Code ode of 0n 0nte tern rnaation tional al Standa Sta ndards rds and 1ec 1ecomm ommend ended ed Pra Practi ctices ces for a Safet' 0nvestigation into a Marine Casualt' or Marine 0ncident (Casualt' 0nvestigation Code). Part 000 of the Code contains related guidance and e9planator' material. $his amm $his ammendm endment entss e9p e9pand and re% re%uir uireme ements nts &' 0nte 0ntern rnat atio iona nall Ma Mari riti tim me Co Conv nven enti tion onss for for /dmini /dm inistra stratio tions ns to und undert ertake ake to con conduc ductt an investigation of an' casualt' occurring to an' of its ship shipss wh when en it :ud :udges ges that that su such ch an investi inv estigat gation ion ma' ass assist ist in det determ ermini ining ng what what
+est (S (Safe) P Prractices.
changess in the pre change presen sentt reg regula ulatio tions ns mig might ht &e desi desira ra&l &lee or im impr prov ovin ingg sa safe fet' t' at se sea a &u &utt mand ma ndat ator' or' in al alll ve ver' r' se seri riou ouss an andd se seri riou ouss accidents causing loss of life or serious in:ur' or serious damage to ships or to the marine environment. $he fin findin dings gs of thi thiss inv investi estigat gation ion sho should uld &e 7 reported to 0M- and made pu&lic . ; has adopted directive< 788=>25>C on the fundamenta tall principle less governing the inve investi stiga gatio tionn of acc accid iden ents ts in th thee mari maritim timee transport sector and introduced the o&ligation of the Mem&er States to send a cop' of the reports to the uropean Commission and pu&lish them.
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0M- and ; have set up a electronic data&ases ?0 ?0S0 S0S S and and M MC0 C0P P cont contai aini ning ng data data from from received accident investigation reports. 2. MARITIME ACCIDENT
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FS/ consists of five steps" 2. id iden enti tifi fica cati tion on of ha haa ard rdss (a list list of all rel elev evan antt ac acccid iden entt sc scen enar ario ioss with with potential causes and outcomes)E 7. as asse sessm ssmen entt of ri risk skss (eva (evalu luat atio ionn of risk factors)E
INVESTIGATION
$he $he Fl Flag ag and and Co Coas asta tall St Stat atee righ rightt and and the the o&ligation to investigate the maritime accidents was alr alread ead'' inc includ luded ed in the mos mostt imp import ortant ant mariti ma ritime me con conven ventio tions ns like like S-3 S-3/S /S 3-/ 3-/D D 30 30* * M/ M/1P 1P-3 -3 and and ;* ;*C3 C3-S -S and and the the adoption of the a&ove regulations indicate the importance of the availa&ilit' of accident data to the improvement improvement of the safet' at sea and the need need to im impr prov ovee the the curr curren entt in inve vesti stiga gatio tionn conduct standard practices &' t he 6 /dministrations . 1epu&lic of Croatia has implemented the a&ove regulatio regula tions ns &' ame amendm ndments ents to the Mar Maritim itimee Code 3aw and new regulations on investigation of maritime accidents. $he accident investigations should &e carried out &' accident investigations agenc'@. 1isk assessment has &een made mandator' &' the amendmentsA to the 0SM Code in force from ,ul' the 2st 7828. Formal Safet' /ssessmentB (FS/) as part of 0M0M - rule rule!m !mak akin ingg proc process ess was was adop adopted ted in 7887 with the goal to ensure that action is taken &efore a disaster occurs unlike the more comm common on prac practi tice ce in the the past past that that the the new new regulations are adopted as a conse%uence or answ answer er to the the seri seriou ouss acci accide dent nts. s. e can can rem remem em&e &err $i $itani tanic c or st ston onia ia onl' onl' as e9amples of the reactive regulator' approach. FS FS/ / is used used to evalu evaluat atee prop propos osals als for for new new regula reg ulatio tions ns or to com compar paree pro propos posed ed cha change ngess with e9isting standards ena&ling a &alance to &e foun foundd &etw &etwee eenn th thee vari variou ouss tech techni nica call and and oper operat atio iona nall issu issues es incl includ udin ingg the the hum human elem elemen ent t and and &etw &etwee eenn sa safe fet' t' an andd cost costss of implementation of the new rules as a rational and s'stematic process for assessing the risks asso associ ciat ated ed wi with th ship shippi ping ng acti activi vit' t' and and for for evalu ev aluat atin ingg th thee cost costss and and &ene &enefi fits ts of 0M 0M- -ss options for reducing these risks5.
<. re rilator skor''comeasu ntroasure l resosptitoonsco (drol elvisan indg regu gulat me cont ntro and reduce the identified risks)E 6. co cost st &e &ene nefi fitt as asse sess ssm men entt (d (det eter erm min inin ingg cost effectiveness of each risk control option)E and @. re reco comm mmen enda datio tions ns fo forr de decis cisio ion! n!ma maki king ng (in (infor format mation ion a&o a&out ut the ha haard ards s the their ir associated risks and the cost effectiveness of alternative risk control options is provided). $he results of the maritime accident investigations contri&ute to the effectiveness of FS/ in the steps 2 7 < and @ as it is clearl' visi&le when these steps are reduced in simple terms as on 0M- we& page" 2. h hat at m migh ightt go wron wrong g G id iden enti tifi fica cati tion on of ha haa ard rdss (a list list of all rel elev evan antt ac acci cide dent nt sc scen enar ario ioss wi with th po pote tenntial tial causes and outcomes)" a. can &e found in accident investigations reports as causes and conse%uences of maritime ac acci cide dent nts s an andd *ear *ear!M !Mis isss reportsE 7. Ho How w &a &add and and ho how w like likel' l' G as asse sessm ssmen entt of risks (evaluation of risk factors)" a. ca cann &e aasse ssesse ssedd from from ssta tatis tistic tical al data of same or similar risks and &' competent anal'sis of all availa&le data from accident investigationsE <. Can matters &e improved G risk contro con troll opt option ionss (de (devis vising ing reg regula ulator' tor' meas me asur ures es to co cont ntro roll an andd re redu duce ce th thee identified risks)" a. can &e found in the safet' recommendations in all properl' conducted maritime accident investigation report as well as +es +estt (Sa (Safe) fe) Pra Practi ctices ces and *ear!Miss reportsE 6. hat would it cost and how much &etter would it &e G cost &enefit
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assessment (determining cost effe effect ctiv iven enes esss of each each risk risk cont contro roll option)E @. hat actions should &e taken G recommendations for decision!making (infor (informa mation tion a&o a&out ut the ha haard ards s their their associated rofiskalternative s and risk the control cost effectiveness options is provided)" a. can &e found in the safet' recommendations as well. $herefore maritime accident investigation and risk risk asse assessm ssment ent hav havee &ec &ecom omee the nec necess essar' ar' step teps for im impproving safe afet' at se seaa also contri&uting to the efforts that action is taken &efore accidents happen as a part of proactive regulator' approach as FS/ is &ased on the anal'sis of all availa&le and relevant data a&out maritime marit ime accid accidents ents &ut data from *ear! *ear!Miss Miss reports and +est Practices can &e a valua&le
3ater version of the I1eason ModelJ"
source of information and knowledge. ithout speculating into what caused the Costa Conc Co ncor ordi diaa case case 0 have have to ask ask m' m'sel selff wh what at measures could &e taken in order to prevent this accident
2.1. Accident investigti!n "et#!ds
0M- Ca 0MCasu sual alt' t' 0nve 0nvest stig igat atio ionn Co Code de (M (MSC SC 56>76>/dd.2 P/1$ 0 7.27.@) re%uires that a marine safet' investigation contains anal'sis and comment on the causal factorsanincluding an' me mecha chanic nical al hum human an and or organ gania iatio tional nal factors not onl' the active error that triggered the accidents. Most of the investigation methods are &ased on $he $he 1e 1eas ason on Mo Mode dell= also also know knownn as Sw Swis isss Cheese and categoriation of errors as /ctive or 3atent rrors.
$he most imp important conclu lussion of all world ldw wid idee researches into errors and investigation methods is that the active error is not onl' result of the operator acts &ut also the resu result lt of ac accu cum mul ulat ated ed la late tent nt er erro rors rs in th thee s'stems and that the human element is the most impo import rtan antt pa part rt of th thee sa safe fe wo work rk an andd er erro ror r prevention. ver' s'stem consist of at least this components" 1egulator' framework -rganiation and management Hardware (Construction and e%uipment including maintenance) Procedures and instructions orkplace conditions -per -p erat ator or ca capa pa&i &ili lit' t' (e (edu duca catio tionn an andd training) • • •
• • •
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3atent errors in an' component ma' remain hidden for 'ears until an active error occurs as an accident waiting to happen.
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areas at least as possi& areas possi&ilities ilities for impr improvem ovement ent so the picture ma' look like this"
hat could have &een the latent errors in case of Costa Concordia
0n case that all areas are in /3/1P range the possi&ilit' of accident is accepta&le. 0n case of Costa Concordia the a&ove diagram ma' look like this"
Fo Foll llow owin ing theeweakest ol oldd sa sa'i 'ing ng"" I$ I$he ch chain ain is as strong asg itsth linkJ wehecan conclude that no effort in the lower level component can reduce the risk of accident due to the errors in the higher level component onl' the effective &arriers of the error prevention. prevention. ;sing the same tragic case again if the error was in the hardware construction of the ship water tightness s'stem the risk of the damage that that ha have ve ac actu tual all' l' oc occu curr rred ed co coul uldd no nott &e reduced &' operators actions &ut onl' triggered &' operators error. 0f the vessel could sustain such the damage she could at least &e towed to the port &ig enough to accommodate the ship of such sie. /t this moment we can not speculate on the scope of the damage as much as it reassem&les the $itanic &ut it is an accident that should not have happened.
e can see how the increase in failure rate of an' component in the s'stem a&ove the /3/1P range ran ge ma makes kes the inc increa reases ses the pro pro&a& &a&ilit ilit'' of error and accident indicated &' the angle of the arrow. 0nvestigation results of the case will as the' alwa's do determine some latent errors in all
0s th thee co comp mple lete te lo loss ss of po powe werr an andd mu mult ltip iple le compartment flooding accepta&le 2. 2.2 2. N! N!n$ n$C! C!n% n%!& !&" "it itie ies' s' c! c!&& &&eect ctiv ivee (&ev (&even enti tive ve cti cti!n !ns' s' Ne& Ne&$M $Mis isss nd nd )S%e* +&ctice
nd nd Best Be st
Comp Co mpan' an' ha hass to im impl plem ement ent th thee pr proc oced edur ures es ensuring that non!conformities accidents and haa haard rdou ouss si situ tuat atio ions ns ar aree re repo port rted ed to th thee
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Compan' investigated and anal'ed with the o&:ect o&: ective ive of imp improv roving ing saf safet' et' and pol pollut lution ion prevention and esta&lish procedures for the implementation of corrective action including measures intended to prevent recurrence 28.
0t is not pos osssi& i&le le to co cond nduuct pr prop oper er ris isk k asse assessm ssmen entt if it is &a &ased sed on onl' l' on pe pers rson onal al e9perience or onl' on cases that have happened within one compan' even within one flag fleet. $here was one master that had no cases in all
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0n so called ,ust cases Culture large num&er of such willorganiation &e reported a&ut in +lame Culture organiations most of these case casess will will re rem main ain unrep nrepoorted rted pos ossi si&l &lee correc cor rectiv tivee or pr preve eventi ntive ve act action ionss wil willl not &e implemente imple mented d and haar haardous dous occur occurrence rence ma' easil' happen again unnoticed until it &ecomes an accident that can not &e hidden.
his histor' until ..Concordia another asssailing a the master of Costa 0mpo 0mport rtan ance ce of *e *ear ar!M !Mis isss re repo port rtin ingg ca cann &e &etter understood if we anal'e the Heinrich triangle ratio26"
;nfortuna ;nfort unatel' tel' a ma marit ritime ime ind indust ustr' r' is still still a closed t'pe industr' in which the information are not shared with others. Man' cases remain not reported even to the compan' companies do not report all such cases to the class insurer or adm adminis inistr trat atio ionn. /t the the sam same tim time the the companies recog companies recognied nied org organiat aniations ions insur insurers ers and administrations do not share information &etween themselves. /vaila&le /vaila&le data is censored su&:ective and almost alwa's un!audita&le 27. $he $he avai availa la&l &lee near near!m !miss iss data data is ver' ver' of ofte tenn su&mit iteed anon'mou ousl sl'' for the fear of cons conse% e%ue uennces ces &' the the crew crew and and as su such ch pu&lished on the we&. $here are ver' few sour source cess of such such repo report rted ed data data to &e foun foundd (Denmark ;S Mars etc.) that give the cases and sol soluti utions ons lik likee Saf Safee Pra Practic ctices es alth althoug oughh these would &e ver' valua&le to all particularl' to the seamen on &oard when conducting the risk asses sessm smeents and determining the safeguards to take an' task on &oard &ut also to the companies companies for the improve improvement ment of the 0SM s'ste s'stems ms and and admi adminis nistr trat atio ions ns for for proa proact ctiv ivee regulator' work. 0mo 0mo has is issu sued ed ?u ?uid idan ance ce on *ear ear!Mi Miss ss reporting to promote a no!&lame culture and to enco en cour urag agee repo report rtin ingg of near near!m !miss isses es so that that rem remedia ediall measu easure ress can can &e take takenn to avoi avoidd 2< recurrences tr'ing to initiate not onl' reporting &ut also the continuous improvement in safet' management s'stems &' implementing remedial measures and sharing such e9periences e9per iences and findi findings ngs &etween all parties in the maritime industr' industr'..
0f we take a *ear!Miss as an accident without conse%uences there could have &een up to A88 mis isse sedd op oppo port rtun unit itie iess to imp imple lem men entt th thee safeguards against the accident occurrence that remained unreported. $his is the area of improvement availa&le at relativel' small e9tra cost &ut not 'et made mandator' other then within compan'. $his is the kno knowle wledge dge and e9p e9peri erienc encee wasted wasted un unless less used. Could the Costa Concordia case &e avoided if it was reported as a non!conformit' or near!miss" !;nauthoried deviation from vo'age plan !/pproaching dangerousl' close to the shore with one of the largest passenger ships in the world
2.,. E"e&genc- (&e(&edness (&e(&edness
$he compan'2@ is o&liged &' the 0SM Code to"
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.7 .7 asse assess ss al alll id iden enti tifi fied ed risk riskss to its its sh ship ips s personnel and the environment and esta&lish appropriate safeguardsE and .< con contin tinuou uousl' sl' imp improv rovee saf safet' et' man manage ageme ment nt skills ski lls of person personnel nel ash ashore ore and a&o a&oard ard shi ships ps includ inc luding ing pre prepar paring ing for eme emerg rgenc encies ies relate relatedd
0 dont like to think what could have happened if.... &ut the pro&lem remains" too much people in too little space in emergenc' even if all 3S/ e%uipment is in perfect order as it was on Costa Concordia.
&oth environmental protection. /lso2Ato" safet' and environmental .@ procedures to prepare for and respond to emergenc' situationsE /nd finall'" 5 M1?*CK P1P/ P1P/1D*SS 1D*SS 5.2 $he Com Compan pan'' sho should uld ide identi ntif' f' pot potent ential ial emergenc' ship&oard situations and esta&lish procedures to respond to them. them. 5.7 $he Compan' should esta&lish programs for drills and e9ercises to prepare for emergenc' actions. 5.< 5.< $he $he safe safet' t' ma mana nage geme ment nt s'ste s'stem m sho shoul uldd provide for measures ensuring that the Compan' Com pan's s org organ aniat iation ion can res respon pondd at an'
/fter saving people then ne9t step is saving the ship and environment.
timee to haa tim haard rds s acci accide dent ntss and and em emer erge genc' nc' situations involving its ships. -n pape paperr Co Cost staa Co Conc ncor ordi diaa had had all all thes thesee re%uirements fulfilled. h' the response action was not successful Can we e9pect from the man that has :ust made one of the greatest errors in maritime histor' to properl' command and coordinate the rescue operations
hat could &e done &' coastal state in such a case $he ship is too &ig and there is no possi&ilit' to even tr' to do an' salvage operations. ven now when the ship is grounded there is no read' solution to salvage the ship and it ma'' ev ma even entu tual all' l' pr prov ovee th that at it wil willl &e mo more re economic to &reak the ship on site then to tr' to salvage her. $hese e9tra large ships leave no possi&ilities of salvage and even if someone tr' like it was the *apoli case it ma' prove to &e more costl' then ship and cargo loss. So we ma' ask our self how &ig is too &ig merge mer genc' nc' pr prep epar ared edne ness ss ma' ma' &e th thee fina finall &arrier against the conse%uences &ut in cases like like Co Costa sta Co Conc ncor ordi diaa da dama mage ge th ther eree wa wass no resp respon onse se ac acti tion on av avai aila la&&le to pr prev even entt th thee catastrophic conse%uences other then a&andon ship as all s'stem redundanc' has &een lost"
$he main point is that the crew did well even without command and coordination and that is the &est indicator that no technical invention wi will ll repl replac acee th thee huma humann elem elemen entt dr dril ills ls and and training. vacuation of 6888 souls has never &een tried &efore. $his time there was not so much panic &etween passengers the' could see the shore there was no wind or sea. $he crew has has done done th thei eirs rs duti duties es as we well ll as coul couldd &e e9pect e9p ected ed and the there re was ple plent' nt' of tim time e the vessel never sank. 0f we di dive vert rt ou ours rsel elve vess from from acti action onss of the the master those will &e investigated thoroughl' &' all administrations and the court one of the main pro&lems was the damage sustained that was greater then it was assumed pro&a&le and the vessel could not &e saved as there was no redundanc' left.
-nce that the &arriers are &reached &ut also that that th thee s' s'ste stem m re redu dund ndan anc' c' is lo lost st al alll th thee conse conse%u %uen ence cess ma' ma' fa fall ll fa farr &e &e''on ondd /3 /3/1 /1P P range actuall' the costs in lives and damages
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can &e unlim unlimited ited and catast catastrophic rophic as indica indicated ted &' the angle of arrow. arrow. -r -rga gani nia ati tion onal all' l' th thee s' s'st stem em had had enou enough gh redundanc' so the crew were a&le to evacuate the passengers even if the error occurred in the command s'stem. +utthehardware redundanc' was lost completel' &' damage sustained. e dont have enough information to speculate if an' of the regulations was not complied with and how man' compartments were flooded &ut the ships will never &e &uilt strong enough to sustain an' damage onl' pro&a&le damages. 0f we look at statistical data onl' this damage ma' &e e9tremel' remote even less likel' to occur once in the lifetime (78 'ears) of a world wo rld flee fleett of @888 @888 sh ship ips s and and in the 1isk 2B Matri9 suc such ris iskk ma' &e classif sified ied as *eg * egli ligi gi&l &le e or / /ss 3ow 3ow /s 1e 1eas ason ona& a&l' l' Practica&le (/3/1P) and no safeguards are normall' re%uired. ;nfo ;n fort rtun unat atel el'' in hist histor or'' man' an' kind kindss of damages were not assumed as pro&a&le and 'et the' happened. $itanic /ndrea Doria to name the most famous cases.
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2.2. S#i( sie nd c!nse/0ences
$here is an old sa'ing &etween seamen sea men that said it all" +ig ship ! +ig pro&lem. hen h en we co cons nsid ider er th thee co cons nse% e%ue uenc nces es of an accident accid ent with the &ig ship we can not avoid the sie and num&er of passengers as a factor. 0n or orde derr to sa safe fet' t' ev evac acua uate te th thou ousa sand ndss of passengers the emergenc' preparedness must &e almost prefect and we know that no&od' and nothing can &e perfect and the value of crew competence in this matter can &e achieved onl' &' education drills and training. +ut in order to assist the &iggest ships in trou&le there is no stand!&' arrangements. ven the towing of these e9tra large ships is not a simple and safe operation. *apoli 1ena and now Costa Concordia si sie e mak akes es re re!f !flo loat atin ingg af afte terr gr grou ound ndin ingg a mission impossi&le and e9tremel' costl'. costl '. e have alread' the case of V/3 &ulkers one suffered damage in loading port others are denied permission to enter Chinese ports on the ground of the their sie. ver' port has its limits and ever' coastal state has its own limited capa&ilities to intervene and assist in case of accident and that is another factor fac tor to con consid sider er whe whenn conduc conductin tingg the risk risk asse assessm ssmen ent t &e &eca caus usee th thee pa part rt of em emer erge genc' nc' response is the availa&le help in case of error and accident that ma' significantl' reduce the conse%uences. /r /ree we cl cloose to th thee da' we ha havve to as ask k ourselves How &ig is too &ig
0n cases of the low pro&a&ilit' risks we should not ignore catastrophic conse%uence regardless of the pro&a&ilit' as it is suggested in most of the Mar Maritim itimee 1is 1iskk /ss /ssessm essment ent ?ui ?uidel deline iness25 such as /+S ?3 and others particularl' in case case of larg largee passe passeng nger er sh ship ips s and and the the 1isk 1isk 2= /cceptance Criteria should &e &ased more on the conse%uences. e have new rules for new passenger ships alread' in place. /re the' effective against such damage
$he final diagram of the Costa Concordia case could look like this"
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e can see that all cost ma' &e much higher then /3/1P assumed. ver' item can have its own scale this is onl' to indicate how the failure in one level can increase the risk of error and accident and how the failur failures esredundanc' in eme emerg rgenc enc' pre prepar paredn edness inade%uate can'increase theess costsand in human lives in ecological damage in clean!up and salvage operation and finall' others costs like claims &' passengers. So th thee 1isk isk Ma Matr tri9 i9 ind indicat icatin ingg that hat the the ultimatel' ultim atel' cat catastrop astrophic hic cost costss should &&ee taken into account no matter how unlikel' to happen would look like this"
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,. CONCUSIONS
$o im impr prov ovee th thee Safet Safet'' Cu Cultu lture re in mari maritim timee transportation s'stem it is necessar' to replace the the C Clo losed sed 0n 0ndu dustr str'' S' S'ste stem m an andd + +la lame me Culture with an -pen 0ndustr' S'stem in which ,ust Culture is implemented in order to improve reporting at all levels ensuring that all informatio infor mationn a&ou a&outt accid accidents ents near! near!misse missess and Safe Practices are reported and shared among all intere interested sted sid sides es sta starti rting ng fro from m sea seame menn to /dministrations and then it will &e possi&le to carr' car r' out con contin tinuou uouss asse assessm ssment ent of cur curren rentt practices and risk assessments with more accurac' accur ac' result resulting ing in impr improvem ovement ent of safet' and pro proact active ive reg regula ulator' tor' pro process cess.. Suc Suchh dat dataa should &e pu& should pu&lish lished ed cat catego egori ried ed and easil' easil' searched.
hen we make the risk assessment we have to look on the other side what happens after an error occurs and after an accident happened in order to estimate the possi&le conse%uences of the given risk and determine the measures that could prevent the error at the first place.
REERENCES
0f the costs of salvage are to &ig due to ships sie s'stem hasthis enough there even is no ifwa' to keep costsredundanc' in /3/1P one other then erro errorr preve prevention ntion.. $he data that could cou ld &e col collec lected ted and ana anal' l'ed ed fro from m *ea *ear! r! Miss Mi sses es 1e 1epo port rtss and and sh shar ared ed +e +est st Pr Prac acti tice ce solutions is one of the most effective wa's of error prevention and the means to improve risk asse as sessm ssmen entt and and Safe Safet' t' Cu Cult ltur uree in ma mari ritim timee industr'. $he onl' wa' to achieve this is to make the maritime industr' an -pen 0ndustr' in which all data not onl' from accidents are pu&lished and shared and ,ust Culture is implemented at all levels. .
2.
0M 0M-" -" 1e 1eso solu luti tion on /.5 .56= 6=(7 (78) 8) 1e 1eso solu luti tion on /.556(72) 1esolution /.287=(7A)E /.287=(7A)E
7.
0M-" MSC!MPC.<LCirc.< MPC.<LCirc.7E
<.
D01C$0V 788=>25>C -F $H ;1; 1-P P/* /* P/13 130/ 0/M M*$ *$ /* /*D D -F $H C-;*C03 of 7< /pril 788= -fficial ,ournal of the uropean ;nion 3 2<2>226E
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Ca Capt pt.. Da Davo vorr Vidan dan is a Ma Mast ster er Ma Mari rine nerr lecturing maritime accident investigation and risk assess sessm ment at Maritim imee ;niv ;n iver ersi sit' t' in Spli Split t Cro Croat atia ia with the e9perience 78 'ears at sea and 28 'ears in maritimeof administration.