“Casualty Investigation, a 4000 year old profession” by Phoebe Cleridou


The need to resolve casualty disputes is not new. Casualty disputes have only become more complex. Casualty investigation – for many years the aviation, nuclear industries as well as the military have investigated the reasons for things going very wrong. These highly developed investigation techniques are now being shared with the shipping industry.

Ancient rules for resolution required expert opinions from qualified investigators 4000 years ago. The traditional forensic investigation is to analyse all data and reconstruct what happened in order to determine the root causes and present opinions/report and give testimony as required.

A casualty is the end result of an accidential sequence of events stemming from one or more root causes. Root causes can be controlled, eliminated or protected against when determined by accident analysis and properly addressed to prevent similar casualties. The purpose of accident analysis is to gain factual knowledge for risk control and loss recovery. A comprehensive investigation will reveal all cause factors. All factors both mechanical and human must be determined.

Forensic engineering is the application of the art and science of engineering and related knowledge to the jurisprudence system to assist in the resolution of casualty investigation disputes. In traditional forensic investigation the aim is protect casualty site and equipment, measure the plot and document the site, tag and secure evidence and relevant records, conduct interviews and make a background research. The investigator must then analyse all data and reconstruct what happened, determine the root causes and prepare report.

Casualty disputes have only become more complex nowadays. A root cause analysis is needed to discover actions or conditions which if eliminated would prevent an accidental chain of events leading to a similar casualty. Results can be applied to litigation and the regulatory processes.

It is difficult to establish what makes a good casualty investigator but speakers at the Baltic Accident conference listed a few: Technical competency, objectivity, persistency, collaborative ability, very effectively communicates, high ethical standards, knowledge of legal procedures, detective skills, flexibility, liberal use of common sense
Examples of marine casualty investigations include ship collisions, groundings and sinkings, engine room and cargo fires, bulkhead weld failures and oil spills, steering gear failures and crew accidents, human factors and CRM analysis

Management of a major investigation is a difficult task which entails NTSB, AAIB or BEA investigation, IIC, lead multidiscipline groups, coordination with multiple parties, large technical resources. Furthermore, as is expected, high profile matters lead to press coverage making the investigator responsible for dealing with the client and the press. For this he will need to have a single point of contact with both, comprehensive and timely communications with the client as well as reviewed and approved communications with the press.
In the 21st century Casualty investigation a marine investigator not only needs all of the traditional skills but also safety management systems, human factors, cultural and language skills, analysis of AIS, DP, GPS, ECDIS, VR & CFD. All of these leaves one unimpressed with the fact that there are less than 100 marine investigators in the whole world.

* All material of this article were gathered from the “Baltic Accident” conference of the London Shipping Law Centre in association with RTI Ltd held in Athens, October 2009.