665/ Incident Investigation and Analysis / 992
SMS Section
8
- Incident In
v
esti
g
ation and
A
nal
y
sis
BOS-
M
NL-0
3
02.900
8
00
1
Introduction
1
.
1
Main
Ob
jecti
v
e
Estab
li
sh
the
use
of
effect
i
ve
report
i
ng
, i
nvest
i
gat
i
on and management
fo
ll
ow
-
up methods
to
l
earn
from
a
ll
i
nc
i
dents
and
near
-
m
i
ss
,
and
thus
prevent
reoccurrence
.
O
ne of
the
fundamenta
l
pr
i
nc
i
p
l
es
of
safety management
i
s
that
a
ll i
nc
i
dents
and acc
i
dents
are
preventab
l
e
.
T
herefore
, i
t
i
s
i
mportant
to
ensure
that
i
f
there
i
s
an
i
nc
i
dent/near
-
m
i
ss
,
the
causes
are
thorough
l
y
i
nvest
i
gated and measures
are
ta
k
en
to
prevent
a
reoccurrence
.
1
.
2
Incident
/
near-
m
iss anal
y
sis
T
he Company
shall
estab
li
sh
and ma
i
nta
i
n
procedure
for
cons
i
stent
l
y
report
i
ng
, i
nvest
i
gat
i
ng
,
ana
l
ys
i
ng and
document
i
ng
operat
i
ona
l,
safety and env
i
ronmenta
l i
nc
i
dents
,
near m
i
ss
and breaches
of
regu
l
at
i
ons
.
1
.
3
Esta
b
lis
h
in
g P
rocedure
T
he procedure
shall
:
x
Prov
i
de
for
the
t
i
me
l
y
i
nvest
i
gat
i
on of
an
i
nc
i
dent
;
x
I
dent
i
fy
the peop
l
e
respons
i
b
l
e
for
report
i
ng an
i
nc
i
dent
,
author
i
z
i
ng and
conduct
i
ng
the
i
nvest
i
gat
i
on
,
and
i
n
i
t
i
at
i
ng
subse
q
uent
correct
i
ve act
i
ons
;
x
I
nc
l
ude
gu
i
dance
on
the
c
l
ass
i
f
i
cat
i
on
of
a
ll i
nc
i
dents
i
n
li
ne w
i
th recogn
i
zed
i
ndustry gu
i
de
li
nes
,
such
as
those
i
ssued
by
I
M
CA
, O
C
I
M
F
and
OS
HA
;
x
Prov
i
de
i
nc
i
dent
i
nvest
i
gat
i
on
tra
i
n
i
ng
to
staff w
i
th
th
i
s
ass
i
gned
respons
i
b
ili
ty
;
x
Ensure
that
the
d
i
rect
,
contr
i
but
i
ng
and
root
causes
contr
i
but
i
ng
to
an
i
nc
i
dent
are
i
dent
i
f
i
ed
,
and
that
steps
are
ta
k
en
to
reduce
the
r
i
s
k
of
a
reoccurrence
;
x
I
nc
l
ude prov
i
s
i
on
for
determ
i
n
i
ng
the act
i
ons
needed
to
reduce
the
r
i
s
k
of
re
l
ated
i
nc
i
dents
;
x
Ensure
that
i
nc
i
dent
i
nvest
i
gat
i
on
f
i
nd
i
ngs
are
reta
i
ned
and
per
i
od
i
ca
ll
y ana
l
ysed to
determ
i
ne where
i
mprovements
to management
systems
,
gu
i
de
li
nes
,
procedures
or
pract
i
ces
are
re
q
u
i
red
;
x
S
pec
i
fy
methods
for
determ
i
n
i
ng
whether
li
a
i
son
i
s
needed
w
i
th
i
ndustry
groups
(
such
as
c
l
ass
i
f
i
cat
i
on
soc
i
et
i
es
or
e
q
u
i
pment manufacturers
)
to avo
i
d
s
i
m
il
ar
i
nc
i
dents
on
other
vesse
l
s
;
x
Ensure
that
l
essons
l
earnt
from
an
i
nc
i
dent
are
shared
among
the
f
l
eet
and
used
to
fac
ili
tate
i
mprovements
i
n operat
i
ona
l
safety management performance
.
Vers
i
on
SF(BOS-
M
NL-0
3
.900
8
00-
ver
.0
4
). O
r
i
g
i
na
l
date:
2
4/
0
5/
20
1
2.
Vers
i
on
date:
31/1
2
/
20
15
.
Va
li
d
vers
i
on
on
l
y
on Q
M
S
s
i
te
.
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ll
ed
document when
pr
i
nted
.
M
anua
l
prepared
by:
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S
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M
anager
.
Approved by:
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M
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.
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li
dated by:
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.
3
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665