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Thursday, May 17, 2012

Confidential Accident Reporting Platform (CARP)

Published:
31 January 2010 04:42
Updated:
17 January 2012 03:43

Introduction

INTERTANKO, through its Vetting Committee, has produced its Confidential Accident Reporting Platform in order to gather pertinent and detailed incident data within the tanker industry, whilst aiming to establish a set of recognised and harmonised set of industry categories of accidents whilst also establishing detailed yet simplified information pertaining to the Direct Cause (DC) of the incident and the Root Cause (RC) of the accident.

Accident classification is a standardised method in the airline industry by which the causes of an accident, including the root causes, are grouped into categories. Whilst accident classification was historically used in aviation it has been expanded into other areas, including the shipping industry. While accident reports are very detailed, the goal of accident classification is to look at a broader picture and learn from mistakes and errors.

By analysing a multitude of accidents and applying the same standardised classification scheme, patterns in how accidents develop can be detected and correlations can be built. The advantage of a standardised accident classification system is that statistical methods can be used to gain more insight into accident causation as well as the corrective actions and root cause.

The Incident Categories, (IC), Root Cause, (RC) and Direct Cause (DC) have been modelled on various parameters currently in use within the industry, attempting to harmonise all of these into a single format that will be recognised as an industry standard.

The Main Objectives of the CARP Database

To provide a recognised respected source of accident information for use by the INTERTANKO secretariat and its members. (This will be very useful in many respects, because although much of this type of information is available to the Oil companies, the P&I clubs and the Classification Societies, all are unable to share this information with INTERTANKO due to confidentiality clauses), thus by establishing our own system, loosely based upon the type of information that is voluntarily reported to the oil companies, we are able to:

  • Harness detailled accident data information which is currently not available to INTERTANKO
  • Learn from the mistakes and corrective actions of others
  • Prevent re-occurrence of similar accidents
  • Enhance supporting information by way of justifications in papers produced for example to IMO and others
  • Reduce the number of member surveys needed to undertake to gather such information
  • Establishes a recognised industry platform.
  • Establishes an industry standardised series of categories of accidents, direct causes and root causes and corrective actions.

  • To provide a recognised respected source of accident information for use by the INTERTANKO secretariat and its members. (This will be very useful in many respects, because although much of this type of information is available to the Oil companies, the P&I clubs and the Classification Societies, all are unable to share this information with INTERTANKO due to confidentiality clauses), thus by establishing our own system, loosely based upon the type of information that is voluntarily reported to the oil companies, we are able to:

    • Harness detailled accident data information which is currently not available to INTERTANKO
    • Learn from the mistakes and corrective actions of others
    • Prevent re-occurrence of similar accidents
    • Enhance supporting information by way of justifications in papers produced for example to IMO and others
    • Reduce the number of member surveys needed to undertake to gather such information
    • Establishes a recognised industry platform.
    • Establishes an industry standardised series of categories of accidents, direct causes and root causes and corrective actions.

    To provide a recognised respected source of accident information for use by the INTERTANKO secretariat and its members. (This will be very useful in many respects, because although much of this type of information is available to the Oil companies, the P&I clubs and the Classification Societies, all are unable to share this information with INTERTANKO due to confidentiality clauses), thus by establishing our own system, loosely based upon the type of information that is voluntarily reported to the oil companies, we are able to:

    • Harness detailled accident data information which is currently not available to INTERTANKO
    • Learn from the mistakes and corrective actions of others
    • Prevent re-occurrence of similar accidents
    • Enhance supporting information by way of justifications in papers produced for example to IMO and others
    • Reduce the number of member surveys needed to undertake to gather such information
    • Establishes a recognised industry platform.
    • Establishes an industry standardised series of categories of accidents, direct causes and root causes and corrective actions.
    • Address some of the issues which have been highlighted within the wider issue of "The Multiplicity of Acceptability" and will assist in the development of common standards for root cause analysis and corrective actions.

The CARP database provides a simple functionality allowing the INTERTANKO member to quickly and easily enter incident data, whilst certain parameters require compulsory entry of data during completion of the on line incident report.

Although the company name and contact details are requested please note that this information will only be shared with the secretariat to enable us to verify information should it become necessary, this information will how ever remain fully confidential as all data entered into CARP is via a user name and password mechanism, enabling members to input their own incident data in a fully confidential basis.

A good accident classification system is:

  • easy to apply
  • covers as many aspects as possible: human performance, organisational issues, technological issues, threat and error management,
  • enables recreation of causal factors and how they correlate with each other

An accident classification system is NOT

·        just a database were all factual information of an accident is stored

To assist in the process the following aims to provide relevant guidance and information on the general principals on incident/accident assessment identification of Direct Cause and Root cause analysis.

Accident Analysis

This is carried out in order to determine the cause or causes of an accident or series of accidents so as to prevent further incidents of a similar kind. Accident Analysis is performed in four steps:
  1. Fact gathering After an accident has happened; a process starts to gather all possibly relevant facts that may contribute to understanding the accident.
  2. Fact Analysis: After the forensic process has been completed the history of the accident is reconstructed and checked for consistency and plausibility.
  3. Conclusion: If the accident history is sufficiently informative conclusions can be drawn about causation and contributing factors.
  4. Corrective Action: In most cases the development of corrective actions is desired or recommendations have to be issued to prevent further accidents of the same kind.

Accident Analysis methods

These can be divided into three categories:

  1. Causal Analysis: uses the principle of causality is to determine the course of events. 
  2. Expert Analysis: relies on the knowledge and experience of field experts.
  3. Organisational Analysis: relies on systemic theories of organisation. Most theories imply that if systems behaviour stayed within the bounds of the organisation then no accidents can occur. 
General principles of assessing Root Cause (RC)
  1. Aiming performance improvement measures at root causes is much more effective than merely treating the symptoms of a problem.
  2. To be effective, RC must be performed systematically, with conclusions and causes backed up by documented evidence.
  3. There can be more than one potential root cause for a given problem.
  4. To be effective the analysis must establish all known causal relationships between the root cause(s) and the defined problem.
  5. Root cause analysis transforms an old culture that reacts to problems to a new culture that solves problems before they escalate, creating a reduction in risk of re-occurance.
General process for performing and documenting an RC-based Corrective Action

Notice that RC (in steps 3, 4 and 5) forms the most critical part of successful corrective action, because it directs the corrective action at the root of the problem i.e. it is effective solutions that are sought, not root causes. Root causes are secondary to the goal of prevention, and are only revealed after we decide which solutions to implement.

  1. Define the problem.
  2. Gather data/evidence.
  3. Ask why and identify the causal relationships associated with the defined problem.
  4. Identify which causes if removed or changed will prevent recurrence.
  5. Identify effective solutions that prevent recurrence, are within your control, meet your goals and objectives and do not cause other problems.
  6. Implement the recommendations.
  7. Observe the recommended solutions to ensure effectiveness.
  8. Variability Reduction methodology for problem solving and problem avoidance.

RC is often considered to be an iterative process, and is frequently viewed as a tool of  continous improvement.

RC initially is a reactive method of problem detection and solving. This means that the analysis is done after an event has occurred. By gaining expertise in RC it becomes a pro-active method. This means that RC is able to forecast the possibility of an event even before it could occur.

Root cause analysis is not a single, sharply defined methodology; there are many different tools, processes, and philosophies of RC in existence. However, most of these can be classed into five, very-broadly defined "schools" that are named here by their basic fields of origin: safety-based, production-based, process-based, failure-based, and systems-based.

  • Safety-based RC descends from the fields of accident analysis and occupational health and safety.
  • Production-based RC has its origins in the field of quality control for industrial manufacturing.
  • Process-based RC is basically a follow-on to production-based RC, but with a scope that has been expanded to include busines processes.
  • Failure-based RC is rooted in the practice of failure analysis as employed in  engineering and maintenance.
  • Systems-based RC has emerged as an amalgamation of the preceding schools, along with ideas taken from fields such as change management, risk management, and system analysis.

To enter data into CARP INTERTANKO Members need to be logged onto the INTERTANKO website - a username and password are required, which can be obtained from the INTERTANKO Secretariat.

Contact Vetting Committee:
Ajay Gour
Sr. Manager, Chemicals & Vetting

INTERTANKO London
Phone: + 44 20 7977 7017
Fax: + 44 (0) 20 7977 7011
Email: ajay.gour@intertanko.com

Contact CARP Administration:
Adele Garnett
Assistant Manager, Marine.

INTERTANKO London
Phone: + 44 20 7977 7013
Fax: + 44 (0) 20 7977 7011
Email: adele.garnett@intertanko.com

 Terms and Conditions of for using the INTERTANKO CARP Database

The use of the CARP database is subject to the following conditions:

The content of the CARP will be used by INTERTANKO to provide feedback to members and provide lessons learned to the benefit of all INTERTANKO members.

It may be subject to change without notice.

The CARP and its contents are copyright of INTERTANKO. Any redistribution or reproduction of all or part of the contents in any form is prohibited save that the user may print or download to a local hard disk extracts for the user’s own use.

The CARP and the use of it are governed by English Law. The English courts shall have exclusive jurisdiction over any disputes connected to or arising out of use of the CARP.

By clicking the following proceed button you agree to be bound by the above captioned terms and conditions of use - Click PROCEED to access the CARP database.