Best Practices for Successful Casualty Investigations

By David Myers

The final success of any fire or explosion investigation is dependent on the management of the incident. 

Fire and explosion incidents on board vessels have always presented challenging situations for the marine industry. However, with the industry as whole facing ever-increasing financial pressures, many of those who suffer from a fire or explosion are seeking out cost saving measures during investigations. As a result, local surveyors or inexperienced investigators are sometimes appointed in place of a more qualified and experienced expert. Often, these local surveyors will lack the detailed knowledge and/or resources necessary to conduct the investigation to a suitably high standard. This means that short-term savings often deliver poor value for money in the long term and offer a false economy. 
If an investigation is not carried out with best practice, all interested parties risk serious financial and legal disadvantage. Among those at risk are vessel owners and operators, managers, charterers, sub charterers as well as those whose cargo was being transported. Along the way, insurers for all the above parties – P&I, H&M or cargo underwriters – are also stakeholders at risk. 
A Best Practice Approach 
While some incidents are small and manageable, other fires and explosions occur extremely rapidly during the same chaotic event. On these occasions, fires can cause explosions and explosions can cause fires. When an incident occurs on a vessel at sea or in a port, the primary concern must be to ensure the safety of the crew and others on board, extinguish the fire and minimize the damage to the vessel and the cargo. However, steps that are taken after safety is assured are also vital, and often mishandled.
A crucial decision to be made as soon as the incident has been stabilized is to decide which experts will be needed on the ground. The correct selection is essential in order to determine the chronology of events at the earliest possible stage in the investigation. If this is established correctly, then the investigation will set off on the right path. During this initial response, a properly equipped, trained and experienced investigator or team of investigators with a keen eye for detail should be mobilized. They should correctly identify, evaluate, collect, process and analyze evidence in a timely manner, as well as managing the scene and all individuals in attendance. 
Fires and explosions are not simple matters; they can occur within very complex systems on board a vessel. Investigators working to determine the cause of an incident can benefit significantly from the support of a highly skilled and qualified multi-disciplinary team. Ship fires and explosions may require the expertise of, for example, marine engineers, metallurgists, fuel chemists, naval architects and cargo scientists, as well as, of course, fire and explosion investigation expertise.
In addition to this multi-disciplinary team of experts, there may also be other experts, surveyors and personnel representing various interested parties and authorities attending the scene. This all needs to be managed effectively to ensure the scene is not compromised and only appropriate and accurate information is provided to other attending interested parties. 
Complex Fire and Explosion Scenarios 
Many fires and explosions on board ships occur within the cargo spaces during carriage of bulk or containerised cargoes, either as a result of the hazardous nature of the cargo itself (e.g. bulk DRI, bulk coal or containerized calcium hypochlorite) or because of operations and equipment associated with cargo carriage (e.g. fumigant explosions/fire or fires caused by buried cargo lights). In this instance, a fire expert with a working knowledge of cargo matters should draw on the expertise of a cargo scientist who can ensure the investigation reaches a timely and successful conclusion. 
In another scenario, if a fire occurs in an engine room, a fire investigator can examine the scene and determine the seat of the fire, source of the fuel, ignition source and map the fire development, growth and spread. However, most engine room fires are a consequence of some machinery or operation failure so to understand how the affected systems operate, and why a machinery malfunction or human error may have occurred to cause the fire or explosion, the fire expert will need the support of a marine engineer in the first place. Hence, the forensic investigation into the root cause of many engine room fires often evolves solely into an engineering exercise. Other resources may also need to be brought to bear, such as metallurgy, fuel chemistry, etc. 
Often the actions of the crew in fire-fighting operations need to be investigated. This requires the fire investigator to have both interviewing skills and the ability to gain a rapid and full understanding of the ship’s fire and safety equipment, aided by the input of a marine engineer. 
The Cost of Poor Evidence 
In addition to assembling the right investigation team, meticulous and painstaking collection, examination, preservation and assessment of evidence provides the highest likelihood of ultimately explaining the cause of a fire or explosion incident. This best practice approach will help prevent the change or loss of invaluable evidence, something that can be difficult, or even impossible, to rectify at a later date. This, in turn, can have a significant impact on the outcome of the investigation. For example, if an investigator does not identify critical evidence, or fails to collect evidence appropriately, their investigation may not add probative value if a case proceeds to litigation.
As legal proceedings are likely to begin months, or even years after the event, the opportunity to collect additional evidence has often passed before errors in an investigation are discovered. In addition to this, the collection of inaccurate or inconclusive evidence may necessitate a new expert to review the investigation. These costs will be in addition to the costs associated with appointing the surveyor or inexperienced investigator who was not ultimately able to provide the service required by the client or during legal proceedings. 
Reducing Long-Term Costs
Although some owners and operators may be reluctant to commit to a perceived higher initial cost, appointing a qualified, recognized and experienced fire investigator or investigation team from the outset is likely to offer significantly better value for money in the long term. The collection, preservation, and analysis of all necessary evidence, managing all parties in attendance at an incident, and presenting evidence clearly and accurately in court is essential to streamline the investigation process and therefore minimise long term costs. A qualified, experienced and multi-disciplinary team is likely to be the quickest route to a successful result. 

The Author
David Myers is part of Brookes Bell’s fire and investigation team, and has attended and managed and investigated fire scenes in a wide variety of environments, including those occurring within and outside the marine industry. 
(As published in the February 2017 edition of Marine News)
Marine News Magazine, page 44,  Feb 2017

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