690/ Incident Reporting, Investigation and Management / 992
Incident
R
e
p
ortin
g,
In
v
esti
g
ation
and Mana
g
e
m
ent
BOS-
P
RD-0
3
02.900
8
01
7
. Ter
m
s and definitions
5 Whys
T
h
e 5
W
hy
s
i
s
u
sed to
i
dent
i
fy
t
h
e root
c
a
u
ses o
f
a prob
l
em to avo
i
d ana
l
yz
i
ng s
u
per
f
ici
a
l c
a
u
ses
.
BMA
B
a
h
amas Mar
i
t
i
me
Au
t
h
or
i
t
y
.
BD
O
B
o
u
rbon
D
o
cki
ng
.
CEO
C
h
i
e
f
Ex
e
c
u
t
i
ve
O
ff
ic
er
.
CO
M
E
X
BOURBON Ex
e
c
u
t
i
ve
C
omm
i
ttee
:
C
h
i
e
f
Ex
e
c
u
t
i
ve
O
ff
ic
er
, C
h
i
e
f
O
perat
i
ng
O
ff
ic
er
and
C
h
i
e
f
Fi
nan
ci
a
l
O
ff
ic
er
.
C
ontri
bu
tin
g C
a
u
se
U
nsa
f
e
c
ond
i
t
i
on
(
s
)
or
u
nsa
f
e a
c
t
(
s
)
wh
ic
h
i
mmed
i
ate
l
y
pre
c
eded
t
h
e
i
n
ci
dent
.
C
orrecti
v
e actions
A
c
t
i
ons
ta
k
en
to
c
orre
c
t
i
ss
u
es
i
dent
i
f
i
ed
f
o
ll
o
w
i
ng an
i
n
ci
dent
.
Direct
C
a
u
se
T
h
e
i
mmed
i
ate
event
or
c
ond
i
t
i
on
t
h
at
c
a
u
sed
t
h
e
i
n
ci
dent
.
DPA
D
es
i
gnated Person
A
s
h
ore
.
FA
C
Fi
rst
A
i
d
C
ase
.
A
n
y
s
i
ng
l
e
treatment
and
s
u
bse
q
u
ent
observat
i
on
o
f
m
i
nor
c
u
ts
,
b
u
rns
,
sp
li
nters
et
c.
wh
ic
h
does
not
ord
i
nar
il
y
re
q
u
i
re med
ic
a
l c
are
. S
u
c
h
treatment
and
observat
i
ons
are
c
ons
i
dered
f
i
rst
a
i
d
wh
et
h
er
prov
i
ded
b
y
t
h
e
onboard
c
re
w
,
b
y
a
p
hy
s
ici
an
or
ot
h
er
reg
i
stered
pro
f
ess
i
ona
l
med
ic
a
l
personne
l. (
re
f
.
OCI
M
F).
FAT
F
ata
li
t
y
H
SE
incident
T
h
i
s
i
s an
u
n
c
ontro
ll
ed or
u
np
l
anned event
,
or se
q
u
en
c
e o
f
events
,
t
h
at res
u
l
ts
i
n a
f
ata
li
t
y
or
i
n
j
u
r
y
to a
sea
f
arer onboard s
h
i
p or
wh
il
st as
h
ore on
c
ompan
y
b
u
s
i
ness
.
NOTE 1
:
F
or
H
SE
stat
i
st
ic
p
u
rposes on
l
y
. NOTE 2
:
T
h
i
s e
xcl
u
des
:
-
S
u
ici
de or attempted s
u
ici
de
;
-
C
r
i
m
i
na
l
or terror
i
st a
c
t
i
v
i
t
y
;
-
A
de
li
berate a
c
t on t
h
e part o
f
anot
h
er
i
nd
i
v
i
d
u
a
l;
and
,
-
I
n
ci
dents
wh
ic
h
o
cc
u
r o
ff
t
h
e s
h
i
p b
u
t
wh
ere t
h
e
c
onse
q
u
en
c
es
appear onboard at
some
l
ater t
i
me
.
LTI
L
ost
Ti
me
I
n
j
u
r
y:
A
n
y
i
n
j
u
r
y
or
o
cc
u
pat
i
ona
l ill
ness
t
h
at
fu
ll
y
prevents
a
person
f
rom
per
f
orm
i
ng
t
h
e
i
r
ass
i
gned d
u
t
i
es
on
t
h
e
da
y
a
f
ter
t
h
e
i
n
ci
dent
. (R
e
f
. OCI
M
F)
LW
C
L
ost
W
or
k C
ase
.
Vers
i
on
0
6
. O
r
i
g
i
na
l
date
:
0
5
/0
6
/2012.
Vers
i
on
date
:
3
1/12/201
5
.
Va
li
d
vers
i
on
on
l
y
on
Q
M
S
s
i
te
.U
n
c
ontro
ll
ed do
c
u
ment
wh
en
pr
i
nted
.
Pro
c
ed
u
re prepared b
y:
BOS IS
M
C
oord
i
nator
.
A
pproved
b
y:
BOS
QH
SE
Manager
.
Va
li
dated
b
y:
BOS
Qu
a
li
t
y
R
epresentat
i
ve
.
Page
24
o
f
2
6
690