Learning from incidents and spills

How do we learn from incidents and spills?

We learn from incidents and spills by investigating oil spills and substantial threats of oil spills. Our investigators methodically collect information that answers the who, what, where, when, why, and how of an incident.

Our investigations focus on two important areas:

• Identifying the immediate cause of the incident and determining the factors that led to the immediate cause.
• Helping vessel operators understand why the problem occurred and what issues need to be addressed to prevent further problems.

We may share lessons learned with parties involved in a specific spill incident or with an entire industry. Sometimes, we identify needed changes to rules or law, but most of our data is shared through prevention recommendations.

Prevention recommendations

We've captured more lessons learned in these publications and resources:

• Safety Advisory Bulletins – Describes single issues related to oil handling, human factors, vessel operations, and maintenance
• Vessel incident case studies – In-depth descriptions of specific incidents
• Specific recommendations – Since 1998, we have made over 900 recommendations to approximately 160 parties involved in a spill incidents, regulatory agencies, and third parties.

Although there is no requirement that our recommendations be implemented, many organizations apply them. We think commercial vessel operators will likely see benefits from:

• Investing in technologies and company procedures that help maintain individual attention, alertness, and information gathering.
• Developing operational procedures that provide checks to trap and correct errors of individual judgment.

A detailed view of immediate cause and contributing factors indicates that vessel operators should continue to build and renew their management systems. Vessel operators can also collect their own information on problems and key causes of incidents to help focus oil spill prevention efforts, which can reduce the risk of incidents.