Extended Operational and Trade Vocabulary
Maritime Casualties and Investigation glossary
The classification and investigation of maritime casualties: casualty categories (abandoned, total loss), the Casualty Investigation Code, the distinction between administrative, judicial, and criminal inquiries, action messages and safety recommendations, and the bodies (MAIB, NTSB, BSU, ATSB) that conduct them. Grounds each term in the investigation framework that produces lessons rather than blame.
215 defined terms.
A
- Abandoned
- Casualty classification where master and crew leave the vessel with no intent to return.
- Abandonment of ship
- Decision by the master to evacuate, typically by lifeboat, liferaft, or rescue craft.
- Accident
- General term encompassing casualties and incidents resulting in loss, damage, injury, or pollution.
- Action message
- Output of a safety investigation directed at a specific party for corrective action.
- Administrative investigation
- Inquiry conducted by a maritime administration, distinct from a judicial or criminal proceeding.
- AIBN
- Accident Investigation Board Norway, the former name of the Norwegian Safety Investigation Authority (NSIA) before 2023.
- AIS data
- Automatic Identification System tracks used to reconstruct vessel movements during a casualty investigation.
- Alcohol
- Recurring causal factor in groundings and collisions, regulated under STCW Code Section A-VIII/1 blood-alcohol limit of 0.05 percent.
- Allision
- contact between a moving vessel and a fixed object such as a wharf or bridge.
- Amoco Cadiz (1978)
- VLCC that grounded off Brittany on 16 March 1978, spilling 223,000 tonnes of crude, prompting MARPOL Annex I tightening and EU coastal-state response measures.
- AMVER
- Automated Mutual-Assistance Vessel Rescue system run by the US Coast Guard, used for SAR coordination and highlighted in the El Faro investigation.
- Andrea Doria (1956)
- Italian liner that collided with MS Stockholm off Nantucket on 25 July 1956 and sank with 46 deaths; foundational case in radar-assisted collision study.
- Anglo-Saxon investigative model
- No-blame safety investigation tradition exemplified by MAIB, NTSB, and TSBC.
- Apparent cause
- Surface-level reason for a casualty before deeper root cause analysis.
- Arrival report
- Mandatory ship report on entering port, used by port-state and casualty investigators.
- ATSB
- Australian Transport Safety Bureau, marine investigator established 2009 from the Australian Transport Safety Investigation Act 2003.
- Audit Trail
- Documented chain of survey evidence including photos, logs, and instrument records.
- Authorized representative
- Person designated by a state, owner, or class to interface with investigators.
B
- Baltic Ace (2012)
- Car carrier that sank after collision with the Corvus J in the North Sea on 5 December 2012, with 11 lives lost.
- Bareboat Charter
- Demise charter under which the charterer becomes disponent owner.
- BEAmer
- Bureau d'Enquetes sur les Evenements de Mer, the French marine casualty investigator.
- Berge Istra (1975)
- Ore-oil carrier lost without trace off the Philippines on 30 December 1975 with two survivors.
- Berge Vanga (1979)
- Sister to Berge Istra, vanished in the South Atlantic in October 1979 with all 40 hands.
- Black swan event
- Low-probability, high-impact casualty used in resilience analysis.
- Blame culture
- Organizational climate that discourages reporting and is contrasted with just culture.
- Bourbon Rhode (2019)
- Anchor-handler lost in Hurricane Lorenzo on 26 September 2019 with 11 of 14 crew missing; investigated by BEAmer.
- Bow visor failure
- Mechanism implicated in the loss of MS Estonia in 1994.
- BRM
- Bridge Resource Management, the systematic use of bridge personnel and information for safe navigation.
- Broken in two
- Casualty descriptor when hull girder fails amidships, as with MV Derbyshire and MOL Comfort.
- BSU
- Bundesstelle fur Seeunfalluntersuchung, the German Federal Bureau of Maritime Casualty Investigation, established under the SUG 2002.
- Bulk Jupiter (2015)
- Geared bulk carrier that sank off Vietnam on 2 January 2015 with bauxite cargo and 18 lives lost, triggering the IMO bauxite circular and 2017 IMSBC Code amendments.
- Bulker loss campaign 1990s
- Series of dry-bulk losses including Derbyshire that drove SOLAS Chapter XII in 1997.
- Bunker spill
- Pollution from a vessel's fuel oil bunkers, governed by the Bunkers Convention 2001.
C
- Capsize
- Overturn.
- Cargo shift
- Movement of cargo within holds or on deck, a recurring contributor to capsize and foundering.
- Casualty
- a marine accident causing or threatening loss.
- Casualty Investigation Code
- Code of the International Standards and Recommended Practices for a Safety Investigation into a Marine Casualty or Marine Incident, mandatory under SOLAS XI-1/6.
- Causal factor
- Condition or action without which the casualty would not have occurred as it did.
- Cause and effect diagram
- Ishikawa or fishbone diagram used in root cause analysis.
- Chain of events
- Sequenced narrative of actions and conditions reconstructed by investigators.
- Chemical release
- Casualty involving spillage of MARPOL Annex II or IBC Code substances.
- Class society role
- Recognized organizations are parties of interest in casualties involving their classed vessels.
- Closed investigation
- Inquiry whose final report has been issued and is no longer active.
- Coast Guard board of inquiry
- US Coast Guard Marine Board of Investigation under 46 CFR Part 4, the highest level of USCG investigation.
- Coastal State
- State with sovereignty or jurisdiction over adjacent maritime zones.
- Coincident causes
- Two or more independent factors that align to produce a casualty.
- Collision
- Casualty in which two or more moving vessels strike one another.
- Common cause failure
- Single underlying defect that defeats redundant safeguards.
- Complacency
- Behavioral factor in which routine experience suppresses vigilance.
- Compliance gap
- Difference between regulatory requirement and observed practice on board.
- Contact
- Casualty in which a vessel strikes a fixed or floating object that is not a vessel, equivalent to allision in US usage.
- Costa Concordia (2012)
- Italian cruise ship that grounded off Isola del Giglio on 13 January 2012 with 32 deaths; investigated by the Italian Marine Casualties Investigative Body.
- Crew change failure
- Logistical breakdown that prolongs tours of duty, a fatigue contributor highlighted during the COVID-19 period.
- Critical safety equipment
- Items whose failure can directly cause casualty, including steering gear, main engine controls, and navigational lights.
D
- Damage Stability
- Required for passenger and cargo ships under SOLAS II-1, Parts B-1 and B-2.
- Deficiency
- PSC finding requiring rectification.
- Departure inspection
- Pre-sailing check whose omission is repeatedly cited in groundings.
- Derbyshire (1980)
- OBO bulk carrier lost in Typhoon Orchid on 9 September 1980 with 44 lives; the 2000 reopened formal investigation linked the loss to hatch cover and hull-girder failure.
- Designated person ashore
- DPA, ISM Code link between ship and shore management.
- DMAIB
- Danish Maritime Accident Investigation Board, established 2011 under the Danish Act on Safety at Sea.
- Double hull
- Submarine construction with separate pressure and outer hulls.
- Drift grounding
- Grounding that follows a loss of propulsion and uncontrolled set.
E
- ECDIS misuse
- Improper configuration or interpretation of Electronic Chart Display and Information System, cited in groundings such as CFL Performer 2008 and Ovit 2013.
- Edmund Fitzgerald (1975)
- Great Lakes ore carrier that sank in Lake Superior on 10 November 1975 with 29 lives; investigated by USCG Marine Board and NTSB.
- El Faro (2015)
- US-flag ro-ro that foundered in Hurricane Joaquin on 1 October 2015 with 33 lives; NTSB and USCG investigations addressed weather routing, BRM, and AMVER use.
- EMCIP
- European Marine Casualty Information Platform, EMSA's accident database mandated by Directive 2009/18/EC.
- Empress of Ireland (1914)
- Canadian Pacific liner that sank in the St. Lawrence after collision with SS Storstad on 29 May 1914 with 1,012 lives lost.
- EMSA
- European Maritime Safety Agency, supporting Paris MoU and EU Member States on PSC.
- Engine room fire
- Recurring casualty type investigated under SOLAS Chapter II-2 standards.
- Erika (1999)
- Maltese-flag product tanker that broke in two off Brittany on 12 December 1999 spilling about 19,800 tonnes of heavy fuel oil; triggered the EU Erika I and Erika II packages.
- ERM
- Engine Room Resource Management, the engineering counterpart to BRM.
- Estonia (1994)
- Ro-pax ferry that sank in the Baltic on 28 September 1994 with 852 deaths; the Joint Accident Investigation Commission report led to SOLAS Chapter II-1 amendments and the Stockholm Agreement.
- Ever Forward (2022)
- Container ship grounded in Chesapeake Bay on 13 March 2022 for 35 days; NTSB report cited pilot distraction.
- Ever Given (2021)
- 20,000 TEU container ship grounded across the Suez Canal from 23 to 29 March 2021; investigated by Panama Maritime Authority as flag state.
- Exxon Valdez (1989)
- Tanker that grounded on Bligh Reef on 24 March 1989 spilling about 37,000 tonnes of crude; NTSB report led directly to OPA 90 and the double-hull mandate.
F
- Failure mode
- Manner in which equipment or a system fails, classified during technical investigation.
- Fatigue
- Physiological factor codified under STCW Code Section A-VIII/1 and recurrent in collisions and groundings.
- Fault tree analysis
- Top-down deductive technique mapping how a casualty could occur from contributing failures.
- Final report
- Concluding public document of a safety investigation under the Casualty Investigation Code.
- Fire
- Casualty type covering uncontrolled combustion on board, regulated under SOLAS Chapter II-2.
- Fishbone diagram
- Cause-and-effect graphic developed by Kaoru Ishikawa, used in root cause analysis.
- Five Whys
- Iterative questioning technique to reach a root cause, attributed to Sakichi Toyoda.
- Flag State
- State of the ship's nationality, with jurisdiction under UNCLOS Article 94.
- FMECA
- Failure Mode, Effects and Criticality Analysis, used for both design assessment and post-casualty study.
- Foundering
- Loss of a vessel by flooding and sinking, distinct from capsizing or breakup.
- Front line operator
- Crew member directly executing the task in which the casualty occurred.
G
- GISIS
- Global Integrated Shipping Information System, IMO's public and restricted-access database platform.
- GMDSS distress
- Activation of Global Maritime Distress and Safety System equipment, a key event marker in casualties.
- Golden hour
- Early window after casualty during which intervention most affects survival.
- Grounding
- Casualty in which a vessel's hull contacts the seabed, the shore, or an underwater obstruction.
H
- Hatch cover failure
- Mechanism implicated in bulk-carrier losses including Derbyshire.
- HAZID
- Hazard Identification workshop used in design and post-casualty review.
- Hebei Spirit (2007)
- VLCC struck by a drifting crane barge off South Korea on 7 December 2007, spilling about 10,900 tonnes.
- Herald of Free Enterprise (1987)
- Townsend Thoresen ro-pax that capsized off Zeebrugge on 6 March 1987 with 193 deaths; the Sheen Inquiry led to the ISM Code adopted in 1993.
- Hoegh Osaka (2015)
- Car carrier deliberately grounded on Bramble Bank on 3 January 2015 to prevent capsize; MAIB report on cargo-loading and stability calculation errors.
- Holes in the cheese
- Reference to Reason's Swiss cheese model of accident causation.
- Hong Kong MAIS
- Marine Accident Investigation Section of the Marine Department of Hong Kong SAR.
- Hot work fire
- Fire originating from welding, cutting, or grinding without adequate controls.
- Hull damage
- Casualty descriptor covering structural failure, fracture, or set-in plating not amounting to loss.
- Human element
- Collective term for human, organizational, and cultural factors in casualty causation.
I
- IAMSAR Manual
- Joint IMO/ICAO SAR procedures manual.
- IMO casualty reporting
- Mandatory flag-state submission under SOLAS Regulation I/21 and MARPOL Annex I Regulation 4.3, channeled through GISIS.
- Incident
- Marine event short of a casualty that could have led to one, sometimes called a near miss.
- Interim statement
- Provisional finding issued before the final report, encouraged under the Casualty Investigation Code where lessons cannot wait.
- Investigation in lieu of
- Arrangement allowing one state to investigate on behalf of another with consent.
- Investigation report register
- Public listing of safety investigation reports, maintained by states and aggregated in GISIS.
- Investigator-in-charge
- Lead investigator designated by the safety investigation authority.
- Ishikawa diagram
- Synonym for fishbone diagram.
- ISM Code
- International Safety Management Code, mandatory under SOLAS IX.
J
- Joint investigation
- Cooperative inquiry involving more than one substantially interested state.
- JRCC
- Joint Rescue Coordination Centre handling combined aeronautical and maritime SAR.
- JTSB
- Japan Transport Safety Board, marine division responsible for casualty investigation since 2008.
- Just culture
- Reporting environment that distinguishes honest error from reckless behavior; central to Casualty Code philosophy.
K
- KAIST report
- Korean Advanced Institute of Science and Technology technical input to the Sewol investigation.
- Key event
- Time-stamped action or condition logged on the casualty timeline.
- Knock-on effect
- Secondary failure precipitated by an initial casualty event.
- Korea Maritime Safety Tribunal
- Marine casualty adjudication body of the Republic of Korea.
L
- Latent failure
- Hidden weakness in the system, often organizational, awaiting an active trigger; from Reason's model.
- Lead investigating state
- State responsible for conducting the safety investigation under the Casualty Code.
- Less serious casualty
- Casualty category in MSC.255(84) below serious, used for trend data.
- Lifeboat-on-fall accident
- Casualty during launch or recovery, often involving on-load release hooks.
- Listing
- Persistent heel of a vessel due to flooding, cargo shift, or stability loss.
- LOF agreement
- Lloyd's Open Form salvage contract, often invoked in major casualties.
- Lookout absence
- Watchkeeping deficiency under COLREGs Rule 5 cited in many collision reports.
- Lusitania (1915)
- Cunard liner sunk by U-20 off Kinsale on 7 May 1915 with 1,198 deaths; subject of the Mersey Inquiry.
M
- MAIB
- Marine Accident Investigation Branch of the United Kingdom, established under the Merchant Shipping Act 1988 and operating from Southampton.
- MAIIF
- Marine Accident Investigators' International Forum, the global association of state marine investigators founded in 1992.
- MAIU
- Marine Accident Investigation Unit of the Republic of Ireland, an independent body under the Merchant Shipping (Investigation of Marine Casualties) Act 2000.
- Marine casualty
- Event defined in MSC.255(84) covering death, loss, damage, grounding, collision, structural failure, or pollution.
- Marine incident
- Event other than a marine casualty that could endanger ship, persons, or environment.
- MARS
- Mariners' Alerting and Reporting Scheme run by The Nautical Institute, an anonymized near-miss database.
- MASTREP
- Australian Modernised Ship Reporting System operated by AMSA.
- MOB
- Man overboard.
- MOL Comfort (2013)
- Container ship that broke in two in the Indian Ocean on 17 June 2013; investigated by ClassNK and Bahamas as flag state.
- MRCC
- Maritime Rescue Coordination Centre established under SOLAS Chapter V Regulation 7.
- MRSC
- Maritime Rescue Sub-Centre operating under an MRCC.
- MSC Hong Kong
- Marine Department's Marine Accident Investigation and Shipping Security Policy Branch.
- MSC Napoli (2007)
- Container ship beached off Branscombe on 20 January 2007 after structural failure; MAIB report focused on hull-girder loads.
- MSC.255(84)
- IMO Resolution adopting the Casualty Investigation Code on 16 May 2008.
N
- Near miss
- Event with potential for casualty avoided by chance or intervention; ISM Code 9.1 reporting expected.
- NSIA
- Norwegian Safety Investigation Authority, formerly AIBN, with a marine department.
- NTSB
- National Transportation Safety Board of the United States, independent agency conducting major marine investigations alongside the USCG.
- Nurdle spill
- Loss of pre-production plastic pellets, prominent after the X-Press Pearl casualty.
O
- Occurrence
- Generic term used in safety investigation for any reportable event.
- Oil Pollution Casualty
- Spill event reportable under MARPOL Annex I Regulation 37 and the OPRC Convention.
- OPA 90
- Oil Pollution Act 1990, US oil pollution liability statute.
- OSC
- On-Scene Coordinator designated under the IAMSAR Manual to lead SAR operations on site.
P
- Parametric roll
- Resonant roll growth in head/following seas due to GM variation.
- Passive countermeasure
- Design feature, like a double hull, that mitigates casualty consequence.
- Pilot error
- Causal classification when the pilot's actions are central to the casualty.
- Port of Refuge
- Port called at to address peril, often triggering general average.
- Port State
- State exercising jurisdiction over foreign ships voluntarily in its ports.
- Post-casualty inspection
- Survey conducted by class and flag after a casualty before return to service.
- Prestige (2002)
- Bahamas-flag single-hull tanker that broke up off Galicia on 19 November 2002 spilling about 63,000 tonnes; led to EU acceleration of single-hull phase-out and port-of-refuge rules.
- Probable cause
- Term used by NTSB for the determined principal cause and contributing factors.
Q
- Quality of evidence
- Investigator's assessment of reliability and weight of each evidence element.
- Quick-release failure
- Lifeboat hook or mooring release malfunction implicated in injuries and deaths.
R
- RAIB
- Rail Accident Investigation Branch of the UK, a sister body to MAIB under the Department for Transport.
- RCC
- Rescue Coordination Centre, generic IAMSAR term.
- Recommendation
- Output of a safety investigation directed to a party empowered to act.
- Reopened investigation
- Reactivation of a closed case when significant new evidence emerges, as with Derbyshire.
- Restricted information
- Material protected from disclosure under the Casualty Code unless overriding public interest applies.
- Risk-based investigation
- Approach prioritizing systemic lessons over individual blame.
- Root cause
- Underlying factor whose correction would prevent recurrence of the casualty pathway.
S
- Safety bulletin
- Urgent investigator publication issued before the final report when immediate action is needed.
- Safety investigation
- Investigation conducted under the Casualty Code with the sole objective of preventing future casualties, separate from criminal or civil proceedings.
- Safety Management Practices
- Operational realization of the ISM Code through the SMS on each ship.
- SAR
- Search and Rescue, governed by the 1979 SAR Convention and IAMSAR Manual.
- SCR
- SAR Cooperation Plan required under SOLAS Chapter V Regulation 7.3 for passenger ships.
- Sealed records
- VDR and bridge audio data protected from open disclosure under the Casualty Code.
- Sequence of events
- Reconstructed chronological list of actions and conditions.
- Serious casualty
- MSC.255(84) category below very serious, involving fire, explosion, grounding, contact, heavy weather damage, pollution, or breakdown necessitating towage.
- Sewol (2014)
- South Korean ro-pax that capsized on 16 April 2014 with 304 deaths, mostly students; investigated by the Korean Coast Guard and the Special Investigation Commission.
- Sheen Report
- 1987 report by Mr Justice Sheen on Herald of Free Enterprise.
- Single point of failure
- Component whose loss defeats the entire safety function.
- Sinking
- Loss of a vessel beneath the surface, typically by flooding.
- SOLAS Chapter II-1 amendments
- Post-Estonia changes adopted by MSC in 1995 strengthening ro-pax damage stability and visor design.
- SOLAS Chapter XI-1 Regulation 6
- Mandatory provision making MSC.255(84) Casualty Investigation Code binding.
- SOLAS Regulation I/21
- Flag-state obligation to investigate casualties to its ships and supply reports to IMO.
- SOSREP
- UK Secretary of State Representative for Maritime Salvage and Intervention.
- SS Marine Sulphur Queen (1963)
- T2 tanker lost in the Bermuda Triangle on 4 February 1963 with 39 crew; USCG Marine Board report cited structural and explosive hazards.
- Stand-on vessel error
- COLREGs Rule 17 misapplication common in collision causation.
- Stellar Daisy (2017)
- VLOC that sank in the South Atlantic on 31 March 2017 with 22 lives lost, prompting bulk-carrier monitoring and VLOC inspection initiatives.
- Stockholm Agreement
- Damage stability requirement for Ro-Pax ferries.
- Stranding
- Grounding that holds the vessel fast, often with hull damage.
- Substantially interested state
- State defined in MSC.255(84) that has a significant interest in the casualty, including flag, coastal, port, and seafarer nationality states.
- Suez Canal grounding
- Casualty type exemplified by Ever Given 2021 and the Tropic Brilliance grounding 2004.
- Survival craft failure
- Casualty involving lifeboats, liferafts, or rescue boats during emergency or drill.
- Swiss cheese model
- James Reason's framework of layered defenses with shifting holes, widely used in casualty analysis.
T
- Tanker casualty record
- Cumulative database maintained by ITOPF on oil spills over 7 tonnes since 1970.
- Timeline reconstruction
- Investigator product mapping events second-by-second from VDR, AIS, and witness data.
- Titanic (1912)
- White Star liner that struck an iceberg on 14 April 1912 and sank with 1,496 lives lost; the British Wreck Commissioner's Inquiry led to SOLAS 1914.
- Torrey Canyon (1967)
- Liberian tanker grounded on Seven Stones reef on 18 March 1967 spilling about 119,000 tonnes; spurred the 1969 Intervention Convention and CLC.
- TSBC
- Transportation Safety Board of Canada, marine investigator under the Canadian Transportation Accident Investigation and Safety Board Act 1989.
- TSIB
- Transport Safety Investigation Bureau of Singapore, established 2016 under the Ministry of Transport.
U
- UKHO casualty notice
- Notice to Mariners issued by the UK Hydrographic Office on wreck or obstruction after a casualty.
- Unsafe act
- Operator-level error or violation as classified in HFACS analysis.
- Unsafe condition
- Workplace, equipment, or environmental factor predisposing the casualty.
- USCG Marine Board of Investigation
- Highest tier of US Coast Guard casualty inquiry under 46 CFR Part 4.
V
- VDR
- Voyage Data Recorder, required under SOLAS V/20.
- Very serious casualty
- Top MSC.255(84) category involving total loss of the ship, loss of life, or severe pollution.
- Vessel traffic service involvement
- VTS recordings used to reconstruct port and approach casualties.
W
- Wakashio (2020)
- Japanese-owned bulk carrier grounded on Pointe d'Esny reef, Mauritius, on 25 July 2020, spilling about 1,000 tonnes of VLSFO; investigated by Panama as flag state and the Mauritian Court of…
- Watchkeeping deficiency
- Failure to comply with STCW Chapter VIII watch standards, common in collision and grounding causation.
- Weather routing
- Optimum-track routing per environmental forecasts.
- Witness interview protocol
- Investigator method ensuring voluntary, recorded, and rights-respecting interviews under the Casualty Code.
X
- X-Press Pearl (2021)
- Singapore-flag container ship that caught fire off Colombo on 20 May 2021 and sank on 2 June 2021, releasing billions of plastic pellets; investigated by Singapore TSIB and Sri Lanka.
Y
- Yard trial failure
- Defect surfacing on builder's sea trials that, if undocumented, can become a latent failure factor later.
- Year-on-year casualty trend
- EMSA and IMO annual statistics aggregated from EMCIP and GISIS submissions.
Z
- Zone of responsibility
- Geographic coverage of a regional PSC MOU, defined in its Memorandum.
- Zulu Time
- Coordinated Universal Time (UTC), the navigation reference.