USCG Marine Board of Investigation

 The US Coast Guard investigates marine casualties for two purposes: (1) to improve marine safety by learning what went wrong; and (2) to determine if a professional mariner engaged in misconduct.  The level of effort applied to the investigation varies with the seriousness of the casualty.  Minor casualties generally lead to informal investigations.  Major casualties, such as those involving multiple loss of life or loss of an inspected vessel, generally lead to a formal investigation.  The highest level of investigation in the Coast Guard’s Marine Safety Program is the Marine Board of Investigation (MBI), frequently called simply a Marine Board.  The MBI is convened by the Commandant.  It consists of three or more members.  The senior member is the Chair.  The junior member is the Recorder.  Specialists and technical experts may also be assigned to assist the Marine Board in its investigation.  The Chair sets the strategy for the investigation and assigns duties.  The Recorder is responsible for collecting pertinent records and evidence.  An initial step in the investigative process is to develop a timeline of events surrounding the casualty.  This involves collecting factual information; classifying the information into actions, events, and conditions; and determining their sequence.  Once all the pertinent information is assembled, the Marine Board conducts a causal analysis.  It identifies the initiating and subsequent events; identifies unsafe acts or decisions; conducts human error analysis on the identified unsafe acts and decisions; and identifies any latent unsafe conditions that may have contributed to the unsafe acts and decisions.  The Marine Board then draws conclusions, documenting the results of the causal and human error analysis.  Finally, the Marine Board identifies actions that it believes should be taken to address and correct unsafe actions, decisions, and conditions identified by the investigation and makes formal recommendations.  The completed report of investigation is then sent up the chain of command to the Commandant for consideration and action as appropriate.  Safety recommendations should only address those unsafe conditions over which some level of control can be exercised through the implementation and use of control measures, such as conventions, laws, regulations, policies, or procedures.  Safety recommendations should not be made when the unsafe condition was the result of non-compliance with an existing control measure.