ABSTRACT

This paper is intended to present the findings of the review of accident investigation reports in engine room fires. The focus of the review was to systematically gather information about organizational factors identified during the investigations in line with relevant recommendations of IMO in this area. The objective of this paper is to demonstrate that information provided in accident reports focuses on events in the accident development observed in the lower levels of the organizational hierarchy of the systems affected by the accidents. Information provided in the accident reports does not allow for conclusions about factors involved on higher levels of the organization. This finding leaves room for two questions. Is the organizational influence on higher levels not as significant as previously suggested? Or, is it simply difficult to address organizational factors on higher organizational levels with currently used methods to gather and analyze information about maritime accidents?