Maritime Incident Investigation Needs a Systems Approach | Pierre Dominé

In this episode of Action Matters, we speak with Pierre, a maritime safety professional, investigator, and former Master with nearly three decades of experience at sea and ashore. We discuss why maritime incidents continue to repeat despite procedures, audits, and reporting systems, why "human error" is often an incomplete explanation, and why effective investigations require a systems approach rather than a search for someone to blame. Pierre shares his perspective on root causes and contributing factors, just culture, investigation methodologies, operational realities on board, and the role technology can play in learning from incidents and preventing future events. 0:00 Introduction 00:58 Pierre's Maritime Journey 02:44 Why Incidents Keep Repeating 06:18 Root Causes vs Contributing Factors 09:56 Are Procedures Really Helping? 12:29 Human Error: Cause or Excuse? 17:08 What Crews Hide During Investigations 18:46 Measuring Investigation Effectiveness 24:14 How To Know an Investigation Worked 29:40 The Most Harmful Investigation Practices 32:38 What Should Change in Maritime Investigations? 37:30 Could We Investigate Without Templates? 39:40 Why Action Matters This conversation is for maritime professionals, ship managers, safety leaders, QHSE teams, investigators, auditors, seafarers, and anyone interested in maritime safety, incident investigation, human factors, and organizational learning. Pierre is a maritime safety and incident investigation specialist with extensive experience as a seafarer, Master, superintendent, and investigator. His work focuses on safety culture, human behaviour, risk-based thinking, and operational excellence. Subscribe to Action Matters for conversations about what actually works in real operations. LinkedIn: Pierre Dominé:   / pierre-domin%c3%a9-afni-1628247a   Vladimir Ponomarev:   / ponomarevvladimir   #maritime #shipping #maritimesafety #incidentinvestigation #humanfactors #safetyculture #leadership #maritimeindustry #shippingindustry #rootcauseanalysis #justculture #operationalexcellence #QHSE #maritimepodcast #ActionMattersPodcast