This document discusses different perspectives on accident investigations and highlights issues with current investigation methods. It argues that investigations should look beyond direct causes like human error and examine underlying organizational, cultural, and motivational factors. Investigations often oversimplify situations and fail to understand why professionals took the actions they did. To be effective, investigations need to consider the context and "local rationality" of situations rather than just focusing on rule violations.
Caught in Numbers, Lost in Focus: What it Means to Manage Safety in Global Sh...Nippin Anand
Have you ever wondered about how safety gets measured and how it became one with the ‘science’ of management (granted there is such a term as management science). What is the relationship between occupational health and safety and technical safety? How reliable is compliance as a measure of safety and how could we possibly distinguish between quality and safety?
Human errors are inevitable. No matter how competent
the people we employ or how much training we do,
human fallibility cannot be avoided. This is why a
resilient socio-technical system must be created to avoid
negative consequences caused by mismanagement of
errors and threats. This is the key to creating a more
advanced and higher level of system safety. Addressing
latent conditions at the workplace, such as bridge
ergonomics, complements such a system.
It is, however, not enough to impart Human Factors’
training to the officers and believe that all weaknesses
will be taken care of. First of all, officers must be
required to have a thorough understanding of the
equipment they use before they are put in charge of a
navigational watch. Second, there must be a consistent
organization, which is not solely depending on the person
in command. Third, ship-specific procedures and
checklists, which are reviewed at frequent intervals, must
be put in place.
Human Factors Training: There's nothing that can't go wrong. This simple insight forms the foundation of human factors training for pilots. In special courses, pilots are prepared for any possible emergency situation and action strategies. Crews learn to analyze and evaluate their own behavior and that of those around them more effectively. Training leads to more efficient work processes, a functioning error management culture, and increased safety. This is a general prsentation and human factors management in aviation training.
Caught in Numbers, Lost in Focus: What it Means to Manage Safety in Global Sh...Nippin Anand
Have you ever wondered about how safety gets measured and how it became one with the ‘science’ of management (granted there is such a term as management science). What is the relationship between occupational health and safety and technical safety? How reliable is compliance as a measure of safety and how could we possibly distinguish between quality and safety?
Human errors are inevitable. No matter how competent
the people we employ or how much training we do,
human fallibility cannot be avoided. This is why a
resilient socio-technical system must be created to avoid
negative consequences caused by mismanagement of
errors and threats. This is the key to creating a more
advanced and higher level of system safety. Addressing
latent conditions at the workplace, such as bridge
ergonomics, complements such a system.
It is, however, not enough to impart Human Factors’
training to the officers and believe that all weaknesses
will be taken care of. First of all, officers must be
required to have a thorough understanding of the
equipment they use before they are put in charge of a
navigational watch. Second, there must be a consistent
organization, which is not solely depending on the person
in command. Third, ship-specific procedures and
checklists, which are reviewed at frequent intervals, must
be put in place.
Human Factors Training: There's nothing that can't go wrong. This simple insight forms the foundation of human factors training for pilots. In special courses, pilots are prepared for any possible emergency situation and action strategies. Crews learn to analyze and evaluate their own behavior and that of those around them more effectively. Training leads to more efficient work processes, a functioning error management culture, and increased safety. This is a general prsentation and human factors management in aviation training.
PD180 Interpreting & Managing Charterparty For Offshore Support VesselspetroEDGE
OSV Owners and the Charterers engage in very complex and high risk ventures with the prime objective of maximizing returns and minimising risks. There is no benefit for either Party to be entangled in commercial or contractual disputes. But due to the abundance of uncertainties’ in the Offshore E & P business, priorities of the parties may differ, giving rise to conflicts. Conflicts can be managed through appropriate clauses in the Charterparty and pre-agreed forums, so as to avoid disputes. However the challenge is in defining and interpreting the so called “appropriate clauses of the Charterparty”.
Safety in Motorsports. Have you seen the F1 movie regarding safety in Formula one racing? That says it all. Or have you paid attention to the safety changes in NASCAR? Look at every motorsport and what do you see? The sport of PWC racing is far behind. Here are facts, studies and terminology to assist the layperson gain a better understanding of the PPE for competition. It is time to change, here is the first measure towards understanding what direction the sport should address, check out this informative booklet.
Interpreting & Managing Charterparty For Supply VesselspetroEDGE
OSV Owners and the Charterers engage in very complex and high risk ventures with the prime objective of maximizing returns and minimization of risks. There is no benefit for either Party to be entangled in commercial or contractual disputes. But due to the abundance of uncertainties’ in the Offshore E & P business, priorities of the parties may differ, giving rise to conflicts. Conflicts can be managed through appropriate clauses in the Charterparty and pre-agreed forums, so as to avoid disputes. However the challenge is in defining and interpreting the so called “appropriate clauses of the Charterparty”.
Gut Editorial #3 of 3
By Shawn Alladio
We handle rough situations. Likewise we must be equipped to manage the stressors and dynamics of these evolving operations. This is not done with taking out one sequence in a solution.
Achievement for failure is a warranty of connective decisions. You must do better than this, especially if you are a Rescue Water Craft program manager.
When the shackles are set from an investigation of an in-service fatality or serious mishap, dismissals will be enabled that further dispel capability. The suspicion of instructors will be blamed for the failures, the student will bear guilt and shame. Programs will fail. The Rescue Water Craft will be blamed. The shut off switch will be blamed. The rescue board will be blamed. The wave will be blamed.
A LAANE report reveals that airlines at LAX may have put the security and the health of the public at risk, while failing to provide adequate services for passengers with disabilities. Although the duties of airline contracted service workers are vital to the health and safety of the traveling public, these workers are poorly compensated, receive little training, and have few incentives to stay in their jobs long term.
Factoring the human into Patient Safety. Rhona Flin. IV Internacional Conference on Patient Safety (Madrid, Ministry of Health and Consumer Affairs, 2008)
The Port Security Plan - Management of Tasks and Responsibilities.docxoreo10
The Port Security Plan - Management of Tasks and Responsibilities
Our week three lesson will explore the maritime port security environment and the resultant security demands inherently placed on the port security management team. More specifically, the security management team is charged with the responsibility for ensuring all port security elements are successfully planned, developed, and executed in order to execute vital security tasks and responsibilities associated with a safe and secure maritime port.
No doubt the security management team is one of the most important components when trying to protect against terrorists, criminal activities, and other commercial, industrial and natural disasters that can impact a maritime port. Further, failure to properly assess, plan and execute the fundamental port security tasks and responsibilities required would be disastrous to port security operations in general. As a result, the focus for lesson three will identify and assess key policy and procedures necessary for successfully executing maritime security management operations. Moreover, the importance in building a solid port security posture must start right at the top of the organization, to include the port security leadership staff and the guard force.
As many already know, it all starts at the top. Poor leadership will result in poor decisions and substandard performance from the staff, which will ultimately flow down and impact the entire security workforce. An inept and incompetent security staff will thoroughly corrupt the ability of the organization to adequately guard and protect the port as a whole. Poor leadership will cripple a port, and potentially jeopardize the national security of the U.S. Also, inexperienced and poorly trained managers will set the stage for major security gaps in the port to emerge rapidly, leading to possible exploitation of these gaps by nefarious individuals…who likely have designs centered on terrorism or criminal acts. This is further complicated by the fact that all U.S port’s security funding for current and future budget years will be substantially cut. Understanding this, it is essential that the port security teams have continuous education and skills training to maintain force competencies.
Just as important, the security team must be knowledgeable of the critical organizational components within the port that tie into port security. Christopher identified these components as the communication systems and information sharing capability; building and maintaining a qualified professional staff; conducting basic and advance security training; fostering teamwork, camaraderie, and mission planning. Parallel to these operational components, it is also important that the port security team effectively respond to and interface effectively with incident management systems, attention to communications interoperability, public/media relations, written plans, policies, procedures, and la ...
AVSS & The Institute for Drone Technology™ joint report government regulation...Paul New
Drones will fail. Drones will crash. Drones will hit humans. Drones will “fly-away”. Birds will interfere
with drones. Drones will be lost. Pilots and software will make errors.
This is the drone reality.
However, regardless of the potential risk factors involved with their operation, drones do provide
citizens, businesses, industries, and governments with tremendous value.
Furthermore, in many cases, drones provide a safer alternative to traditional manned aircraft
applications or civilian labour such as in oil and gas and mining inspection services.
Therefore, AVSS and The Institute for Drone Technology believe the challenge of the emerging drone
technologies is not to detect, exclude, or avoid the use of drones, but to determine how we can
safely utilize this growing and beneficial technology.
New organisation for safe and effective operation of cruise ships CSMART
Navigating a large cruise ship in confined or restricted waters involves risks that must be managed
carefully, so that safe operation is maintained by using all available resources effectively. This is
exactly what Carnival’s new role based bridge organisation is pursuing.
PD180 Interpreting & Managing Charterparty For Offshore Support VesselspetroEDGE
OSV Owners and the Charterers engage in very complex and high risk ventures with the prime objective of maximizing returns and minimising risks. There is no benefit for either Party to be entangled in commercial or contractual disputes. But due to the abundance of uncertainties’ in the Offshore E & P business, priorities of the parties may differ, giving rise to conflicts. Conflicts can be managed through appropriate clauses in the Charterparty and pre-agreed forums, so as to avoid disputes. However the challenge is in defining and interpreting the so called “appropriate clauses of the Charterparty”.
Safety in Motorsports. Have you seen the F1 movie regarding safety in Formula one racing? That says it all. Or have you paid attention to the safety changes in NASCAR? Look at every motorsport and what do you see? The sport of PWC racing is far behind. Here are facts, studies and terminology to assist the layperson gain a better understanding of the PPE for competition. It is time to change, here is the first measure towards understanding what direction the sport should address, check out this informative booklet.
Interpreting & Managing Charterparty For Supply VesselspetroEDGE
OSV Owners and the Charterers engage in very complex and high risk ventures with the prime objective of maximizing returns and minimization of risks. There is no benefit for either Party to be entangled in commercial or contractual disputes. But due to the abundance of uncertainties’ in the Offshore E & P business, priorities of the parties may differ, giving rise to conflicts. Conflicts can be managed through appropriate clauses in the Charterparty and pre-agreed forums, so as to avoid disputes. However the challenge is in defining and interpreting the so called “appropriate clauses of the Charterparty”.
Gut Editorial #3 of 3
By Shawn Alladio
We handle rough situations. Likewise we must be equipped to manage the stressors and dynamics of these evolving operations. This is not done with taking out one sequence in a solution.
Achievement for failure is a warranty of connective decisions. You must do better than this, especially if you are a Rescue Water Craft program manager.
When the shackles are set from an investigation of an in-service fatality or serious mishap, dismissals will be enabled that further dispel capability. The suspicion of instructors will be blamed for the failures, the student will bear guilt and shame. Programs will fail. The Rescue Water Craft will be blamed. The shut off switch will be blamed. The rescue board will be blamed. The wave will be blamed.
A LAANE report reveals that airlines at LAX may have put the security and the health of the public at risk, while failing to provide adequate services for passengers with disabilities. Although the duties of airline contracted service workers are vital to the health and safety of the traveling public, these workers are poorly compensated, receive little training, and have few incentives to stay in their jobs long term.
Factoring the human into Patient Safety. Rhona Flin. IV Internacional Conference on Patient Safety (Madrid, Ministry of Health and Consumer Affairs, 2008)
The Port Security Plan - Management of Tasks and Responsibilities.docxoreo10
The Port Security Plan - Management of Tasks and Responsibilities
Our week three lesson will explore the maritime port security environment and the resultant security demands inherently placed on the port security management team. More specifically, the security management team is charged with the responsibility for ensuring all port security elements are successfully planned, developed, and executed in order to execute vital security tasks and responsibilities associated with a safe and secure maritime port.
No doubt the security management team is one of the most important components when trying to protect against terrorists, criminal activities, and other commercial, industrial and natural disasters that can impact a maritime port. Further, failure to properly assess, plan and execute the fundamental port security tasks and responsibilities required would be disastrous to port security operations in general. As a result, the focus for lesson three will identify and assess key policy and procedures necessary for successfully executing maritime security management operations. Moreover, the importance in building a solid port security posture must start right at the top of the organization, to include the port security leadership staff and the guard force.
As many already know, it all starts at the top. Poor leadership will result in poor decisions and substandard performance from the staff, which will ultimately flow down and impact the entire security workforce. An inept and incompetent security staff will thoroughly corrupt the ability of the organization to adequately guard and protect the port as a whole. Poor leadership will cripple a port, and potentially jeopardize the national security of the U.S. Also, inexperienced and poorly trained managers will set the stage for major security gaps in the port to emerge rapidly, leading to possible exploitation of these gaps by nefarious individuals…who likely have designs centered on terrorism or criminal acts. This is further complicated by the fact that all U.S port’s security funding for current and future budget years will be substantially cut. Understanding this, it is essential that the port security teams have continuous education and skills training to maintain force competencies.
Just as important, the security team must be knowledgeable of the critical organizational components within the port that tie into port security. Christopher identified these components as the communication systems and information sharing capability; building and maintaining a qualified professional staff; conducting basic and advance security training; fostering teamwork, camaraderie, and mission planning. Parallel to these operational components, it is also important that the port security team effectively respond to and interface effectively with incident management systems, attention to communications interoperability, public/media relations, written plans, policies, procedures, and la ...
AVSS & The Institute for Drone Technology™ joint report government regulation...Paul New
Drones will fail. Drones will crash. Drones will hit humans. Drones will “fly-away”. Birds will interfere
with drones. Drones will be lost. Pilots and software will make errors.
This is the drone reality.
However, regardless of the potential risk factors involved with their operation, drones do provide
citizens, businesses, industries, and governments with tremendous value.
Furthermore, in many cases, drones provide a safer alternative to traditional manned aircraft
applications or civilian labour such as in oil and gas and mining inspection services.
Therefore, AVSS and The Institute for Drone Technology believe the challenge of the emerging drone
technologies is not to detect, exclude, or avoid the use of drones, but to determine how we can
safely utilize this growing and beneficial technology.
New organisation for safe and effective operation of cruise ships CSMART
Navigating a large cruise ship in confined or restricted waters involves risks that must be managed
carefully, so that safe operation is maintained by using all available resources effectively. This is
exactly what Carnival’s new role based bridge organisation is pursuing.
THE CRITICALITY OF HUMAN FACTORS ENGINEERING INTEGRATIONDewang Malam
It doesn’t seem to matter what happens, whether it be in the oil sector, aviation, maritime or construction, we all embark on "relentless pursuit of delivering incident free operations" but focus only on the behaviours of the operators where clearly the operator has often been set up to fail through poor plant design or unworkable procedures.
THE CRITICALITY OF HUMAN FACTORS ENGINEERING INTEGRATIONDewang Malam
It doesn’t seem to matter what happens, whether it be in the oil sector, aviation, maritime or construction, we all embark on "relentless pursuit of delivering incident free operations" but focus only on the behaviours of the operators where clearly the operator has often been set up to fail through poor plant design or unworkable procedures.
CHC Safety & Quality Summit 2016 - Risk Culture in Commercial Air TransportCranfield University
This presentation was given at the 2016 CHC Safety & Quality Summit in Vancouver. The aim was to present an argument to introduce 'Risk Culture' as a new component of 'Safety Culture. This is an academic research which aims to explore what/how operational risk decisions are made by pilots and engineers and if such decisions are also acceptable at different levels including senior management.
Jennifer Schaus and Associates hosts a complimentary webinar series on The FAR in 2024. Join the webinars on Wednesdays and Fridays at noon, eastern.
Recordings are on YouTube and the company website.
https://www.youtube.com/@jenniferschaus/videos
Russian anarchist and anti-war movement in the third year of full-scale warAntti Rautiainen
Anarchist group ANA Regensburg hosted my online-presentation on 16th of May 2024, in which I discussed tactics of anti-war activism in Russia, and reasons why the anti-war movement has not been able to make an impact to change the course of events yet. Cases of anarchists repressed for anti-war activities are presented, as well as strategies of support for political prisoners, and modest successes in supporting their struggles.
Thumbnail picture is by MediaZona, you may read their report on anti-war arson attacks in Russia here: https://en.zona.media/article/2022/10/13/burn-map
Links:
Autonomous Action
http://Avtonom.org
Anarchist Black Cross Moscow
http://Avtonom.org/abc
Solidarity Zone
https://t.me/solidarity_zone
Memorial
https://memopzk.org/, https://t.me/pzk_memorial
OVD-Info
https://en.ovdinfo.org/antiwar-ovd-info-guide
RosUznik
https://rosuznik.org/
Uznik Online
http://uznikonline.tilda.ws/
Russian Reader
https://therussianreader.com/
ABC Irkutsk
https://abc38.noblogs.org/
Send mail to prisoners from abroad:
http://Prisonmail.online
YouTube: https://youtu.be/c5nSOdU48O8
Spotify: https://podcasters.spotify.com/pod/show/libertarianlifecoach/episodes/Russian-anarchist-and-anti-war-movement-in-the-third-year-of-full-scale-war-e2k8ai4
A process server is a authorized person for delivering legal documents, such as summons, complaints, subpoenas, and other court papers, to peoples involved in legal proceedings.
Jennifer Schaus and Associates hosts a complimentary webinar series on The FAR in 2024. Join the webinars on Wednesdays and Fridays at noon, eastern.
Recordings are on YouTube and the company website.
https://www.youtube.com/@jenniferschaus/videos
This session provides a comprehensive overview of the latest updates to the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (commonly known as the Uniform Guidance) outlined in the 2 CFR 200.
With a focus on the 2024 revisions issued by the Office of Management and Budget (OMB), participants will gain insight into the key changes affecting federal grant recipients. The session will delve into critical regulatory updates, providing attendees with the knowledge and tools necessary to navigate and comply with the evolving landscape of federal grant management.
Learning Objectives:
- Understand the rationale behind the 2024 updates to the Uniform Guidance outlined in 2 CFR 200, and their implications for federal grant recipients.
- Identify the key changes and revisions introduced by the Office of Management and Budget (OMB) in the 2024 edition of 2 CFR 200.
- Gain proficiency in applying the updated regulations to ensure compliance with federal grant requirements and avoid potential audit findings.
- Develop strategies for effectively implementing the new guidelines within the grant management processes of their respective organizations, fostering efficiency and accountability in federal grant administration.
ZGB - The Role of Generative AI in Government transformation.pdfSaeed Al Dhaheri
This keynote was presented during the the 7th edition of the UAE Hackathon 2024. It highlights the role of AI and Generative AI in addressing government transformation to achieve zero government bureaucracy
What is the point of small housing associations.pptxPaul Smith
Given the small scale of housing associations and their relative high cost per home what is the point of them and how do we justify their continued existance
Understanding the Challenges of Street ChildrenSERUDS INDIA
By raising awareness, providing support, advocating for change, and offering assistance to children in need, individuals can play a crucial role in improving the lives of street children and helping them realize their full potential
Donate Us
https://serudsindia.org/how-individuals-can-support-street-children-in-india/
#donatefororphan, #donateforhomelesschildren, #childeducation, #ngochildeducation, #donateforeducation, #donationforchildeducation, #sponsorforpoorchild, #sponsororphanage #sponsororphanchild, #donation, #education, #charity, #educationforchild, #seruds, #kurnool, #joyhome
Accident investigations at Sea: Learning from Failure or Failure to Learn?
1. Feature: Accident investigations
24 | Seaways | March 2015 Read Seaways online at www.nautinst.org/seaways
Learning from failure or failure to learn?
Accident investigations
Dr Nippin Anand
PhD MSc Master Mariner MNI
B
ehavioural sciences are increasingly becoming concerned
with the learning that follows from accidents. Many scholars
have questioned the underlying causes of ‘accidents’ and the
conventional methods of accident investigations, but their
conclusions vary.
l James Reason, widely cited for the famous ‘Domino effect’ and
‘Swiss cheese’ models, identifies accidents as the outcome of unsafe
practices such as rule violations and ‘human error’. According to
Reason, the investigation should begin by identifying unsafe practices.
l According to Andrew Hopkins, accidents result from corporate
mindlessness and the desire for endless pursuit of profit. He believes
investigations should focus on latent and organisational factors that
motivate and shape the behaviour of employees.
l Charles Perrow does not consider accidents any different to normal
operations, except that complex interaction between sociological,
economic, technical and cultural forces results in an undesirable
event. Such undesirable events are ‘normal accidents’ for Perrow.
l Erik Hollnagel considers that failures (and accidents) have much
in common with success. Investigation should consider focusing
on routine and normal work rather than the unusual circumstances
surrounding an isolated case of accident.
These alternative perspectives are not merely abstract theories. They
play an important role in how we analyse and investigate accidents.
In general, accidents are investigated for two reasons – to settle
litigation and for professional objectives – that is, to prevent these issues
occurring again. Litigation tends to be about apportioning blame and
settling court cases. Unfortunately, the wording of the regulations often
appears to promote finding fault rather than objective investigation.
Learning from failures
Accident investigations have a deeper purpose. To this end, the United
Kingdom’s Merchant Shipping Regulation (Accident Reporting and
Investigation) Regulation 2012 requires that the purpose of accident
investigation ‘shall be the prevention of future accidents through the
ascertainment of its causes and circumstances. It shall not be the purpose
of an investigation to determine liability nor, except so far as is necessary
to achieve its objective, to apportion blame’. Reputable independent
organisations such as the UK’s Marine Accident Investigation Branch
(MAIB) are equipped with the professional expertise and specialised
knowledge to investigate accidents objectively and with the aim to
prevent recurrences.
Many companies list similar intentions in their policy statements
– but policy statements do not always relate well to practices at the
grassroots. Of course investigation reports are not outright blame and
finger pointing exercises, but the quality of investigations in many cases
lacks rigour and shows traces of pre-conceived values and value-laden
judgement. The knowledge and skills we acquire as professionals can
come with baggage that frequently becomes a decisive factor in judging
between right and wrong.
Realistic recommendations?
A recent official accident report stated that an accident could
potentially have been avoided had the OOW made a ‘far greater’
course alteration, taking the vessel well clear of the hazardous situation
that was developing. The same report highlighted the use of VHF in
collision avoidance as a contributing factor leading to the accident.
Furthermore, according to the investigation, drills and exercises
onboard were conducted either through instructions or video-
based training and were not of much practical value. Faced with an
emergency, the Master was not fully confident to rely on his crew and
chose to carry out most emergency and recovery functions on his own
with the assistance of selected crew members.
However, identifying what the crew and the Master should have done
does not help in addressing the underlying root causes of the problem.
In such complex, dynamic and demanding situations, rule violations
and deviant behaviour are neither surprising nor difficult to discover.
What we need to know is why they took the actions they did.
Every navigating officer knows that any manoeuvres to avoid
collision should be large and readily apparent to the other vessel. No
navigational publication or procedures will suggest otherwise. Yet,
failure to comply with the most basic collision regulations is the single
greatest factor in many collisions. So why do these collisions happen?
In practice, large alterations of course or drastic reductions in vessel
speed are not straightforward and easy choices. Consider everything
which makes that choice more difficult, particularly for a junior officer;
the pressure to make estimated arrival time at a port, the sudden
revving and load increase on main engines, hierarchical crewing
structures, the power distance between a junior officer from the
Philippines and a senior officer from a ‘traditional’ seafaring nation, the
electronic recording of every single manoeuvre during night watch, the
possibility that the junior officer may be summoned to account for the
deviation next morning in the Master’s office.
While the consequences of violating rules are both serious and
obvious, the incentives and motivations for following those rules
are invisible. Organisational KPIs rarely allow for factors such as the
Master’s overriding authority to make the safe decision, junior officers
seeking assistance at odd hours or vessels slowing down and missing
port arrivals to ensure safe navigation. Never mind appreciation or
appraisal; such actions are not even worthy of attention. On the other
hand, the social recognition and financial incentives for making arrival
timings despite fierce production pressures are plentiful.
Technological issues
There is no shortage of VHF, AIS or radar assisted collisions. Terms
such as over-reliance and complacency are frequently associated
with technology assisted collision. But these terms, too, raise many
questions. At what stage does dependence on navigational and collision
avoidance aids becomes over-dependence (or complacency)? While
understanding the limitations of equipment is fundamental to safe
navigation, how could one possibly understand all the complex
operations that go on within electronics and computer based systems?
This would require a whole new set of competencies, but neither
the curriculum nor training institutes are geared up to embrace this
challenge – let alone the manufacturer’s unwillingness to provide
2. Feature: Accident investigations
Read Seaways online at www.nautinst.org/seaways March 2015 | Seaways | 25
access to anything beyond routine operations of technological systems.
Similarly, under the pressure of regulatory and commercial
constraints, emergency drills and exercises have gradually shifted focus
from ensuring organisational resilience (ie crew readiness and response
to emergencies) to being compliance exercises aimed at meeting
KPIs. Instead of considering context-specific emergencies relevant to
key shipboard operations, drills and exercises are often drawn up to
meet comprehensive statutory and commercial requirements. The
average time spent on exercising and learning from drills has reduced
considerably in recent years. On one ship, for example, the drill itself
took less than fifteen minutes. The administrative work that followed
took much longer since drills were entered in four separate records.
Between theory and practice
If operating ships were a matter of following a set procedure, monkeys
could have successfully taken over long ago. Between procedure
and practice lies the human ability to make decisions and use
problem-solving skills to turn instructions into successful operations.
Occasionally, these skills fail, resulting in an accident. At this point, it is
easy to argue with hindsight that the rules and procedures should have
been followed to the letter. Litigation thrives on this argument.
However, procedures and instructions are necessarily static – they
cannot make allowance for context. In an ideal world, the professional
would ascertain the situation by all available means before coming to a
decision. In practice, however, there is a limit to cognitive knowledge,
resources are constrained, time is finite and the outcome is uncertain.
Moreover, goals are conflicting, and it is sometimes tacitly accepted
that efficiency and profit far outweigh the official rule of ‘Safety First’.
In one company, for example, the internal meeting started with a
30 second elevator speech about ‘Putting safety at the heart of every
operation’. It was followed by a two hour presentation on improving
efficiencies and enhancing customer satisfaction.
Methodological rigour
While most aviation incidents patiently and respectfully await the
outcome of investigation, the maritime industry does not. Often,
Masters are criminalised in public perception long before the facts are
established. Sometimes, these value judgements are based on outdated
perceptions. Technology has developed so rapidly that the perception
of safe distance from a navigational hazard, for example, has already
changed and may continue to change with the advent of state of the
art positioning systems and highly reliable propulsion systems. Two
decades ago, who would have imagined that positional accuracy of up
to one metre was achievable?
In one case, a senior safety manager pointed at ECDIS as the reason
for most accidents at sea. The comparison he made was with paper
charts and his apprentice training that in his understanding kept ships
safe and accident free. What rigour and objectivity can we expect from
investigations that result in such value laden judgements?
The question here is who gets to draw the line between safe and
unsafe practices, and on what basis? A large number of investigations are
inundated with biases and judgements based on personal experiences
and values that may have marginal temporal importance or contextual
relevance. Adding to this, the methods of investigation are highly
reductionist, breaking down complex dynamic situations into simplified
stories of human errors and technical failures. The analysis becomes a
question of ticking boxes to identify familiar errors such as fatigue, loss
of situational awareness, lack of training, violation of procedures, etc. All
too often, the underlying reasons behind these errors go uninvestigated.
The investigator’s dilemma
Society as a whole views accidents as morally wrong and
psychologically disturbing. Professional integrity and societal
expectations create an immense burden to identify a reason for the
accident. Something is bound to have gone wrong, someone must have
screwed up – there must be someone to blame. These issues constantly
confront those who carry out investigations and analysis. The example
of the fishing trawler Trident which sank off the North East coast of
Scotland resulting in the loss of seven lives is of particular interest.
The original inquiry that concluded one year after the accident found
no major problems with the vessel, crew or management. It was
considered a case of ‘normal accident,’ with the trawler being hit by
successive waves. Such reports are shocking and disturbing for the
families of dead and injured and for society as a whole.
According to Sidney Dekker in his 2015 Masterclass in safety
managment and human factors, the investigator is faced with a
dilemma. Safety of personnel, assets or environment cannot be
compromised. If that happens, searching for what went wrong is a
matter of (professional) integrity – and there is an organisational and
societal expectation that someone, or something, will be to blame. Of
course, there are practical implications when resources are limited
and deadlines are approaching. Faced with ethical, professional and
practical constraints it is reassuring to refer back to rules and procedures
to bring an investigation to a convincing closure. Once a case for rule
violation or breach of procedures has been established, no further
questions need arise. The onus is then on the mariners to undergo
further training, follow procedures more strictly and strive for higher
professional standards. Companies respond with enhanced internal
controls and monitoring – increased inspections, more detailed
procedures. And still the root cause goes unaddressed.
Conclusion and recommendations
Gaps between procedures and practice should not become the basis
for conclusions about an accident. Such gaps are bound to exist, since
modern ships are not laboratories for controlled experiments guided
by rehearsed instructions. As accident investigators, the fundamental
question that we need to ask is, why do such gaps exist? This question
brings others in its wake. How do companies consciously and
unconsciously encourage such behaviours? What is their culture of
reward and incentivisation? How do they present success and failure?
The problem with continued success and improved profit margins is
that they often imply that all is well and encourage further risk taking.
Behavioural patterns are symptoms of organisational culture and
motivational factors. Regardless of the safety talks, the posters on every
bulkhead, the boardroom speeches and email footers, professionals
are often caught in two minds between safety and commercial goals.
Of course you should call the Master when in doubt – but make sure
you have a convincing explanation why you have done so. Of course
you should choose not to depart port if it means breaching rest hours
– but you had better be ready for the resulting email traffic. Of course
you should reduce to a safe speed if visibility is restricted – but be
ready to miss out on your performance bonuses. What looks like rule
violation and negligence on the surface can be a symptom of deeper
organisational and motivational issues. ‘Human error’ should be the
starting point for a serious investigation, not the conclusion of the report.
For accident investigations to be truly effective, it is important to
look through the eyes of the professionals involved and develop a sense
of ‘local rationality’. A competent officer does not intend to collide
or run aground. Keeping hindsight aside (which is a challenge), the
investigator’s role is to curiously and open-mindedly ask – why did those
actions make sense at the time? If lessons are to be learnt, we need to
consider that actions that made sense to one competent mariner may
make sense to others. It is important that investigators engage critically
and reflectively with their own experiences, views and values. The
language of litigation and liability may not be much use given the room
it creates for interpretive and subjective opinions that only serve vested
interests.