This article first appeared in
Seaways 11/2016, reproduced here with permission from The Nautical Institute
Imaginary checklists and defensive procedures
When safety tools serve another purpose
BY NIPPIN ANAND FNI ØSSUR JARLEIVSON HILDUBERG
An accident happened because a procedure was not followed. This has become a popular belief when analysing accidents in the maritime industry. And the countermeasures to prevent accidents often invoke even more procedures. The underlying assumption is that procedures act as barriers between safe operations and accidents, and hence safety results from following the procedures.
However, we rarely ask why people deviate from the procedures, or how exactly procedures ensure safety. And what is the purpose of procedures in the first place? This paper is an enquiry into procedures, checklists and similar instruments of formal knowledge incorporated in the safety management system (SMS) and their contribution towards managing safety.
Procedures and checklists
The ISM Code requires ship operators to establish procedures, plans, instructions and checklists for all key operations. For the
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purpose of this paper we will focus on procedures and checklists only. A procedure is typically a message from the managers to the employees about ‘How we carry out work in this organisation’. Examples may include procedures for maintenance of firefighting and lifesaving equipment, procedures for cargo operations, procedures for navigation, etc. A procedure may be anything from precise instructions for carrying out a task to a general policy statement; it can be specific or abstract; it can be of good or poor quality. A procedure may serve different purposes or even multiple purposes. It is critical to be aware of these differences when using procedures as a tool for managing safety, and to understand why procedures cannot always be followed.
A checklist, on the other hand, serves as a reminder to ensure that in undertaking a task the essential actions (or checks) have been considered. A checklist could also be seen as a ‘precondition’ to be met before initiating a task. In the hierarchy of formal knowledge
within the SMS, checklists may be used to break down high level procedures into a group of tasks and sub-tasks. For instance, navigation procedures may include a checklist for port arrival and departure, a checklist for navigation with pilot onboard, a checklist for anchoring etc. A checklist is therefore an integral part of a procedure.
Even the checklist for a routine operation such as departure from port appears highly problematic (see case study, below and right). It is apparent that the document serves multiple purposes – an aide-memoire, a work instruction, an instrument for allocating responsibility and monitoring the conduct of seafarers, as a record and even as a tool for risk assessment. On the face of it, imperfect checklist design simply reflects the competence of those responsible for implementing the safety management system. However, careful examination reveals that the problem arises due to the multiple and conflicting goals of the safety management system.
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