By swinging between the two extremities of ensuring that even minor details such as window wipers are included, and at the same time that an overall risk assessment is carried out, the shore based management aims to encapsulate the risk management of everything in one document.
When a seafarer puts their signature at the bottom of the checklist, this is not only an affirmation that they have completed the checks, but also that they take overall responsibility for the imperfect and ambiguous nature of the checklist. In the event of an accident, it is issues such as this ambiguity that become the subject of detailed investigation. The risks arising from an imperfect procedure are transferred to seafarers who may not have had much involvement in designing those procedures in the first place.
‘Defensive proceduralism’
The problem is not limited to the ambiguous nature of procedures. It is also the volume of procedures, checklists and tasks that are introduced in the wake of an undesirable outcome. As one seafarer stated:
‘We had a communication breakdown with the engine room while departing from port – and the next thing was that two more checks were added to the checklist. They never remove anything, only keep adding.’
On the surface this may appear like an appropriate move to limit responsibility and safeguard the reputation of the company. The danger arises when everyone from the top management down to the seafarer becomes concerned with managing their own risks, at the expense of everyone else’s. All this creates a risk in itself.
When professional judgment is limited and replaced with procedures and checklists, seafarers respond by adopting a casual approach towards such control measures. Over time, checklists and procedures are met with a mere ‘autotick’ response. They move from facilitating the safety of operations towards being record-keeping for audit trails of risk management. Contrary to popular belief, the effectiveness of these documents in preventing accidents becomes questionable.
Barrier or catalyst?
We return to the original theme of discussion – an accident happened because a procedure was not followed. Starting from this point, we get into the mind-set that procedures are intended as ‘barriers’ (or deterrents) against accidents. We are therefore convinced that procedures should be followed. This paper was an attempt to initiate a discussion on this topic.
By examining a specific case this paper has highlighted that rocedures are not always
introduced for safety reasons. Given the conflicting and competing goals of safety management system, procedures may be introduced for economic, legal, and reputational reasons. All this may turn procedures away from their original objective of managing safety risks. Delving deeper into the case, we find that where procedures are abstract and ambiguous, this may be a deliberate move to limit the risk and responsibility of the company. When accidents happen, the imperfect design of procedures becomes a source of individualised risk for the end user.
When the blame game combines with the risk game, the result could be a defensive attitude to both designing and following procedures. This may turn procedures into imaginary documents which have little to do with the realities of work. The role of procedures in such instances becomes even more questionable.
Procedures may be intended to manage several risks; their role in enhancing safety may not always be as straightforward. An accident happened because procedures were not followed. Could it also be that procedures could not be followed?
ABOUT THE AUTHORS Nippin Anand works as a Principal Specialist, Safety Management System at DNV GL. The views expressed by the author in this paper may not be the views of the organisation that the author represents.
Te checklist is intended to
ensure safety – but does it?
Øssur Jarleivson Hilduberg is Head of the Danish Maritime Accident Investigation Board.
The paper is an edited section of a recent report published by the Danish Maritime Accident Investigation Board (DMAIB) that undertakes a detailed investigation into the role of procedures in safety management system.
The full report can be accessed at
http://bit.ly/2bKdtvA
52 | The Report • March 2018 • Issue 83
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76
