KEY POINTS
- Procedural compliance in time- pressured, under-resourced, messy environments is problematic. Procedures are extensive, complex, conflicting and inaccessible when needed.
- Working alone without proper monitoring and supervision is common at sea, and is associated with many lost lives.
- Safety audits and inspections rarely reveal many of the day-to-day adaptations to degraded work environments.
- A hindsight perspective may consider unwanted human performance as non-compliant behaviour, which requires more behavioural control.
- A foresight perspective may consider unwanted human performance as adaptations to a badly designed and degraded environment, which requires more attention to the system as a whole.
the mooring lines clear off from the quayside at the same time. Jo has a solution, but one that may not align with the design intent and company procedures. He pulls in the winch control lever, ties it with a rope (see Figure 1) and leans outwards from the shipside to monitor the rope. But to his bad luck, the harbour pilot watches Jo from the bridge and informs the captain. The captain calls Jo to the bridge and reprimands him for violating the procedures.
Why is it that no one noticed the deeper symptoms of Jo’s behaviour in everyday work?
It’s 4PM and a container ship is getting ready to depart from port. The crew has had a long day going through an intensive safety audit with a company superintendent onboard. Now the mate is dealing with last minute cargo manifests. Cargo lashing is still not completed by the shore gangs. The engineers are waiting to test the main engines but for this the gangway needs to be cleared off from the quayside. The duty officer is down in the engine room ballasting the ship to bring her upright. The harbour pilot is on the bridge pressing the captain to leave the berth soon.
The tug boats have arrived, and the captain calls for harbour stations to be manned within the next 15 minutes. The captain then announces on the radio, “Single up forward and aft as soon as you can”, implying that all but one mooring line should be dropped off and retrieved onboard once the cargo operations are complete to avoid any further delays to the vessel schedule.
At the back deck, there are two able seamen, Jo and Max, eagerly waiting for the duty officer and the ordinary
seaman to arrive before they can commence the undocking of the ship. Once they hear on their hand- held radios that cargo operations have completed, and the gangway is cleared off from the quayside, Jo and Max feel the pressure of time. While Max proceeds to the seaward side of the ship to make fast the tug, Jo takes the responsibility to drop off the mooring lines all by himself.
The winch control is located at the centreline of the ship. The position makes it difficult for one person to operate the controls and watch
A detailed investigation follows soon after departing from port. The management is now seeking an explanation. With policies and procedures that preach so hard to prioritise safety over commercial interests, the management is annoyed with Jo’s actions. There are at least two ways of understanding this situation – the hindsight view and the foresight explanations. Let’s look closer into each.
THE HINDSIGHT VIEW
If I were the safety manager, it would make perfect sense to disapprove of Jo’s ‘reckless’ behaviour. I would have difficulty proving otherwise. If I approved of Jo’s behaviour, what is the difference between me and him? What examples of (safety) leadership am I setting? What message am I sending down the chain? I have invested so much in behavioural safety programs, I have warned each one of them not to take undue risks, I have asked them to reach out to me when in doubt. I expect them to follow procedures, conduct thorough risk assessment, and I always encourage them think in the moment. Think about your families and your loved ones before you do something silly! Clearly, Jo did not think. He chose to go against the rules, violating procedures. He needs to be disciplined. They must take risk assessments and tool box talks more seriously. We will continue to enforce better (more) procedures for mooring operations. This is certainly one way of looking at this event in hindsight.
The Report • March 2019 • Issue 87 | 69
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