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an enormous build-up of time pressure and far too much to be achieved in limited time. Cargo securing, cargo planning, gangway watch, ballasting and stabilising the ship, preparing the bridge and engine room for departure, communicating with port officials, discussing the voyage plan with the pilot, manning the harbour stations, undocking the ship and making fast the tugs.


Figure 1: Winch control lever tied with a rope THE FORESIGHT EXPLANATION


We now consider some foresight explanations and for this, we should get rid of what we know so far. Let go of the fact that anyone saw Jo overriding the winch control and ask some fundamental questions. Notice there was a company safety representative on the ship and a safety audit had just been completed. Why is it that no one noticed the deeper symptoms of Jo’s behaviour in everyday work? Why is it that such behaviours are so hard to detect until they show up? What does this tell us about the state of safety audits and the overall effectiveness of control measures in ensuring safety? Is it really Jo’s problem alone or is there more to it?


SAFETY AUDITS


In my view, safety audits (and other forms of shipboard inspections) are not designed to uncover such issues. Rather, the focus is just the opposite, which is to conceal deep-rooted problems under bureaucratic, paper-heavy controls. Who would inform an inspector about shortcuts and compromises that form the basis of everyday work, and risk their jobs? The inspector is not interested, and neither are safety


70 | The Report • March 2019 • Issue 87


departments in most companies. Their goals are different. The inspector has an incentive to find fewer problems and those that do not do this ruffle too many feathers. The safety department has an incentive to aim at zero deficiencies, whatever it takes. Questions aimed at understanding messy realities (such as manual overriding of safety devices) are seldom directed at understanding the users’ perspectives – their ‘local rationality’ (see EUROCONTROL, 2014). Rather, the aim is to provide an accurate (procedural) response from the highest rank on the ship to avoid confrontation and skim through the safety inspection. Contributions from crew members in lower positions who actually carry out the work are not considered necessary.


In


many cases they are sidelined. Jo’s behaviour on the day gives us an insight into the state of safety audits in many safety critical industries including the maritime sector – superficial exercises aiming at minimum compliance.


PRESSURE AND PROCEDURES


What can we learn from Jo’s behaviour about the effectiveness of control measures? Closer to departure time, there was


There is a procedure for each of these activities but the boundaries between where one activity ends and the next one starts become blurred. With a handful of crew members performing multiple activities, it is problematic to identify which procedure is most suited to the situation, who is responsible at what point and where exactly lies the ‘violation’ from procedures. In order to follow all the procedures one may well end up not complying with the hours of rest and work.


Indeed, there are detailed and extensive procedures for most shipboard operations in most safety management systems, but what is their real usefulness? Many of these procedures cross-refer to other procedures, regulatory requirements, industry standards and the so called ‘best practices’, whose practical usefulness for an average seafarer is questionable. This is not to raise questions about the competence and intellect of the end users of procedures.


It is


to understand the intent behind including such detailed documents that are both inaccessible and impractical for front-line work. Here it is important to raise a few more questions. How do people make sense of procedures and instructions in a time-constrained and a constantly evolving work environment? Are procedures readily available and accessible as work is being performed? Are we expecting people to carry procedure manuals along with them while they perform their jobs? Or do we expect them to memorise all of the procedures beforehand?


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