SAFETY RELEASE
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“You have passed the audit! Everything seems to be in place. But you have a non-conformity for the atrocious handwriting in the logbook.”
Ensuring that every operation at sea involves at least two people may save so many more lives than reprimanding a crew member.
STAFFING AND ORGANISATION
It is important in managing operational safety risk that one can monitor (watch for) and intervene (prevent) an escalating situation. Jo’s story serves as an example to understand how the most effective risk control measures are forgotten in paper-based risk assessments and checklists. When Jo requested that Max go away and make fast the tug, he unknowingly removed a crucial control measure from the scene. Far too many lives are lost at sea whilst rigging the gangway in the dark, operating incinerators, working in confined spaces and painting aloft. It is not uncommon that the person is left alone without proper monitoring or direct supervision. Ensuring that every operation at sea involves at least two people may save so many more lives than reprimanding a crew member.
SEAMANSHIP
A final thought on Jo’s behaviour. When people see the picture of a winch control being tied with a rope, their eyes tend to pop out. When I first encountered this situation I too felt deeply concerned and agitated. But such examples are reported in numerous industry publications (UK P&I Club Mooring Report). We may choose to call it a ‘behavioural problem’ and impose further controls. But we could also view Jo’s behaviour as adaptation in the face of bad design, poorly written procedures, ineffective monitoring and limited resources. Interestingly, very little
REFERENCE
EUROCONTROL (2014). Systems thinking for safety: Ten principles. A white paper. Brussels: EUROCONTROL, August 2014. See
http://bit.ly/ST4SAFETY
of these issues surface even with copious safety audits, inspections and other forms of governance.
Merchant seamen have long been acclaimed for their ability to ‘make do’ and adapt against the odds. Until such time as everything is properly designed to ensure things go well (or no one has spotted it), people will adapt. This is commonly referred to as ‘seamanship’. But when things go wrong, the same adaptation turns into ‘error’ or ‘violation’. Through the story of Jo, we have seen adaptation in hindsight and foresight. The one we choose defines our frame of reference as much as what Jo did in the heat of the moment.
The Report • March 2019 • Issue 87 | 71
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