Today we find ourselves in possession of stupendous know-how, which we willingly place in the hands of the most highly skilled people. But avoidable failures are common, and the reason is simple: the volume and complexity of our knowledge has exceeded our ability to consistently deliver it - correctly, safely or efficiently.
— Atul Gawande
A system is a set of things ... interconnected in such a way that they produce their own pattern of behaviour over time. ... But the system’s response to these forces is characteristic of itself, and that response is seldom simple in the real world
— Donella Meadows
Most marine craft represent Systems of Systems (SoS) and are an ensemble of complex systems, which have the potential for an extraordinary amount of structural and technical complexity.
Because of this, a SoS can be vulnerable to sudden catastrophic collapse because of small and insignificant partial functionality losses in one of the constituent systems.
System Thinking
Unanticipated failures find more potential and more pathways to their occurrence when interventions in SoS operations, standards or processes are conducted without enough insight or understanding and without consideration of the fundamental nature of the complexity of the System of Systems (SoS).
1.
2. 3.
System thinking is simply thinking about something as a system: the existence of entities-the parts, the chunks, the pieces-and the relationships between them.
Avoidance: is the prevention of a disruption. Avoidance goes beyond traditional system safety considerations (Madni and Jackson, 2009) in that it encompasses the anticipation of a mishap based on the ability to detect ‘drift’ towards system brittleness, a harbinger of potential accidents.
Survival: is the ability of a system to resist destruction or incapacitation in the face of a disruption.
Recovery: is the ability of a system to survive a major disturbance even with degraded performance.
Given these definitions, one can argue that if avoidance is achieved, then the need for survival and recovery are indeed reduced. However, avoidance is achieved through intervention, namely detection and isolation of threats/errors/ failures, so as to avoid their propagation.
The marine surveyor is a key enabler of avoidance, by applying systems thinking, a marine surveyor would be better equipped to contribute to avoidance by understanding critical systems and seeking out critical faults ahead of time and ensure resolution preventing cascading failure of systems in the System of Systems.
Improving Practice and Process
Typically, there can be two main modes of operation for marine surveyors depending on whether their primary objectives are proactive or reactive.
Proactive role
• Aim to identify problems before they occur.
• They are generally responsible for assessing vessels before purchase or during routine checks. In case any flaw or damage is located, a potential mishap is averted. Hence, these surveyors are considered to be proactive as the attempt to avert problems or mishaps.
Reactive role
• Are called in after some incident has occurred.
• They assess the problem or damage to the vessel
Since they assess the vessel as reacting to some occurrence, they are referred to as reactive surveyors.
72 | ISSUE 110 | DEC 2024 | THE REPORT
The survey process
To carry out a survey on a vessel a marine surveyor:
• Follows a standardised practice that they have developed
• Follows a standardised process that they have developed
• Use checklists to ensure coverage of all items to be inspected
How good are your
— -Professor Edward Crawley, MIT.
processes & checklists?
The Theory of Active and Latent Failures was proposed by James Reason in his book, Human Error.[1]
According
to Reason, accidents within most complex systems caused by a breakdown or absence of safety barriers.
The checks in our checklists create these safety barriers.
"
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