Violations which Include:
• Routine Violations: Often referred to as “bending the rules,” this type of violation tends to be habitual by nature, engaged in by others, and tolerated by supervisor and management.
• Exceptional Violations: Isolated departures from authority, neither typical of the individual nor condoned by management
• Skill-based Errors can occur as marine surveying is a broad field and not all surveyors have all the necessary skills or depth of skills.
• Routine Violations and Exceptional Violations: How many marine surveyors are guilty of skipping what they consider some less important checks because they are in a hurry to get the job done?
How many less experience surveyors make isolated departures from authority, which are not typical nor condoned by management?
Does a marine surveyors evaluate all his checklists in terms of coverage to ensure that the alignment of holes is the “Swiss Cheese” model is less likely to occur?
Have industry standards bodies encouraged comparison of checklists and validation of checklist coverage?
Checklists
As indicated, checklists are an essential tool for marine surveyors to ensure structure and comprehensive coverage of the craft being surveyed.
Bad checklists do not spell out every single check and are: - Impractical - Vague - Imprecise
Consequently, bad checklists promote holes in the Swiss Cheese and creates opportunity for deviation.
Good checklists, on the other hand, are:
- To the point - Precise - Efficient - Easy to use in the most difficult situations.
Deviations from the process or checklist
Skill-based Errors, Routine Violations and Exceptional Violations can cause deviation from the required practice which introduces us to the deviation spiral.
Normalisation of deviance is the gradual process through which unacceptable standards or practice become acceptable. The process of normalisation of deviance can be seen in the “Deviation Spiral” (figure 3) where you can see a deviation from the original normal causes a new normal which, again, can be deviated from, causing another normal. Each of these deviances need only be small but the gradual acceptance of each, and subsequent “getting away with it” teaches us that the deviance is acceptable – until a problem / accident occurs.
Good checklists prevent holes in the Swiss Cheese and provide clarity that limits opportunity for deviation particularly unintentional deviation.
The marine surveying discipline should increasingly apply a systems-thinking lens that allows us to:
• hone our abilities to understand parts • see interconnections, • ask “what-if” questions about possible future behaviours
• be creative and courageous about process and practice redesign.
The techniques covered in this article are actively and successfully used in other disciplines and I believe are just as applicable to our own discipline.
Blame is the enemy of safety. It misses
opportunities to learn.” — Captain Chesley Sullenberger (aka Captain Sully), Pilot (SafetyCulture Virtual Summit)
I like to encourage people to realize that any action is a good action if it’s proactive and there is
positive intent behind it.” — Michael J. Fox
1. Reason JT (1990). Human error. Cambridge, England: Cambridge University Press. [Google Scholar] 2. Wikipedia 3. Thinking in Systems - Donella H. Meadows: First published by Earthscan in the UK in 2009 3. MIT Open Learning Ask an MIT Professor: What Is System Thinking and Why Is It Important? | Open Learning 4. Webinar “System Thinking: Improving Survey Practice and Process” – Nicholas Parkyn 2024 5. Donella Meadows, Thinking In Systems
https://en.wikipedia.org/wiki/Thinking_In_Systems:_A_Primer
74 | ISSUE 110 | DEC 2024 | THE REPORT
Figure 3: Deviation Spiral
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References
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