What should we misses?


near


learn from


Safety and performance are often perceived as conflicting aspects of shipping. In the aftermath of an untoward event, typical safety interventions or fixes bring about more stringent procedures or more procedures, retraining, replacement of people, and changes to work conditions, argue Professor Andy Smith, School of Psychology, Cardiff University, and Dr Romanas Puisa, Thales Group.


These changes are not necessarily for the better. Consequently, the interventions can be postponed, amended or waived. Neither ‘just culture’ nor retributions - i.e. carrot or stick - seem adequate. Fortunately, there have been significant advances to resolve this conflict to a win-win situation. Early safety integration through systems engineering practices and system safety allows for safer designs at a lower cost.


In turn, onboard safety management can benefit from the ideas of resilience engineering and the positive view on safety management (aka Safety II). The assumption here is that failure is the flip side of success, and hence constraining work to improve safety inevitably inhibits performance. Instead, we have to learn how people effectively work at the fringes of safety and performance and yet manage to avoid accidents. “Near misses”, which are specific instances of successful accident prevention, represent the ultimate source of knowledge for future success.


The International Safety Management (ISM) Code requires reporting and analysing near misses, incidents, and accidents, identifying risks, and developing safeguards. The Code reasons that “it makes good business and economic sense because it can improve vessel and crew performance


and, in many cases, reduce cost”. A near miss is defined as a sequence of events and/or conditions that could have resulted in an accident without timely and effective recovery. Hence, a near-miss is safety management at work. The Code contains a separate chapter on near-miss reporting and investigation.


Strangely, near misses are often perceived as close calls, symptoms of poor safety management and, hence, as highly undesirable. This negative connotation has roots in the accident pyramid (aka Bird’s triangle), familiar to safety professionals. The pyramid is commonly misinterpreted as suggesting more incidents for every significant accident and even more near misses or events with no consequences. Hence, more critical events can be prevented if more anomalies are identified.


Although it may have been reasonable for occupational accidents in the 1930s, it is inappropriate today. There is no systematic relationship between small and big failures with pre and post-incident events in modern socio-technical systems such as large passenger and cargo ships and oil platforms. When it comes to near misses, the situation is notably different. Near misses have no consequences and represent normal safety management activities.


110 | The Report • June 2022 • Issue 100


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76  |  Page 77  |  Page 78  |  Page 79  |  Page 80  |  Page 81  |  Page 82  |  Page 83  |  Page 84  |  Page 85  |  Page 86  |  Page 87  |  Page 88  |  Page 89  |  Page 90  |  Page 91  |  Page 92  |  Page 93  |  Page 94  |  Page 95  |  Page 96  |  Page 97  |  Page 98  |  Page 99  |  Page 100  |  Page 101  |  Page 102  |  Page 103  |  Page 104  |  Page 105  |  Page 106  |  Page 107  |  Page 108  |  Page 109  |  Page 110  |  Page 111  |  Page 112  |  Page 113  |  Page 114  |  Page 115  |  Page 116  |  Page 117  |  Page 118  |  Page 119  |  Page 120  |  Page 121  |  Page 122  |  Page 123  |  Page 124  |  Page 125  |  Page 126  |  Page 127  |  Page 128  |  Page 129  |  Page 130  |  Page 131  |  Page 132  |  Page 133  |  Page 134  |  Page 135  |  Page 136