Page 64 - CHIRP Annual Digest 2017

CHIRP Maritime

Article. 50 own ship – if so, what are you doing to prevent it from hap-
pening in the first place? All of the above examples could
The Human Element – have been prevented if the people on board, backed up by
still a long way to go shore management, had a healthy TEAMWORK ethic which
encourages people to challenge unsafe procedures where
appropriate, and which involves proper planning and co-ordi-
CHIRP has received many reports which may be catego- nation of onboard activities. Good planning also reduces the
rised individually as minor near misses. Whilst the report- danger of people being placed under too much PRESSURE
ing of these shows that a behavioural-based safety pro- since tasks are more evenly distributed.
gramme is in place, it also shows that the Deadly Dozen
has yet to be embraced (see page 73). For any “near misses” that you become aware of, try to
decide which of the twelve aspects of the Deadly Dozen are
Several of these near miss “one liners” are detailed below. most appropriate. There may be more than one, in fact there
They all had remedial action applied, in the form of direct are often several categories. From a personal perspective,
intervention. thinking about your surroundings or the tasks that you have
• A first trip deck hand’s first mooring experience had him been allocated helps you become more self-aware and able
actively tending moorings. CAPABILITY. (The inexperienced to see the dangers before they cause an accident. Why not
deck hand should have been mentored until he was discuss the near misses that you experience at your Safety
deemed experienced enough to actively engage in Committee meetings and bring in the aspects of the Human
mooring operations). Element? You might be surprised at the results.
• A bunker tank nearly overflowed when the engineer
overseeing the operation left to answer an engine room The above article was published in MFB48
alarm. DISTRACTIONS. (A dangerous oversight – proper
planning would have freed up personnel in order to Article. 51
prevent this near miss).
• A lower forepeak space required cleaning – during the CHIRP Maritime Causal Analysis
planning the supervisor asked for everything to be made
ready in half an hour and he would return at that point. Introduction
When he returned personnel were already at work inside the For every article that CHIRP Maritime publishes in its quar-
compartment even though they had not received an Entry terly FEEDBACK magazines, and posts upon the Chirpmari-
Permit. COMMUNICATIONS. (The supervisor had in fact tested time.org web site, an analysis of the article is undertaken
the compartment and had gone off to write up the permit – in order to identify the root cause(s) behind the incident.
the crew however misunderstood the correct procedure). The analysis is based upon James Reason’s research which
• An oiler taking daily tank soundings walked under a crane dates back to 1990 and his book Human Error. The underly-
that was in use for storing operations. SITUATIONAL ing principle is described by the Swiss Cheese model which
AWARENESS and ALERTING. The oiler could not have shows clearly the defences which have been missed in order
been aware of his surroundings or else he would not for an incident to occur.
have stepped under a crane with a load. But who had the
forethought to stop him? Organisational
• Sunglasses were used instead of safety goggles during deck inuences
scaling maintenance CULTURE, COMPLACENCY and LOCAL Missing or
PRACTICES. If “That’s the way we’ve always done it around failed defences Unsafe supervision
here”, is the philosophy then the culture both on board and
ashore needs to be modified to change how people think. Latent failures
• A supervisor became involved in a mooring operation. The Preconditions for
ship had undertaken several port calls in the previous unsafe acts
few days, with associated cargo and administrative Latent failures
operations. Amongst other factors, FATIGUE could have Unsafe
been an issue. Tired people make mistakes and the acts
supervisor should have restricted himself to supervision Latent failures
and NOT become involved in the actual work.

The above reports are encouraging and indicate that people Active failures
are thinking about safety, but it is worth remembering that ACCIDENT!
the Human Element can involve multiple factors. Take the Figure 1 – Swiss Cheese Model
first example of our deck hand getting involved with moor-
ing - this points to a poor on-board safety culture, a lack of The latent failures are grouped into eleven categories; these
standard operational procedures, and a poor company cul- are Communications, Defences, Design, Error Enforcing Con-
ture within the Safety Management System. A proper risk ditions, Hardware, Housekeeping, Incompatible Goals, Main-
assessment and toolbox talk would have prevented the deck tenance Management, Organisation, Procedures and Train-
hand from getting involved. ing. James Reason further subdivided these “basic” failures
based upon causal explanations for the failed defences.
Some of the examples may sound very familiar from your There are many of these for each basic category, and CHIRP

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