Page 65 - CHIRP Annual Digest 2017

CHIRP Annual Digest 2017

has identified three of the more common failed defences in isation being referred to is generally not shipboard organi-
order to produce their analysis. These are shown on graphs in sation, but often commitment from the Company, and even
the following sections, and terminology is further explained. organisational failings at the ship design and construction
stage which might involve classification societies, flag, and
In addition, we analyse articles in order to identify Human naval architects. There is much to reflect upon in order to
Element issues – this uses the information from the MCA make permanent improvements in this respect. It should
Guidance Notice MGN520 – The Deadly Dozen, and is cat- be understood that the analysis is based upon near miss
egorised as follows; Alerting, Capability, Communications, reports – when the same rationale is applied to actual inci-
Complacency, Culture, Distractions, Fatigue, Fit for Duty, dents then surely something should be done by the “powers
Local Practices, Pressure, Situational Awareness, and Team- that be” to address these failings – this includes organisa-
work. This is further explained in Article 50 and in the human tions at company, national and international levels. And yet
element analysis section later in the paper. examination of the vast majority of accident reports world-
wide suggests that the root cause is nowhere close to being
properly identified. Until this mindset changes, seafarers’
lives will continue to be endangered, accidents will continue,
and blame will be laid to rest upon shipboard procedures or
11 1 non-compliance with the SMS.
2
10 The introduction mentioned that the basic latent failures
were broken down into three sub categories for each latent
failure. These are shown on the diagrams that follow and
3
some significant data is shown which is worthy of note.
9
Let’s examine some of these failed defences in a little
4 more detail.
8
7 6 5 Communications – By far the greatest communications fail-
ing has proven to be ambiguous or incorrect communica-
tions. In this age where multinational crews are the norm,
language problems are not the real issue, and nor is com-
1. Communication – 198 (9%) 7. Incompatible goals – 183 (8%) munication overload. It is simple messaging, whether this
2. Design – 160 (7%) 8. Maintenance management – 153 (7%) be verbal or from over-complicated procedures. It shows that
3. Defences – 301 (14%) 9. Organisation – 302 (14%) closed loop communications where a message is known to
4. Error enforcing conditions – 248 (11%) 10. Procedures – 278 (13%) be clearly understood requires a lot more attention.
5. Hardware – 133 (6%) 11. Training – 195 (9%)
6. Housekeeping – 35 (2%) Communication
200
Figure 3 – Latent Failures – Basic Causal Factors 182 11 1
2
The analysis has been produced in the form of a pie dia- 150 10
gram, and shows the number of incidents for each category
where a latent failure has been identified. The number is
also shown as an overall percentage. 100 3
9
It should be noted at the outset that the analysis is only
based upon the information received. In many cases there 50
is insufficient data to truly identify the root causes behind 16 4 4
a near miss, and thus the graph and those that follow, are 0 8
simply a rough and ready indication of where the maritime Incorrect or 7 Language 5 Over
ow of
6
sector is today. Also worthy of note is the fact that CHIRP ambiguous problems information
conducted a similar exercise to that shown, but using only information
recent reports, (from 2014 onward). The graphs were almost Figure 4 – Communications: causal explanations for failed
identical which is indicative of the same age-old problems defences
not being rectified.

It should perhaps not be surprising that Housekeeping pro- Design – Where design has been identified as a failed
duces a relatively low score – the maritime sector has con- defence, it can be seen that there are a high number of
centrated on this for many years as a part of accident pre- latent failings due to a lack of standardisation, followed by
vention. But look at some of the higher scores – Defences a lack of indication of the condition of the equipment. We
which have been breached, Organisational failings, and Pro- need look no further than quick release hooks on life sav-
cedures not being complied with. We should perhaps ask ing appliances, and the high number of wire rope failures to
ourselves why this is so. Just to take organisation as an show why this is so.
example, if we are really looking at a root cause the organ-

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