Page 66 - CHIRP Annual Digest 2017

CHIRP Maritime

Design Error Enforcing Conditions
120 200
11 1 11 1
101 171
100 2 2
10 150 10
80

60 3 100 3 85
45
40 9 9
50
18
20 4 4
8 3 8
0 0
5
Not ergonomic 7 No indication No standardisation Abuse or 7 External 5 Human
6
6
of condition addiction inuences physical
Figure 5 – Design: causal explanations for failed defences constraints
Figure 7 – Error Enforcing Conditions: causal explanations for
failed defences
Defences – The following tends to show that we are all
experts in writing procedures and instructions – following
them is another matter entirely judging by the number of Hardware – The largest number of reports where hardware
reports received where it was determined that one of the fac- is an issue comes down to the hardware not being suitable
tors was insufficient awareness of risks. This is often attrib- for purpose. For example, an uninsulated screwdriver is not
uted to an individual; the true root cause however lies with fit for purpose for any type of electrical work. Another factor
management, and not necessarily company management. In has been the condition of the equipment – wear and tear or
order for all to become aware, the causes need designing corrosion. Wire is an obvious example, particularly when it is
out and procedures need to be put in place which prevent sheathed – don’t use it!
defences from being breached.
Hardware
Defences 100
250 11 85 1
18 11 1
80 2
200 2 10
10
60
150 43 3
3 40
100 9
9
58 20 14
50 4
17 4 8
8 0 Bad condition 5 Procurement
6
0 7 Not suitable
5
Insufcient 7 No emergency Unsuitable (wear/corrosion) for purpose and stock
6
awareness procudures or detection management
of risks instructions systems Figure 8 – Hardware: causal explanations for failed defences
Figure 6 – Breached defences: causal explanations for
failed defences
Housekeeping – As previously indicated there have been very
few reports received by CHIRP where housekeeping has been
Error Enforcing Conditions – The term error enforcing con- identified as a root cause. In very general terms much of the
ditions simply means that no matter what the near miss housekeeping is now addressed by behavioural safety pro-
was, it would have happened anyway due to external factors. grammes where storage, cleanliness, and personal protective
Abuse or addiction is extremely rare with the near misses equipment are being effectively monitored. However, from the
that have been reported. However external influences, pri- reports that we have received, the main issue is planning.
marily weather related, and human physical restraints, (it is
not possible for a person to do the task without endanger-
ing himself), are both frequent root causes. For the former,
proper planning and risk assessment can prevent the dan-
ger, while for the latter the problems need to be engineered
out, preferably at the design stage.

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