Page 67 - CHIRP Annual Digest 2017

CHIRP Annual Digest 2017

Housekeeping Maintenance
20
20 150 68
11 1 11 1
2 120 2
15 10 10

90
10
10 3 3
7 60
9 9
22
5 30
4 83 4
8 8
0 0
5
Bad planning 7 Lack of management Unclear Insufcient 7 Insufcient 5 No relevant
6
6
of housekeeping commitment responsibility planning of supervision on documentation
Figure 9 – Housekeeping: causal explanations for failed defences maintenance maintenance
Figure 11 – Maintenance: causal explanations for failed defences
Incompatible Goals – The term “incompatible goals” simply
refers to a conflict between two parties – they have differ- Organisation – The breakdown of defences with organisa-
ent objectives. This might include a task being unable to tion once again show us that tasks are usually properly
be performed correctly without disobeying instructions in the assigned, or have procedures in place. The failings, how-
Safety Management System. In the graph below, we see a ever, are generally in the planning – this may be on board
large number of discrepancies between formal procedures, departmental or shore instruction, and has upon occasion
(the SMS), and what is actually carried out in practice at the been the organisation at a shipyard on new build tonnage.
work site. To a lesser extent there may well be financial con- There is also a high level of incidence where the procedures
straints and time pressure – these are uncommon in near and instructions are fine, but the execution of them is poor,
miss reports but would almost certainly be higher for any resulting in a near miss.
formal investigations of an incident.
Organisation
Incompatible goals 200 191

150 145 11 1
11 1
2
120 2 150 10
10
100
90 100 3
3
9
60
9 50 38
35
30 4
13 4 8
8 0 Bad planning 5 No or unclear
0 7 Discrepancy
6
Discrepancy – 7 Financial 5 Time or co-ordination between policy tasks, authorities
6
formal and constraints pressure and execution and responsibilities
informalpractices Figure 12 – Organisation: causal explanations for failed defences
Figure 10 – Incompatible Goals: causal explanations for
failed defences
Procedures – With Safety Management Systems having
been in place for many years it is somewhat incongruous to
Maintenance – For the near miss reports that CHIRP has find that we have to experience an incident or near miss in
received relating to maintenance, most relate to activities order to determine that procedures are difficult to find or are
on the deck – more engineering reports would be extremely completely missing. There is, to a lesser extent, evidence
useful. Nevertheless, it would seem that the documentation to show that the scope is unclear – poorly written in other
(whether this be instructions or procedures) is in place - the words, and there is often a lack of feedback as to the use
main problem is planning and supervision. Once again this of the procedures – i.e. “it is difficult to do this because…”
is often at a higher level than the on-board management.

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