Page 69 - CHIRP Annual Digest 2017

CHIRP Annual Digest 2017

It should be mentioned that, as with the latent failings, The Traditional Approach
CHIRP compared all reports with those from 2014 onwards. The maritime industry by nature is very technical, so it is
The difference in the graphs was negligible and thus the natural to look for technical and procedural solutions to
same conclusions were reached – the maritime sector drive forward improvements in safety and operational per-
needs to address these issues to be able to move forward. formance. This approach has been applied for decades,
probably much longer, and has been successful in improv-
Simple Root Cause Analysis ing standards. Firstly, the 20th century saw great technical
Some of the latent failings may seem to be complex but advances in ships and ships’ equipment which led to far
there is a very simple method that anybody can use to drill greater operational capability. This has picked up pace into
down through any event, whether it be a near miss or serious the 21st century particularly with the digital age and modern
incident, in order to determine the root cause of the event. electronic equipment. Secondly, the increasing complexity
The method is called “Five Whys”. Quite simply for any inci- of operations gave rise to a commensurate increase in for-
dent you take the starting point and ask what happened? To malised operational procedures and management systems.
that answer you ask “Why?”. At this point there may be two However, accidents continued.
or more reasons and so a small matrix begins to be built
up. For the answer to each “Why” you ask “Why?” again. Throughout the 20th century the international seafaring
Some of the matrix may well end up as a dead end with no community, through IMO, tried to address safety through
particular learnings, but the other parts of the matrix should developing a culture of compliance with prescriptive regu-
be followed through. When you get to the fifth “Why?” you lation, underpinned by effective enforcement supported by
will be at or very close to the true root cause of the event, appropriate penalties for transgression, SOLAS , MARPOL ,
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and be in a position to identify the causal factors and failed COLREGS and STCW being the instrumental Conventions.
defences. Throughout the “Why” questions all aspects of Whilst this approach had some success it was not a pan-
the Deadly Dozen should be incorporated to ensure that all acea, accidents continued, people were blamed, punished
human factors are adequately addressed. and careers ruined.
If the above is carried out correctly then it will almost cer- At the end of the 20th century a cultural shift towards
tainly be found that the conclusions are not, “Non-compli- self-regulation was developed, encapsulated in the ISM
ance with company instructions or the SMS” or “Human Code . This represented a step change, recognising that a
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Error”. Human error is not a root cause – the sequence of one-size-fits-all prescriptive approach was neither effective
events that caused the human error will identify the true root nor possible. It enabled operators to assess and manage
cause. The old adage that “an accident on board a vessel their own risks in the most effective way for their operation.
has its roots in the company boardroom” is very true. Again, it has had some success, but accidents, including
preventable accidents continue.
Conclusions
This paper certainly shows that there are many areas in The Common Factors
which improvements can be made, but to do so requires These approaches to addressing safety share some com-
commitment from all sectors of the maritime industry. In mon factors;
very general terms ships and their crews act responsibly i. They are based upon a comprehensive set of rules,
but play with the cards that have been dealt to them. Thus, regulations and procedures. Compliance was supposed to
the areas where analysis such as the foregoing reveals a ensure safety.
need for improvement starts with commitment in company ii. They assume crews are fully trained and proficient in all
boardrooms, at Flag State administration level, with classifi- respects.
cation societies and indeed at the naval architect’s drawing iii. They assume the rules, regulations and procedures can
board. The analyses being discussed now can only bear fruit be complied with at all times.
if future decision making takes note of the findings.
The focus is on the rules, regulations and procedures, not
Article. 52 the human struggling to operate them, and that can be prob-
lematic. Not only is the crucial role of people often over-
MCA Insight Article – Why the looked, they are also seen as the weak link in an otherwise
Human Element? supposedly sound system. They are seen as a source of
error and something to be conveniently blamed when things
go wrong. But this not a fair reflection of the real world and
In their seminal 2010 work Gregory & Shanahan posed the we are missing a crucial opportunity to identify safer and
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question “where is safety – in people or in rules?”. Whilst rec- more effective ways of working through a better understand-
ognising that the traditional focus on rules and procedures ing of people.
seemed a reasonable way to improve safety, the crucial role
of people was increasingly apparent. They contended that The Regulatory Environment
whilst rules have a significant role to play, real safety lay in Rules and regulations generally stem from two sources,
the expertise, understanding, risk mitigation and decision either national or international regulation; or company based
making of operators at all organisational and regulatory lev- policies, procedures and management systems. This gener-
els. The more we learn about human behaviour, capability ates a mass of information for the seafarer to absorb, under-
and performance the more their assertion proves to be true. stand and follow. When things go wrong we very often see
This raises another question – “what do we do about it?” people blamed for failing to comply with a procedure, proce-

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