Accidents at sea: Causes or constructs?

Has limiting liability, in place of genuine improvements in safety, become a fix-all?

If limiting liability trumps real action on vessel safety, then astute lawyers and shrewd solicitors should make a better choice than safety  departments, writes Nippin Anand, principal specialist, safety management systems, at DNV GL Maritime

There is a paradox in how we manage safety. While success is often credited toleadership and commitment from the top, failure, as in accidents, incidents or any formof undesirable outcomes, are generally understood as problems on the shop floor. The problem, to some extent, is how we understand, analyse and construct accidents in our industry. The outcome is undesirable but also one that is morally wrong and psychologically disturbing. From the investigator’s perspective, the first question raised is what went wrong? Technically speaking, “root cause” analysis.

The German philosopher Friedrich Nietzsche provides a befitting psychological explanation to this disturbing question that almost every investigator faces in the wake of an accident. “To trace something unknown back to something known is alleviating, soothing, gratifying and gives moreover a feeling of power. Danger, disquiet, anxiety attend the unknown — the first instinct is to eliminate these distressing states. First principle: any explanation is better than none.”

In a budget-constrained organisation where reporting and closing is often a matter of deadlines and key performance indicators (KPIs), any explanation really is better than none. In principle, the root cause is identified through gradual step-by-step backward reasoning of each possible pathway leading to the accident until alternative pathways can be considered. In practice, however, the first story that convinces the investigator becomes known as the root cause.

And how exactly is the root cause constructed? Usually by comparing the actions of those involved against a panoply of rules, regulations, procedures and standard practices to the last grain of sand. The grey, greasy, slippery, fatigued, corroded, inaccurate, chaotic and multiple perspectives of front-end operations are captured and presented as neat, colourful, organised, orderly and accurate slides in a PowerPoint presentation.

Split-second decisions made under intense production pressures, harsh weather conditions, under-resourced and uncertain circumstances are analysed, judged and reported in weeks (if not months) of playback screenings and coffee meetings. Far from any genuine attempt to understand the context in which those decisions were made, the focus is on establishing how many procedures were breached and rules violated. And since drilling down to the root cause by its very nature requires a cap, what follows is even more procedures, rules and checklists.

But expensive barriers and demanding compliance procedures are met with uncanny resistance from the workers — “you think you can make it harder, we know how to make it easier and faster”. Bypassing safety critical alarms, turning a blind eye to warning signs and mindless tick and flick through checklists leads to even more accidents.

One wonders which is the root cause: procedural violations or management’s unrealistic controls that left the workers with little choice but to violate the procedures. Call it the corruption of reasoning! Part of the problem is that adding more procedures, checklists and barriers has become the solution to all safety issues. The “HSE” specialist staff have minimum formal training in accident investigations, let alone any broader understanding of human behaviour.

Every accident brings with it the opportunity for learning and improvements. But learning starts with a bold admittance that the disease within the “body corporate” is systemic and not isolated to an individual’s attitude, “situational awareness” (that which the investigators need more than the victims) or competence. But such a bold admittance runs the danger of incriminating and exposing the corporation to legal liability. It is here that the latent and organisational factors are disregarded as speculative and the actions of those physically closer to the scene of an accident become known as the root cause.

It makes you wonder what exactly are safety departments needed for? If the question is of limiting liability rather than any genuine improvements in safety, then astute lawyers and shrewd solicitors should make a better choice. For one, they are formally educated in what they do but more importantly their intentions are unequivocal. Why shake the entire organisation when the solutions are so simple. Blame it on the bellboy and get on with it, mate!

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