The article examines an accident investigation report and provides an alternative to the conventional ‘human error’ approach to managing safety in time critical operations in the maritime sector.
WHEN LESS IS MORE
For overworked crew in stressful situations, too many procedures and checklists can be counterproductive to maintaining vessel safety
Words: Nippin Anand*
On 16 February 2013, during berthing at Holyhead, the port fin stabiliser of the ro-ro passenger ferry Finnarrow made contact with the jetty resulting in damage to the hull and ingress of water. Among other things, the official investigation found that the ‘procedures for pre-arrival checks were inadequate’ and that the crew lacked familiarity with the vessel’s equipment.
The Finnarrow case is by no means unusual, in that the investigation set out to ascertain and understand the root cause’ behind the accident. Invariably, the problem is found to lie with the fallible human and an extensive vocabulary has grown up to support this viewpoint communication breakdown; lack of situational awareness; lack of foresight; complacency; error of omission; over-confidence; to mention just a few.
This is the legacy of the relentless search for human error and procedural inadequacies. To use a metaphor, it’s like trying to find the holes in Swiss cheese. And the solution, obviously, is to plug those holes with more procedures, checklists, barriers and the all too familiar familiarisation programmes.
But are we missing something important in this approach? As the investigation report suggests, the crew on board the Finnarrow were certainly competent and experienced.
They were familiar with the operation of fin stabilisers. Although the stabilisers were designed to house automatically at ship speeds below 6kt, the officer had deliberately chosen to operate the equipment in manual mode until the last leg of the voyage.
Because the Finnarrow was a ro-pax ferry, perhaps the officer was concerned about cargo care and passenger comfort. Before the officer stepped down from the bridge for harbour stations, she had even discussed the status of the stabilisers with the master. But the information from this brief verbal exchange was lost during the final moments of berthing. The task of housing the stabilising fins was never ticked off the checklist and never completed, eventually leading to an accident.
How could a competent team of professionals miss out something so crucial? Why did they screw up? Was It an error of omission or more than that? To answer these questions, we need to get into the shoes of those on board. Approaching the port at around 0500h on a dark cold morning in February, a duty officer is caught between leaving the fin stabilisers deployed until the last moment for passenger comfort or housing them beforehand for safety reasons. Added to this is a half-awake master on the bridge taking over controls, a duty officer eager to hand-over controls and run down for harbour stations, communicating with port control in a foreign language, as well as the constraints of pilot exemption and the most important task of ensuring navigational safety. Those with seagoing experience will recognise it as a stressful operation.
Now consider the following arrival checks on the checklist. Reporting to port control diligently as marked on the chart, informing the master, removing anchor lashings, engines on standby mode, ensuring all steering gears on, bow thrusters turned on, notifying the crew, helmsman on the wheel, deploying bridge wings monitors, getting windows washed, unlocking cargo doors, isolating certain fire alarms and somewhere hidden amongst these checks is ‘house stabilisers’.
It is understandable that certain checks are intended reply for efficiency gains (e.g. unlocking cargo doors prior to arrival); most were for avoiding the risks that may arise during berthing (e.g. removing anchor lashings, switching on standby machinery), some were of less serious consequence (e.g. washing windows, isolating fire alarms) and with the benefit of hindsight the most important check was ‘house stabiliser’. Credit must be given where it is due. The investigation report clearly highlighted that “the safety management system (SMS) did not include any reference as to when specific aspects of the day voyage checklist should be completed”. However, the problem here is far more serious than introducing reminders or signposts to those ‘forgetful humans’. A check has been overlooked not because of slips, lapses and mistakes but because far too much is set to be achieved in a restrictive timescale and with limited resources. Miss this point and the lessons learnt take a completely different direction. Going by the traditional approach, what follows is adding two more procedures and half a dozen checks when the need of the hour is removing tasks of lesser consequences from a time-critical operation. The sprawling vastness of SMSs-not its omissions – is the crux of the problem. Unless companies are committed to providing additional manpower, introducing more procedures would only be to the detriment of an overstretched system.
This proceduralisation of everything myth has been researched extensively in industrial psychology. Supported by several famous experiments (see box), psychological studies have consistently warned against imposing excessive checks, procedures and barriers. To the contrary, as it was found in the famous Munich taxi experiment, removing barriers (such as anti-lock disc brakes) from the taxis made the drivers more aware of the risk of collision. It tells us that too much control can sometimes lead to a false sense of security – yet another reason to disrespect rules and procedures.
I hope someday that method will replace orthodoxy in making sense of human behaviour in the maritime world. Perhaps those in power will wake up to realise that volume, weight and size of paperwork does not make an organisation safe. As regulators, investigators, operators and seafarers we all need to take a hard look at the monster we have created called ‘safety management system’.
Critics would say that this sounds good on paper but, in practice, how should companies react to the outcries of lawsuits and insurance claims that expect risk assessments even for a handshake on board these days. To this I say an organisation should find itself much less exposed in a courtroom with meaningful procedures being followed mindfully than a plethora of unrealistic checks being ticked and flicked mindlessly or even worse left ‘omitted’. Small is beautiful and less is more for safety and for business.
* Nippin Anand is a principal specialist at DNV GL. The views expressed in this article may not represent the views of the organisation that the author represents.
A Munich taxi driver once told me …
Risk homeostasis holds that everyone has their own fixed level of acceptable risk, which they adjust in response to the introduction of new safety technology. Evidence of this was most famously gathered from a group of German taxi drivers. For three years in the early 1980s half the taxi-cabs in Munich were fitted with anti-lock breaking systems (ABS), while the other half had to make do with conventional breaks. All the cabs were fitted with sensors and monitoring equipment.
Among the 747 accidents that occurred during the study, those involving cabs fitted with ABS were clearly over-represented in accidents where the driver was not at fault. Further analysis of the data revealed that drivers of cabs with ABS made sharper turns in curves, were less accurate in their lane-holding behaviour, proceeded at a shorter forward sight distance, made poorly adjusted merging manoeuvres and created more ‘traffic conflicts’. Non-ABS drivers were found to drive more carefully since they could not rely on ABS to evade a dangerous situation.
Similar conclusions were reached in experiments with passenger vehicle seat belts, airbags, cycle helmets and the removal of traffic signals or other road furniture. Counter-intuitive as it may seem, it is possible that some safety technologies increase rather than reduce risk. This is because humans tend to resist external controls and prefer to ‘own’ their decisions.
