Tag: ISM

It’s Not Gambling……It’s Risk Assessment

“You’ve got to know when to hold’em,

Know when to fold’em,

Know when to walk away

And know when to run.”

-Kenny Rogers, The Gambler

Much like the gambler in a poker game, the master on a merchant vessel is sometimes put in that position of making a hard (and fast) call.  While the other players are holding their cards close to their chests, it’s up to the gambler to assess the game, read the “tells” from his opponents and make a calculation as to which one of the above choices he might take.  It’s not that much different at sea….

No, there’s no cards involved, but the players are much more powerful.  On one side of the table sits Mother Nature – all powerful, able to create devastating hurricanes, mountainous seas and screaming wind.  On another side sits Neptune, the Roman God of freshwater and the sea – the same God that merchant mariners might slip a small offering when crossing the equator.  And the fourth player?  The shipping company.

The master of the vessel has been given a trump card, however, in the form of the International Safety Management (ISM) Code.  This internationally recognized code specifically stating that the company should establish in its safety management system that, “….the master has the overriding authority and the responsibility to make decisions with respect to safety…”  Taken alone, this trump card could shift the onus of the game’s outcome solely on the shoulders of the master.  Luckily, one of the very next lines in the ISM Code states that, “The Company should ensure that the master is….given the necessary support so that the master’s duties can be safely performed.”  Not only does the master have a trump card then, but the shipping company must also stake him enough chips that he can safely play the game.

As the cards are dealt, the master has to assess the look on Mother Nature’s face – is she bluffing, does she really have a poor hand or is she holding a Royal Flush?  If he’s doubtful, perhaps he’ll walk away from the table.  Likewise, if King Neptune is looking too confident or a little treacherous, perhaps the master will fold.  And then there are the times that the look on King Neptune’s face grows darker and darker and Mother Nature is non-committal.  Perhaps, that is the time to run!

And where is that fourth player, the shipping company, through all this?  Well, they certainly play a roll, as they have chips on the table in front of them, as well as the ones they have provided to the vessel master.  With a larger stake in each hand, they will prefer that neither Mother Nature nor Neptune walk away holding the pot.  They are, however, limited by that trump card provided by the ISM Code that the master holds and the fact that sometimes the stakes are larger than they appear.

Playing that trump card – the overriding authority to say where the ship can go and what it can do safely – is not without its potential repercussions.  If the vessel master folds or walks away, allowing Mother Nature or King Neptune to take the hand with a pair of 2s, the shipping company might not want to stake him the chips again.  It is here where his experience and knowledge come into play – knowing if or when to play that trump card.  The knowledge that the shipping company will stake him in the next hand and support his decisions – understanding that Mother Nature and Neptune sometimes play erratically – is all important in allowing the vessel master to err on the side of caution.

In reality, this is not so much a competition, but a balancing act – ensuring that all players are satisfied and that the master walks away with all his chips – crew, ship and cargo.  At the end of the day, Mother Nature and King Neptune will continue doing whatever mythical deities do.  The shipping company and vessel master, however, will walk together to the next table to deal the cards yet again.  Or they may not.  The other possibilities include the shipping company staking a different vessel master in the next hand or, on a very bad day, King Neptune sweeping away all the chips – crew, ship and cargo – down to the watery depths.

Having Trouble Explaining the Difference Between Near Misses and Unsafe Acts?

Is it a near miss?  Or was it an unsafe act?  Maybe just an unsafe condition.  What’s the difference and how do you explain it to your crew when introducing them to your safety management system?

Check out nearmiss.dk for more cartoons like the one below.  It’s a good visual explanation of the differences between some of the terms used in our safety management systems.  As the safety culture of a vessel and/or company evolves, many are moving away from the simple reporting of near misses.  By identifying (and resolving!) unsafe acts and unsafe conditions, the goal is to break the error chain before a near miss even occurs.

So, where is YOUR safety culture on the evolution chain?


Near Miss - Lifting Gear

Near Misses: Saving Ourselves One Miss at a Time……

 “Near-miss : A sequence of events and/or conditions that could have resulted in loss.  This loss was prevented only by a fortuitous break in the chain of events and/or conditions.  The potential loss could have been human injury, environmental damage or negative business impact (e.g., repair or replacement costs, scheduling delays, contract violations, loss of reputation).” – International Maritime Organization

 Near-miss reporting and investigating is something that mariners have been doing for many years now.  Initially, many viewed them as a passing fad – the latest gimmick rolled out by the newest consultant.  Unfortunately, the rationale behind near-miss reporting and investigation wasn’t and probably hasn’t been explained to many.  That’s an opportunity that was certainly lost, as this is all much more than a passing fad or gimmick.

Whether it is the data gathered by Frank E. Bird, Jr. in 1969 – represented above in the graphic – or the more recent studies conducted by Conoco-Phillips Marine in 2003, there’s solid evidence that looking at and understanding the root causes of near-misses will reduce injuries and fatalities.  Why?  Because we’ve caught the situation before it produced that injury or damage and now, we have the opportunity to learn.  It doesn’t matter if it was equipment failure, personnel error or an inadequate procedure, something has been identified as a problem.  Once that root cause is identified, those lessons learned can be used to prevent further incidents of the same sort: future incidents that might not be caught and might lead to equipment damage, human injury or fatality

“The safety management system should include procedures ensuring that non-conformities, accidents and hazardous situations are reported to the Company, investigated and analysed with the objective of improving safety and pollution prevention.” – ISM Code 9.1

 So, there is a system whereby a vessel is creating a library of near-misses and lessons learned.  But, wouldn’t it something if those near-misses and lessons learned were shared across a fleet or a whole company?  Does someone within your company compile a newsletter that contains some lessons learned?  Very frequently, there will be similar near-misses from many vessels which could indicate a systemic problem.  Sometimes it is a slew of trips, slips and falls or possibly equipment that fails, such as gratings or handrails that leads to near-miss observations.  If so, a concentrated safety campaign in that area might be warranted.  At a minimum, if this information is passed around, other vessels get the opportunity to learn from the mistakes or observations of others.  Designated Persons Ashore (DPA), safety departments or loss prevention groups’ buy-in would be crucial to making this happen on a company-wide basis.

Going to the next level, what would happen if these near-misses were passed around the whole industry?  Wouldn’t it be great to stop a problem onboard your vessel before it became an issue by hearing about lessons learned from another company or possibly, another segment of the maritime industry entirely?  Oddly enough, there are already some systems set up for doing just that.  One of the most notable is the Nautical Institute’s Mariners’ Alerting and Reporting Scheme (MARS).  Drawing near-misses from across a wide swath of the maritime industry, their database goes back over 20 years.  That’s no small amount of lessons learned!  In the UK, there is CHIRP, which gathers near-misses from both the aviation and maritime industries.  The Confidential Hazardous Incident Reporting Programme (CHIRP) compiles near-misses received into a quarterly report which is quite interesting to read.  Not only do they report on information received, but they follow-up on it to see what best practices companies might have implemented in response to the near-miss.

CHIRP is definitely European-centric, whereas MARS is more international.  On the U.S. side of the Atlantic, the U.S. Coast Guard publishes lessons learned under their Incident Reports.  These lessons learned come more from inspection observations and incident investigations, rather than from within the maritime industry itself.  Perhaps, the U.S. Maritime Administration should establish its own database of near-misses – all the better for passing along lessons learned and making the industry – and mariners! – safer.

Does it take effort to pass along near-misses, especially outside the company?  Absolutely it does!  But, remember how onerous it seemed to fill out those near-misses onboard your vessel a few years ago?  And now, it’s just how you do business.   Perhaps, in a few more years, it might be just as natural to send a report into one of the national or international databases.  In the meantime, mariners, DPAs and companies should continue to look at lessons learned inside and outside their organizations to ensure best practices are used and mariners are safe!


Additional Reading and Links

U.S. Coast Guard Investigations – Investigations

MARS (Mariners’ Alerting and Reporting Scheme)

CHIRP for Maritime (Confidential Hazardous Incident Reporting Programme)

IMO MSC /Circ. 1015 “Reporting Near Misses”

IMO MSC-MEPC.7/Circ.7 “Guidance on Near-Miss Reporting”