В настоящей публикации продолжается обсуждение, начатое в статье “ISM complacency: can the criminal law help?” (автор Craig Laverick, AMNI, – Seaways. — 2016. — October. — Р. 25 — 26). Автор настоящей публикации Dr. Kevin Ghirxi,
PhD, AFNI, полемизирует. Он полагает, что такие категории, как: небрежность, вина, неосторожность имеют смысл только в судах. В управлении безопасностью мореплавания они абсолютно бессмысленны. Наказание моряков может устранить симптомы, но не причины чрезвычайных морских происшествий, – такова позиция автора настоящей публикации.
Mr Craig Laverick’s article ISM Complacency: can the criminal law help? (Seaways, October 2016) worried me on three accounts, namely:
- It uses the term ‘complacency’ in a very prominent manner;
- It concludes that punishment is an effective way to ‘combat ISM complacency’; and
- The preliminary results of Mr Laverick’s research indicate that the absolute majority of seafarers subscribe to the above.
There is no question in my mind that the article is explicitly coming to the conclusion that human error and procedural violations are the most prominent causes of accidents. I very much fear that the philosophy being elaborated here takes us back to the beginning of the 20th century, when there was still the belief that some people (more than others) were prone to be involved in an accident (the accident proneness theory) – those who are negligent, unreliable and liable to forget.
To start with, if we think that punishment will enhance safety, then we are off track. Not only that, but this approach is doing irreparable damage to safety investigators who carry out investigations without apportioning blame. If we introduce the fear of punishment, seafarers will not volunteer information on the dynamics of the accident as they have witnessed them. Why should they? To have that information used against them in a court of law? Of course they will not run the risk; the only option is to submit a statement, which will have been filtered and scrutinised by lawyers to the extent that any details on the actions or inactions are deleted. That leaves us without the very information needed to reveal why an accident has happened.
It really baffles me how seafarers – the very same people we are trying to protect from criminalisation – are not only subscribing to their own criminalisation but even contributing to the selection of punishment that they would like to get!
As safety investigators, we encounter countless situations where seafarers do not follow procedures. Unfortunately, there is a dominant mentality that following procedures is a guarantee to achieve positive safety results. Regrettably, this means many investigations are actually a witch hunt to identify where people went wrong, what procedures were not followed and which collision regulations were breached by the OOW – what we call a Newtonian perspective of analysing accident dynamics. More often than not, these conclusions are then followed by recommendations to introduce even more procedures to the company SMS! The natural question is, if violations of ISM procedures are deemed to be a major contributing factor to any accident, then why are more procedures being recommended?
A safety investigation should go deeper than this. In fact, a safety investigation carried out in accordance with the requirements of the IMO Casualty’ Investigation Code should start exactly at the point
where violations and human error are identified (contemporary academic concepts do not even label these actions as ‘violations’ but define them as ‘performance variability’).
The problem of non-compliance with ISM procedures has nothing to do with complacency. As one distinguished scholar clarified, ‘People at work must interpret procedures with respect to a collection of actions and circumstances that the procedures themselves can never fully specify… ’
How could any procedures do this? There is a significant misconception that ISM procedures are a guarantee of safety. This is not always the case. While ISM procedures are there to guide us in how to do a job well, there are occasions when following these procedures will simply frustrate the operator in carrying out the job; cases where procedures are ill-matched to the realities on board ship. This is the reason for the gap between work as imagined (procedures in a safety management system) and work as actually carried out.
If we want to enhance safety on board ship, then applying criminal law and seeking democratic consensus on the most appropriate punishment is not the answer. The answer is helping ship management companies to monitor the work carried out on their ships, to understand the reasons for the gap between ideal procedures and reality, and to equip their crew members with the necessary skills to judge when and how to make adaptations (performance variability) during their normal day-to-day work.
Safety and accidents are two faces of the same coin. As Karl Weick said, ‘Safety is a dynamic non-event’. It is dynamic because any organisation needs to evolve and change. It is a ‘non-event’ because it emerges from the work that the seafarers do and is not something that one would find installed and nicely fitted.
A ship is not an inherently safe place compromised only by negligent people. It is the seafarers (including those who make adaptations in the application of ISM procedures) who create safety, because they are the ones who have to deal with the inconsistencies and complexities that they encounter on a daily basis. They are the ones who have to address the goals in their job description and at the same time remain loyal to the commercial and financial goals that have to be reached – what Erik Hollnagel defined as the Efficiency-to-Thoroughness Trade-Offs (ETTOs). That is why it makes no sense to punish seafarers for not following ISM procedures.
Negligence, fault, recklessness are very important legal concepts… but only in a court of law. They have absolutely no place in the management of safety. Punishing seafarers will treat the symptom but not the cause. We need to protect the seafarers from the system and not vice versa!
Автор: Dr. Ghirkxi
Источник: Seaways. — 2016. — December. — Р. 5.