Check List, Procedures, Training and Experience


#1

Continuing the discussion from How much does the Safety cost?:

Port engineer I knew once used to like to say “ya gotta be smart”. I think that’s what lacking, a deep understanding of the proper role of procedures and check lists. But this isn’t just shoreside, it’s on the ship side as well.

We’ve had problems where our procedures were insufficient and we didn’t realize it but the office fix was on the wrong track. It would have been better to fix out system than to replace it entirely with another stupid excel spreadsheet.


#2

Training officers and crew to actually inspect something instead of just checking off the box can be daunting at times. Over the years I’ve edited our pre arrival / departure checklists to be more in a chronological order and streamlined for a more logical approach to preparing the bridge.

I still occasionally find the course recorder signed as being inspected but one of the inks is completely spent or the fathograph has been tested on arrival but there is no bottom return on the graph yet it is signed as “OK”. Pointing these things out to the Mates and Re-enforcing the need to perform an inspection of the equipment with a focus on recognizing flaws and errors is the end goal. To me it is the mark of an excellent seafarer to recognize there is a problem, report it, and then set about fixing it. Otherwise, what is our actual value as professionals?


#3

One of the problems today is that the training officers themselves often are not properly trained, often chief officers or second engineers with 1-2 years experience who see this as a career move . When things goes wrong there answer for many companies is to change the checklist, and little focus is on the human aspect of the incident. Some countries even make their examines for officers with tick boxes, how can we then expect that they understand the underlying purpose of the instruments? Yes most can be trained, but it takes time.


#4

It seems to me that bad check lists and procedures, which is one thing I deal with, is a first tier problem, officers not understanding or not properly trained is a second tier problem. Solving the problem of poorly trained officers is made doubly difficult with poorly written instructions.

But I don’t know how wide spread that problem is, maybe the problem of poor checklists is not widespread?


#5

My test for written instructions has always been to give them to the cadet and see if they can complete the task with the instructions alone. If not, they need more detail.

My other rule of thumb with checklists is that they should be few in number and no more than one page long. Anything more should require its own control number in the SMS.


#6

Several years ago I was tasked with rewriting the procedures in the company’s SMS that involved operation of the OWS and pumping Bilges. This involved writing several sets of procedures as there were different classes of ships and equipment involved. What had been in the SMS was viewed as worse than useless as some of it was not even applicable to some of the ships.

Having procedures to cover various systems, operations, or evolutions are critical to prevent errors both great and small. But writing good clear Procedures takes work.

I like using Procedures when dealing with new and untrained crew. Checklists are good to note significant mile markers so that situational awareness and preparation is maintained. Procedures can lock you in to a set way of doing things without variation which is why I many times prefer a set of Guidelines where a certain amount of flexibility is allowed depending on non standard operating conditions. Knowing the difference between the two is important.

Edit due to grammar correction


#7

Brilliant.


#8

“tanquam ex ungue leonem,”


#9

My last company had checklists for just about everything. The problem was that after a couple of months these forms were “Pencil Whipped” and if you were to ask what was on a given form, most would be hard pressed to recall most of what they just checked. I personally, thought that most of them were a good idea but human nature took over and they were ignored as time passed. About the only time they were used properly was during Vettings and Audits!


#10

I think, to some extent at least, that’s OK. If the check lists are correct and useful once everyone is following them the situation is better then they were without the check lists. For example as @Chief_Seadog points out, still fully useful for new crew members.


#11

Fortunately, I mostly work for small companies that may have checklists, but in practice don’t get too carried with them. However, when working for larger companies, my experience has been similar to yours. The checklists are mostly pencil whipped and everybody knows it, expects it, and accepts it.

At one company with computerized checklists and a variety of daily, weekly, monthly reports, I learned very quickly not to tell the truth on the checklists and reports. I had to make sure to only tell them what they wanted to hear, just like the guy that I relieved had been doing. They were not interested in safety or the truth; they just wanted to make money. Oh yes, there was a lot of safety theater to keep the customers and regulators entertained, but it was mostly smoke and mirrors.


#12

This is a really good article.

Light bulbs, red lines and rotten onions

The smoke and mirrors serve as layers of an onion to hide the rotten center.

. This exemplifies a ‘rotten onion’ style of management; one where multiple layers of procedures and checklists can cover up the core issues. These procedures (referred to as ‘objective evidences’ in the language of SMS) make it extremely difficult for an outsider (i.e. regulator) to gain insight into the core practices and culture of an organisation. I am reminded of a fire damper that was found fully corroded and inoperable during a survey, despite maintenance management plans indicating fully operational firefighting systems in ‘excellent condition’. No amount of processes, procedures and checklists can solve core problems of this nature. If anything, they only make core issues more inaccessible.


#13

Interesting article about how people think what happens at work compared to how things really are:

The varieties of human work

Similarly, work-as-imagined applies to what we think we would do in a scenario, which may well be different to what we would really do. Martin Bromiley (2016) reflected on a tragic incident where his wife Elaine Bromiley died in a routine operation. He said that “As clinicians the world over have reviewed my late wife’s case, many have stated that ‘I wouldn’t have done what they did.’ Yet place those same people in a simulated scenario with the same real-world disorder, which deteriorates into the same challenging moment, and most actually do.” Similarly, Hollnagel (2016) stated that, especially when something goes wrong, “work-as-done differs from what we imagine we would do in the same situation, but thinking about it from afar and assuming more or less complete knowledge.”

This diagram is from the article.

varieties-of-work


#14

One vessel that I was relieving on had several checklists under glass in the ER Control Room. When I went to erase the previous checks, one of the AE’s laughed and asked why I was doing that. Well, I found out that they had been “checked” off for so long the check marks were permanent. Unfortunately, we had a Vettor come onboard and we got written up for the “Permanent Check Marks”.


#15

With the implementation of SMS there had been a few improvements, but overall it seems like it was implemented poorly. Which has to mean it’s fundamentally flawed. It can’t be right in theory and wrong in practice. If it doesn’t work where the rubber hits the road, at the sharp end, than it’s no good.

The underlying problem, shoreside not knowing what works and what doesn’t, hasn’t been resolved.


#16

What about shoreside changing something that works simply because they can or need something to do?

Not to track back to that other thread about some people ashore’s thought process that the brain trust only needs to be in the office, but they used to value the opinions of the seagoing employees. They really don’t anymore.


#17

I agree, but, there are also things ship’s crews don’t understand. Procedures and check lists can be created aboard ship by people most familiar with operations but they need to be vetted/approved by someone with understanding of the broader picture. Likewise if they are created ashore they have to pass a usability test aboard ship.

One big problem is shoreside will not accept feedback.


#18

That about sums it up


#19

One of the reasons the check lists and procedures are such a mess is the incentives faced by the office.

From the point of view of the office the main objective is to avoid responsibility. If the check lists and procedures are fully comprehensive, covering every detail and possibility than they’re covered. No matter what goes wrong they can show it was the crew fault because in almost every case it can be shown something was missed.

This is how the Osaka ends up with a 214 item check list just to prepare for cargo. What do you suppose happened to person who created that list after the incident? Probably busy making an even longer list.


#20

Let’s be fair. It’s not only shoreside. Mates and masters make night orders, cargo load directives or import orders that function the same way (to shift the blame of failures to others).