Existing approach to safety management has proven deeply flawed and dangerously misleading

I’ve posted this before on another thread - this is a really good article about SMS, procedures checklist etc Light bulbs, red lines and rotten onions

For me it hit the target because it uses the example of the report on (PCTC) Hoegh Osaka incident as example of a ship having procedures the crew can’t follow, the difficulty a change in schedule can cause, the role of the non-working ballast gauges, the tempo of cargo operations, the unregulated role of shore-side and other problems that I am very familiar with.

Here is the paragraph from which the thread title was taken:

If the capsize of the Herald for Free Enterprise led to the introduction of safety management system, the stranding of the Hoegh Osaka has surely reaffirmed that we need more of it. More rules, procedures and checklists to plug those holes! But the existing approach to safety management has proven deeply flawed and dangerously misleading. For the rest of this paper I will illustrate some myths about safety management systems, and then debunk these myths by offering a new view about safety management system.


Thanks for finding that. Accurate tank sounding systems along with robust remote draft reading equipment are few and far between and most engineering superintendents do not regard their failure as something worth bothering about.
On one new vessel an cash adjustment was made when the vessel was handed over for the inoperative forward draft indicator. With the large crew at the time it wasn’t a problem, later with a crew of 20, daily soundings and different people doing them each day gave inaccurate results.
As for those written procedures that are issued from all in sundry in copious content where are the time and motion experts when you need them. One guide written by a P & I company for the master made the three mates redundant. The master did it all.


Sailing C/M on a PCTC it’s very helpful to be able to keep a very close, almost constant watch on the drafts and ballast tank levels. Some ports require extra ballast moves to maintain ramp clearance while the tide changes, don’t want to botttom out and don’t want the ramp angle to get too steep.

Of course it can be done without but it a pain, for sure there is going to be more guessing to save having to make trips around the ship, taking attention off other duties.

I going to bet that the car ship Golden Ray that just went over in Brunswick had non-working gauges. That’s a safe bet I think, if they were in fact working nobody will remember this post.

Oh, built in 2017, most likey working.

The linked post is two years old now so we could see if and how anything has changed since then. Quick answer – nothing that I can see from my corner of the world.

The recitation of what’s wrong with most implementations of ISM and the resulting SMS out there seems close to what my own experience is and that includes a great deal of time with a drilling contractor. One could be forgiven for thinking that if any group is going to get this right it would be them with dedicated HSE departments, rig based HSE personnel, a budget etc. Unfortunately that has not been my experience, they are just as apt to, in my opinion, mis-interpret the ISM code in creating their SMS. Extra layers of management/policy/procedure sometimes ill conceived, often not subject to review by “subject matter experts” and just as often harsh towards genuine “continuous improvement” comments from the field.

It is hard to find fault with his analysis of things gone wrong in SMS-land.

But while whole heartedly agreeing there has to be a better way, I’m just not picking up exactly what his/the “new view of safety management system[s]” consists of.

At the end of his post he author lists off four things. I don’t know if they were intended to be the “new view” or what is wrong with what we have.

  1. Purposeful Compliance
    His take-away here appears to be “Compliance must have a meaning and purpose, not be something demanded for its own sake.” After I guess decades by now of innumerable bitch and moan sessions, training, planning, training, actively contributing to HSE programs and did I mention training, this seems just plain banal. And I think it would to most senior sea-going personnel. If this is aimed at shoreside ship management then I say “from your lips to God’s ears”! Otherwise I don’t think it is at sea staff that is making this stuff up the way it comes out now.

  2. Approximate adjustments
    Here I think he is arguing for something I would call professional, competent, discretion with regard to the written procedure. I’m pretty sure this is what is already going on on every ship I know of. Why do I think that? Because if it wasn’t already going on then ships would never leave port. Daily? Weekly? Monthly? Senior officers are called on to balance spirit and intent, compliance and not complying, delegating and saying oh F-it I’ll do it myself, prioritizing the vast array of requirements to the time-place-circumstance they are faced with. Which lists are important now? What’s important on this list now? This is reality, the real life we are faced with. It is a situation fraught with risk to the seamen and not much to the shoreside ship management team.

  3. The equivalence of success and failure
    Here I am unclear on his message. If he is saying it is a thin line between operating in a faulty manner and succeeding and operating in a faulty manner and failing (an incident) then to that I say – do you think? Lets look at a typical organization:

  • Dense, voluminous documentation system with generic procedures, forms, reports and of course checklists. Lets say it’s poorly organized and cross referenced as well. Lets say it’s redundant in places also.
  • An unforgiving operational tempo.
  • Lack of crew resources (at least less than desired) – manhours and competency.
  • Record of past “success” (lack of incident) when same routine employed in same situation with same resources.
    There are ships very close to the edge out there. Winning some, losing some. Not the best result to be hoped for in ship ops. The SMS far from preventing going over the edge, may actually be allowing it to happen.
  1. Business is Safety
    Here the author states “Safety is not a crime against business. Business is safety.” At first I threw up a little in my mouth but then I realized this was another way of saying something I strongly believe in. I mentioned it here sometime ago as coming from an old Getty Oil book of matches cover, “Seamanship is safety”.

In other words doing it right takes into account doing it safely.

This may be too cute by half but if I could ban the word “safety” I would. However, there is plenty of room to engineer, plan and do things “safely”. The difference being that adding a giant layer of Safety departments, Safety professionals, Safety procedures can arguably be shown to not help much in actually doing things safely.

If in the end it was only the authors intent to point all this out then I would hope shoreside ship management would read the memo. If he was pointing out to senior seagoing personnel what they face everyday then it seems redundant.

So the open questions still are, is the ISM code the best it can be and is any given SMS the best it can be?

Getting flag states and IMO in the first place and ship owners in the next place to admit that what’s in place now (despite best intentions) has resulted in a folly would be a monumental challenge. Upon such admission there is no guaranty they would come up with something better especially if only “safety professionals” are involved.

Two thoughts come to mind regarding any reform effort. One is Conways Law (paraphrasing) – “An organization (IMO) that designs a system (ISM) will invariably produce a design whose structure is a copy of the organizations communications structure”. So to my mind it would take a deliberate effort to avoid a hodgepodge of “improvements”. The second thought is something I read in “The Undoing Project” – “man is a deterministic device thrown into a probabilistic universe”.

Our imperfect organizations and the very way our brains work may have the final word on whether there can be any improvement in this arena. So keep using that discretion, doing it safely as opposed to what Safety says at times and takes your chances. Which leaves me with one last thought.

“When did you start thinking every wrong had a remedy Wu?”
Al Swearengen


They probably didn’t even have sounding pipes to all tanks.

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The "new view’ I though was aimed at shoreside, the people writing procedures not the one’s following (or not), an explanation on how things get done on ships.

For example this

It is unthinkable for many of us to imagine that a vessel could ever sail from port without obtaining final stability calculations.

A “good chief mate” is going to be able to very closely ballpark the numbers. If the exact numbers are not available there will be past stability calculation there is going to be very close to the current.

Sailing without doing the calculations is a big no-no but in practice it happens all the time.

Anand, the author is saying this is considered by mariners to be good seamanship. I’ve been making this point for a while, I don’t need no stinking compass.

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The auditor finds a few non-conformances and the company addresses them by adding a set of procedures and half a dozen checks to the SMS. The quest for paperwork to prove safety generates even more paperwork for managing safety. Everything from starting the main engines to turning on the kettle is ‘proceduralised’ and ‘risk assessed’ and the SMS eventually becomes a monster to manage. There is very little foresight and thinking in this mundane ‘check-do’ process.

One vessel in the fleet has a problem with a particular piece of equipment. The office adds a Standard Job to every single vessels maintenance program. (Regardless of whether or not the job applies). Then follow up the email with an email to every C/E, advising them they must investigate this piece of equipment and immediately report back its condition. (Please repair it onboard the vessel without outside assistance).

Push that keyboard back and power down the PC. You’ve done plenty! You are the port engineer after all. Let that moron C/E and First figure it out. They’re right on the vessel, they should be able to figure it out if they’re worth their salt. It’s time to head on over to the bar and grab a few cold ones. Maybe one of those cheeseburgers with the bacon and bleu cheese. Maybe not, it was a struggle getting into that ballast tank last time you visited the vessel.


This issues is that the belief shoreside is each incident just demonstrates the need for more pages of more detailed instructions.

Here is as link to the MAIB Hoegh Osaka report. (pdf) )

From the ship’s point of view there were three factors: the last minute schedule change, the inaccurate cargo weights (supplied by shoreside), inaccurate ballast tanks levels (gauges not working), the trim down by the head may have contributed as well, causing a higher than expected rate of turn.

On a high-tempo coastwise the stability must be computed in advance, if all the information is not available than estimates must be used. It’s often the case the ports on a coastwise schedule will demand arrival and departure drafts days in advance but will not supply cargo amounts and weights. So it’s all estimated, as better information becomes available everything can be updated. If the port sequence and schedule is changed everything goes out the window and must be redone.

In total the ship works with information that has errors but usually within a small range. If multiple errors cancel the the total error is small. On the Osaka the errors were outside the expected range and the errors compounded rather than cancelled.


This is from Nippin Anand’s article with regards to the MAIB report:

The remote gauges for tank sounding were not operational at the time of the accident – but this was not necessarily a non-compliance, as long as tank soundings could be obtained manually. It appears that in the absence of compliance risks, the company regarded rectifying the fault in the remote gauges as a low priority. The official accident report stated that: ‘In light of the low priority given by the company to repairing the gauges, a similar low priority was assumed by Hoegh Osaka’s chief officer, who resorted to estimating ballast tank quantities.’

In particular this:

‘In light of the low priority given by the company to repairing the gauges, a similar low priority was assumed by Hoegh Osaka’s chief officer, who resorted to estimating ballast tank quantities.’

Here the assumption is made that the C/M has no understanding of ship stability and based on the fact the company will not repair the gauges decides that the amount of ballast in the tanks is unimportant. This just perpetuates the idea that the ship’s crew has no expertise and the ship can be run properly if only there were sufficient detailed checklists.

More likely the chef mate understands that a company that would send out a 218 items pre-cargo check list is a company that is run by idiots and the most prudent move is to disregard them as much as possible.

This report from the MAIB appears to be just another cog in the machine intended to protect shore-side management from responsibility.


For me, the push toward companies using a dense, increasingly complicated SMS to seemingly attempt to focus the brain power into the office is the most insulting part of working for them. It displays a complete lack of respect for the abilities of the people standing on the deck plates doing the job. This then fosters a mutual disrespect as the crew gets tired of being told what to do, and having to add procedures to something they have been doing safely for years, but someone on another vessel did it wrong.

I have genuine concern for my crew’s safety but once an incident or minor injury happens, my almost immediate worry shifts to “how is this going to affect the SMS moving forward?” Very little is ever subtracted. More and more just gets added and at a certain point it gets overwhelming to make sure every form is signed and that the proper control number is being used on said form. The focus always seems to be on the paperwork being tidy enough for lawyers and the actual safety onboard being a result of it. It’s the other way around but I don’t always think the office sees it that way.


That’s what it seems like to me as well, but that raises the question of what’s up with the MAIB? Are they in on it too? How hard is it to say Hoegh should have had the gauges fixed even though there is no legal requirement?

The real purpose of SMS is for shore people to avoid liability in the event something happens. Most of the time an SMS checklist is a worthless waste of time and paper.

Reading that piece makes me feel better about my job. My ballast tanks leak, none of the tank level indicators are anything near accurate, the forward draft indicator always reads the bow is under water. Engineering has other priorities besides fixing the ballast system. I’m required to maintain an ammo program no one but me is qualified to maintain. The leadership won’t make the required courses mandatory so the program lapses when I pay off. Leadership declares ‘thy will be done’ but won’t support their requirements to carry out their will. All the while I have to gundeck SMS to make it pass inspections with useless forms and checklists I complain to the DP annually about. I just thought it was MSC. I guess it’s a common problem.

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That bloody mantra from the office, “if it isn’t written down it can’t be measured.” I never considered when I began my career at sea that typing was going to be a useful skill.

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Maybe the office should consider that the mere act of writing more and more down interferes with actually accomplishing the work. In many ways it seems to me that society has shifted from trying to foster excellence, to trying to ensure no bad outcomes which is not achievable.

Of course too much emphasis on getting the job done leads to things like the Triangle Shirtwaist fire, and ~96,000 lost-time accidents in Massachusetts in 1915 on a population of 3.7 million.

It’s a conundrum.

The ISM Code and safety management systems are only as effective as the people behind them. Specifically, a corporate management culture and philosophy focused on safety. Without that, the SMS will be just another example of a safety management system that exists on paper. From my perspective, when there are incompetent, dishonest and unethical individuals in corporate (and sometimes vessel) management the SMS becomes a threat as it has the ability to hold individuals accountable and responsible.

The other flaw in the system is that the regulatory agencies such as the U.S. Coast Guard and the Flag-States will not enforce ISM compliance. ISM compliance is required under SOLAS. I have witnessed this first-hand with my experiences at Noble Drilling. Corporate management knows they don’t have to comply because they know the U.S. Coast Guard or Flag State will not do anything. Until the U.S. Coast Guard and the Flag States start enforcing ISM compliance the effectiveness of safety management systems will be minimal at best.

As with the success or failure of most organizations, it all comes down to the people and the culture.

Jeff Hagopian

It’s probably more common than not. However, I’ve heard that several companies are very strict and consistent on safety…usually related to the oil exploration/drilling industry. Simple things like mandatory PPE enforcement and rigging inspection/procedures are usually indicative of a better organized culture that gets the “big picture” correct.

On land, the USA has OSHA/MSHA as the major agency over workplace safety. On the water, it’s the USCG, to which I think anybody who has worked both places will gladly agree USCG is way behind the times.

However, the true enforcement of safety culture ashore is not OSHA, it is the insurance companies. This applies to nearly everything, including pressure vessel inspections.

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In the article referenced by @Kennebec_Captain it says “Light bulbs either light up or they do not. There is no middle way to determine whether they work or not.” The implication is once they are out, they are out. In some circumstances this is not true. My neighborhood street lights use sodium vapor bulbs. The one near my house didn’t just fail to turn one night. At the end of their life they begin failure mode cycling where sometimes they will be normal for several hours (or days) and then slowly go dim for a while. Some nights they will be bright white instead of yellowish and then suddenly go dim. This cycling can last a few weeks of several months before the light just doesn’t turn on. Perhaps an analogy to Safety Management is when there is disfunction in management where on the surface everything may appear normal before a complete breakdown occurs.

I understand the need for procedures (and I have had to write them). I personally prefer to formulate guidelines that allow flexibility for existing circumstances. The key is always to be aware of the end goal. Procedures by their very nature do not allow for much variance.

With regards to the light bulb analogy what the author was trying to get at was that the MAIB’s analyst was of little use because the method used was a binary compliance/non-compliance approach using an almost worthless check list.

The MAIB’s job in this case is simple because they can use the same brain dead approach the company had taken and simply site any checklist item not done as “crew error”.

With regards to the ballast tank gauges not working, that’s not a requirement thus it’s not a non-conformance so not an error in the MAIB’s binary view.

The MAIB and the company can both pretend that a mariner’s job is like a computer running code but the C/M has to deal with reality.