SPOTLIGHT ON SAFETY: WHY ACCIDENTS ARE OFTEN NOT ACCIDENTAL - MM&P and Dalhousie University Reporrt

Report is here: SPOTLIGHT ON SAFETY: WHY ACCIDENTS ARE OFTEN NOT ACCIDENTAL

gCaptain post here:Study Looks at the Impacts of Commercial Pressures on Shipboard Safety

The report focus on the relationship between the company and the ship, SMS, the DPA and master.

One of the principal purposes of the SMS is to provide a link between onboard safety management and a designated person ashore (DPA) who has access to the highest level of management in the company. The designated person is responsible for monitoring the safety of the ship and ensuring that adequate resources and shore-based support are provided.

The current structure still does a poor job of holding shore-side personnel accountable given the degree of authority they hold over the ships.

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Definitely on the “to read” list for tonight. At MITAGS this week for classes so it should be good for some discussions throughout the next few days.

Safety is not the job of shoreside peronel it’s the job of the ships crew.

How does that work when you’re a crew member on a bulker that breaks in half and sinks in good weather?

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May I respectfully suggest that here we have an example of the situation that bedevils both safety and security work, the necessary but not sufficient condition. Yes, the crew must do their job, but no, there are circumstances where it is not enough.

I continue to advocate the position that crews in a crisis situation must play a hand dealt by others. Understanding how they played the hand is mandatory, but ignoring what the hand was and how it came to be dealt that way means your understanding will inevitably be incomplete. My reading of the paper by Capt. Loftus and his co-authors is that they have much the same perspective. IMHO, YMMV, and all that :slightly_smiling_face:

Cheers,

Earl

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The crew has SWA and the buck should stop there.

If I may, I can see @AHTS_Master point with regards to day to day safety management. The crew should be responsible for performing the job safely and not be micromanaged from the beach.

What I think @Earl_Boebert1 and @Kennebec_Captain are referring to is bigger picture safety of life at sea items that those in charge ashore may be trying to cheap out on or cover up their inattention to detail, alla El Faro. Their responsibility for being the first link in the error chain should not be glossed over.

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My understanding is the USCG is tasked with overseeing safety of American Flagged ships. On land, OSHA is the primary agency in charge of workplace safety. Many ships are way behind shoreside safety culture.

For example, how many American flagged ships require safety glasses be worn at all times? On land, nearly every industrial facility requires safety glasses in the plant area, and some require 100% PPE once one enters the facility from the parking lot. This is just a simple example…we aren’t even getting into more complex stuff like ArcFlash studies/protection. Lock out/tag out procedures…etc

Omg. If you keep this up they’ll be requiring 100% PPE on ships all the time. I’ll have you know I never once hit my head on the overhead until I had to start wearing the hard hat. Completely unnecessary unless doing overhead cargo transfer.

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The case parallels that of Jeff Hagopian, who was abruptly terminated from his job as captain of Noble
Drilling’s Noble Danny Adkins after filing a report of safety violations.

Didn’t that guy make a thread on here?

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Yes, you are correct. This past January I posted the details of my retaliatory termination from Noble Drilling. I was one of the whistleblower Captain’s that contributed to the “Spotlight On Safety” report.
It is not the current structure that does a poor job of holding shore-side personnel accountable. Unfortunately, it is the U.S. Coast Guard, the Flag State(s) and, in my particular case the Department of Justice, who refuse to hold shore-based management accountable by enforcing compliance with the International Safety Management (ISM) Code as well as other applicable laws. I was terminated eleven days after filing a report of safety violations. At the time of my termination, Noble Drilling had just commenced a term of four years probation. I brought Noble Drilling’s illegal and unsafe conduct to the attention of the U.S. Coast Guard, the Liberian Flag State and the U.S. Attorney’s Office for the District of Alaska (where Noble Drilling was sentenced to probation). Despite providing all of them the evidence and documentation as to Noble Drilling’s conduct (while they were on probation) none of them took any action. If the regulatory/law enforcement agencies aren’t going to hold shore-base management accountable then who else is?
The ISM Code is very clear as to the “Master’s Responsibility & Authority.” Unfortunately, corporate cultures such as Noble Drilling that do not value safety only comply with the ISM Code and safety management system “on paper.” They know they will not be held accountable for their actions, therefore, they have no incentive to change their “culture.” Termination/Retaliation and intimidation against those who speak up and the self-preservation of management is their priority, not safety.
It is also not as simple as saying the “buck stops” with the ships crew. While the Captain is ultimately responsible for the safety of his crew and vessel there has to be support from shore-based management.
No crew member should be fired or retaliated upon for reporting safety issues and/or safety violations. In particular, when a Captain is retaliated/terminated for such it sends a very loud and powerful message as to the “culture” of that organization as well as to what ones fate will be if they report safety violations.
This impacts mariners in all areas of our industry. The one common denominator between all of us should be safety. Hopefully, this paper will be the beginning of dialogue to bring much needed change to a very broken system.

Jeff Hagopian

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Yes, structure was the wrong word, the lines in organizational charts are all drawn in the right places. It’s the culture, how things work in practice.

On paper the DPA responsibility is:

To ensure the safe operation of each ship

In practice the notion that the DPA is responsible to identify risk seems absurd.

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You are absolutely correct regarding “culture.” When a Captain or any crew member is terminated within days of making a report of safety violations to a DPA/ADPA there is no safety culture and the safety management system is completely dysfunctional and broken.

The function of the DPA/ADPA is not to identify risk. The function of the DPA/ADPA is to act as a neutral party between vessel management and shore-based management to assist in resolving safety issues. Per the ISM Code they are required to have access to the highest levels of management and their contact information is required to be publicly posted for all crew members to have access.

The master is responsible for the safe operation of his ship. How could that happen if the captain can not or does not identify risk?

Same with the DPA, the IMO says that the DPA is: “to ensure the safe operation of each ship”. Again, if the DPA does not identify risks to the ships how would it be possible to ensure their safe operation?

I realize that the idea seems absurd in practice but it’s there in writing.

This is from the CG report on the loss of the EL Faro:

9.1.1.2. TOTE did not identify heavy weather as a risk in the Safety Management System
(SMS) and the Coast Guard had not exercised its flag state authority to require identification of specific risks.

As you know, the Master is ultimately responsible for the safety of his crew and vessel. The Master and other Officers identify safety risks and/or safety issues and mitigate them as best they can on board with the resources they have. There are, however, situations that can become more complicated. The DPA/ADPA is supposed to be there to assist in rectifying these issues and/or “non-conformities.” As previously stated they are supposed to be a “neutral” party to assist in resolving safety issues and non-conformities.

This is from the code:

The designated person should verify and monitor all safety and pollution prevention
activities in the operation of each ship. This monitoring should include, at least, the following internal processes.

1 communication and implementation of the safety and environmental protection policy

  1. evaluation and review of the effectiveness of the safety management system;

How can the DPA evaluate the effectiveness of the SMS if he can’t identify risks? Just sitting around waiting for a report or complaint is not sufficient. It would be like a captain that just sat in his office all the time without having a walk around from time to time.

In the case of the TOTE SMS failing to identify heavy weather as a risk what ship captain is going to report to the DPA that he needs guidance for coping with bad weather? Not going to happen.

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Isn’t it fairly simple, the officers and crew report any safety hazards or infringement to the Master.
If it can be mitigated on board he take necessary action to get it done.
If it require external action the Master report it to the DPA, or the Manager involve for advise and action. (Or to both)
If nothing happen from the shore side, there is the option of reporting it as a non-conformity, which will be picked up by any reasonably competent and conscientious Inspector of whatever stripe. (There are usually plenty of inspections carried out)

PS> As an inspector I used to ask the Master/Ch,Eng./Mate if they had any problem with getting the necessary actions from management, in which case just let me know the nature of their problem and I would put it down as a requirement/recommendation in my report.

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With all due respect, I am not understanding where you are going with this and the point you are trying to get across.
I am surmising you have not sailed on a vessel that is required to comply with the ISM Code or that had a safety management system.
The ISM Code and the safety management system is supposed to foster a safety culture from top to bottom. The reporting of safety issues and non-conformities is paramount to mitigating risk. The DPA/ADPA is a very crucial component of a functioning safety management system as it is the link between vessel and shore-based management. They don’t “sit around” waiting for complaints but they are the mechanism by which safety issues and non-conformities are reported. I have seen where they do conduct vessel inspections and/or walk arounds. They also conduct internal ISM audits as well.

Yes, everyone understands this function of the DPA, to take reports from the ship. Necessary but not sufficient. What people don’t understand is that it is the DPA also must also identity risks to the vessel, reported or not.

You are correct, they should identify risks whether they be reported or not.
However, the DPA/ADPA is not supposed to encourage, advocate and condone illegal conduct…especially when he is a 27 year veteran of the U.S. Coast Guard as was the case with Noble Drilling.
In my particular situation, what I didn’t realize was that the DPA/ADPA was involved with and actually encouraged the illegal safety violations. Once I reported the safety issues to him it exposed him and others. Not only did it involve the ADPA but the other vessel Captain, the shore-based manager and the VP/Chief Compliance Officer of Noble Drilling; hence, my termination 11 days later.