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Monday, 27 April 20
INCIDENT INVESTIGATION: SEARCH FOR THE CAUSE, NOT THE VILLAIN - GARD
Incident investigations often conclude with placing the blame for an incident on the crew. Causes of the incidents are usually identified as procedural violations, incompetence, lack of situational awareness or the catch all, human error. Take for example a grounding incident which occured because the officer on watch fell asleep. Investigations of such incidents would usually blame the fatigued officer or the Master when the investigation is limited to individuals.
An investigation should ask questions such as why he fell asleep?
Were last port operations too strenuous on the officer?
Was the manning adequate for the vessel’s operations?
What commercial pressures were at play? How would the company have reacted if the master was to request a delayed departure citing fatigue as a reason?
And finally, what is the company culture like?
The above questions can provide an overview of the conditions that led to the incident and to help understand the underlying issues.
An investigator’s ability to conduct a fact based investigation and understand the conditions that prevailed during the incident is sometimes derailed by their focus on finding a guilty individual. This is known as the ‘blame instinct’ and greatly undermines the ultimate aim of incident investigation, which is to find the root cause and prevent a similar occurrence happening in the future. Such practices are usually reflective of an organisational culture that does not support open and honest reporting of failures due to the fear of consequences.
To bring about a change in the way we investigate incidents, we should bear in mind that it is not just about the individual or group of individuals involved in the incident, but multiple interacting causes which make up the conditions surrounding the incident.
Next time there is an incident, no matter how small, treat it as a symptom that there is something in the system that needs improving. It is about learning, not blaming.
Source: Gard
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Wednesday, 22 March 23
MARKET INSIGHT - INTERMODAL
The crude tanker market continues to gather momentum as we head towards the end of 1Q2023, against a backdrop of strong U.S. exports paired with a ...
Wednesday, 22 March 23
WILL LOWER GAS PRICES SPARK SWITCHING IN EUROPE AND ASIA?
Record high prices devastated demand for gas and LNG across Asia and Europe last year. But with prices falling, companies are starting to re-evalua ...
Monday, 20 March 23
NTPC MULLS 5.4 MILLION TONNES COAL IMPORT IN FIRST HALF OF 2023-24: PTI
State-run power giant NTPC is planning to import around 5.4 million tonnes of coal to meet the supply shortage during the first half 2023-24 fiscal ...
Monday, 20 March 23
S. AFRICA’S EXXARO RESOURCES SAYS COAL PRICES COOLING OFF - REUTERS
South Africa’s Exxaro Resources on Thursday posted a 28% jump in 2022 profit after seeing average coal prices surge more than 150%, but warne ...
Saturday, 18 March 23
RUSSIAN LNG EXPORTS TO EUROPE REMAIN HIGH - VESSELS VALUE
Russian LNG exports to Europe remained at very high levels in February at 3.6 million CBM, following a 13 month high in January of 4.1 million CBM. ...
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- The University of Queensland
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- Petron Corporation, Philippines
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- Ministry of Transport, Egypt
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