Monday Morning Coffee : A little reality to add to the caffeine…
A sampling of news, topics and trivia from across the internet. The crew here at the Maritime Safety Innovation Lab have compiled a few of the stories, trends, theories and anecdotes that crossed our inboxes, feeds and minds over the weekend.
What is an Event Review?
The late Dr. Richard Cook made “Some Observations On the Messy Realities of Incident Reviews” back in 2019, noting:
- Incident reviews serve multiple purposes.
- The ostensible rationale for incident reviews is always incomplete and often misleading.
- People learn different things from incident reviews.
- The learning is seldom narrowly technical.
- Although written summaries of review meetings are common, it is impossible to capture what is learned from the experience.
- We take it that one purpose of post-incident review could be to create as rich an opportunity for learning as possible.
- It’s a marathon, not a sprint.
- There are other units of analysis.
If our organizations are conducting event reviews (incident or near miss investigations?), are the lessons learned being promulgated? In the maritime industry, one of the goals of incident investigation (IMO Casualty Investigation Code) is to prevent marine casualties and marine incidents in the future. So, once the accident investigation is complete, is it stuck in the drawer never to be seen again? Until the next similar incident?
Event reviews – we could learn something here.
Many in the industry might be asking themselves, “What would we do in a similar circumstance?” While we will likely have to wait some time for an official accident report, the internal processes for docking/undocking and pilot/crew interactions should be addressed by container vessel operators.
In this case, we don’t see some of the risk factors we might normally – such as, did you know a larger percentage of accidents occur in the early morning due to fatigue and the normal circadian low for humans? We do not have any information, however, on what evolutions the crew may have been involved with previously or what pressure there may have been to be at the berth at a particular time.
There are best practices out there that might help prevent this – what are yours?
Captain V.S. Parani, author of “Golden Stripes: Leadership on the High Seas,” gave a presentation on crew welfare at the Safety4Sea Form in Limassol last month. In it, he discussed Maslow’s Hierarchy of Needs as it pertains to seafarers. At the bottom of the needs pyramid lies physiological needs, which includes food, water, warmth and rest. As Capt. Parani notes, these basic needs are ensured by the Maritime Labor Convention of 2006.
Why then, on a LinkedIn post, simply addressing fatigue as noted by the UK MCA in “The Deadly Dozen – 12 Significant People Factors in Maritime Safety” were there comments such as:
“That we are still talking about this is almost “criminal”. This has been going on for far too long with the oversight of Flags, owners and international bodies. Is will not change until there is a proper implementation of the infamous “safe manning.”“
“Fatigue is scary because it can be hard to gauge. You can be fatigued and your performance degraded without realizing it, especially if fueled with adrenaline. I think it’s helpful if people do a thorough self-analysis so they can discover what their own “warning signs” of fatigue are (I think it can vary vastly depending on the individual). I’m so glad more light is being shed on this subject. Working at sea (especially if it’s rough out there) can be exhausting, and judgment and coordination can easily go out the window. Fatigue management plans are a great idea, as they can help alleviate the pressure mariners may feel at sea to “get the job done or you’re off the ship.”“
“Nothing good comes from the sleep deprived Mariner.“
If we, as an industry, company or vessel, aren’t able to provide the FIRST level of Maslow’s Hierarchy of Needs for our crews, how can we hope to provide for those higher levels, such as psychological safety?
Stay safe.
Stay happy.
Have a great week.