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ROLE OF PROCEDURES IN AN EFFECTIVE SAFETY MANAGEMENT SYSTEM
Published: 1 February 2021
With the implementation of the International Safety Management (ISM) Code in the mid-1990s, it became mandatory for owners to have a Safety Management System (SMS) in place. The SMS contains the necessary procedures to support an owners safety and environmental protection policies. Since then, procedures and SMS have been widely discussed and a common question is:
HOW DO YOU ENSURE THAT PROCEDURES BECOME A PRACTICAL MEANS OF IMPROVING SAFETY?
In the Cambridge English Dictionary ‘procedure’ is defined as: ‘a set of actions that is the official or accepted way of doing something’. When procedure becomes part of a SMS, this can also become accepted as the safe way of carrying out a task, where it is assumed that safety is created simply by following the procedure.
This assumption can can lead to incidents where non-compliance with procedure is identified as the main contributing factor. In other words, the incident investigation concludes that if the procedure had been followed then the incident would not have happened.
However, an important part of an incident investigation is to try and understand why the procedure was not followed. Was it due to pure negligence, or was it perhaps because the procedure was too complex, or was not clearly set out? This could mean that the person carrying out the task did not understand the procedure and so did not follow it correctly.
To try and avoid this confusion, it is important that all procedures are properly thought through and carefully structured. Developing a procedure that combines all the necessary safety precautions, while at the same time being ‘user friendly’, is not always easy and may require considerable effort and input from several stakeholders.
These five keywords may be helpful when developing new, or amending existing procedures to maximise their effect and improve the overall efficiency of the SMS:
- LIMITATIONS– the fact that a procedure is put in place does not, in itself, remove the risk. A procedure provides a work sequence and instructions which, if followed correctly, can act as a ‘safety barrier’ and help to manage and mitigate any risks associated with the task. However, there are limitations to this and if a faulty procedure is followed, the task might, in fact, be less safe than if no procedure was followed. Therefore, each task must be assessed to see if a procedure can reduce the risk or whether there are other, more suitable, methods to reduce the risk, such as a design modification.
- RELEVANT– the content of some procedures is regulated by statutory requirements and these must always be complied with. However, not all risks are governed by statute and owners should carry out a risk assessment to ensure that their SMS contains all the relevant procedures for their particular operation. They should regularly review their procedures to ensure that they remain relevant and that any new risks are properly assessed, and the SMS amended accordingly. It is also very important that any obsolete procedures are removed from the SMS so that the effectiveness of the SMS is not hindered by outdated or contradictory content and becomes too long and confusing for the user.
- FOCUSED– a procedure should focus on how to mitigate an identified risk and must clearly set out the precautions and resources needed to ensure that the procedure is carried out safely. The content should be specific to the operation and, if appropriate, to the ship and should clearly communicate its purpose to the crew members. If procedures are too long and complicated there is a risk that the procedure may not be read or properly understood. This can lead to the procedure becoming an obstacle, rather than a useful tool to safely carry out the task.
- DYNAMIC– it is important that a procedure is never regarded as finalised but is seen as a dynamic document, meaning that it is continuously updated to include all new lessons learned. Owners should review past incidents and near miss situations and incorporate the lessons learned into their procedures. In incidents where non-compliance with applicable procedures has been identified as a possible cause, the incident investigation should identify any underlying causes which may provide an understanding of why the correct procedures
were not followed in order to try and prevent similar incidents in the future. In addition, the concept of learning from positive outcomes, also referred to as Safety II, can provide owners with ways to learn from the experience of others and update procedures, rather than waiting for an actual incident to take place. To help with this process, there should be an
open reporting culture on board where crew members are encouraged to provide constructive feedback on any procedure which can then be amended if necessary. - OWNERSHIP– in the shipping industry, there is often a disconnect between the originator of a procedure, usually based at the owner’s office (sometimes with the assistance of an external consultant), and the end user – the crew member. This means that the originator may be detached from the working environment for which the procedure is intended and may not fully understand the situation on board the ship. The crew may then feel that the procedure is not useful or practical and can lead them to ignore or change the procedure. This is a dangerous situation as it increases the likelihood of an accident and also compromises the efficiency of the entire SMS. A way to increase the sense of ownership among the crew is to involve them in the whole process. If the initial drafting process for a procedure is moved from the office to the ship, this allows the crew to have an input based on the specific operational procedures of their ship. This draft can then be submitted to the office for statutory and company policy compliance review and approval. This collaborative process can lead to clear procedures drafted by the actual user and provides an increased sense of ownership and also a higher probability that the procedure will be correctly followed.
It is important to understand that, when it comes to the SMS and procedures, there is no simple solution. While a procedure might be seen as a quick and cost-effective way to increase safety, a procedure also has its limitations and may not suit all situations and types of risk. A comprehensive risk assessment by owners is essential in order to identify the right safety measures to be implemented as part of their SMS, and to decide where and when a procedure might be an appropriate choice.
When developing a procedure, all situations should be considered, and all stakeholders should be involved to ensure that the procedure is effective in reducing risks. It must also be useful, easy to follow and practical to make sure that it is properly followed by the user. When there is an incident, this should always trigger a critical review of the applicable procedure to determine its suitability. Failure to acknowledge this may not just compromise safety, but also the crew’s commitment to and belief in an owner’s safety culture.
If you have any questions or would like further advice on ways to improve your safety culture, please contact the Britannia Loss Prevention team at: lossprevention@tindallriley.com
The Danish Maritime Accident Investigation Board’s (DMAIB) report ‘Proceduralizing Marine Safety – Procedures in Accident Causation’ provides further reading on this topic, including some of the issues that can occur with the use of procedures to formalise safety.