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Danish Maritime Accident Investigation Board Report - Maersk Shipper and Searcher Su

7K views 57 replies 20 participants last post by  Andrew Craig-Bennett 
#1 · (Edited)
#4 ·
About twenty years have now passed since I first heard the term "Risk Assessment". This was about ten years after I had left my last ship, after almost thirty years in pilotage.

The new words (risk assessment) were drawn to my attention as though they were holy writ; and my reaction was to wonder how on earth any of us had survived before this jargonistic expression was coined. That is a thing which I still wonder, in light of the knowledge that any assessment of risk, if relied upon as a guarantee - or holy writ, as might be urged - is in point of fact complete bullsh1t, as the Conclusions in the Report make clear.

The truth is that a mariner spends his entire life assessing risk - and there simply isn't time available to commit every single thought to paper.

Thank you Andrew, for posting!
 
#28 ·
The mariner does spend his life doing risk assessments, and in the past - many were prepared to 'play the odds' with their own and with others' lives. Risk assessments 'should' encapsulate those mariners' experience and knowledge, and when done correctly in a forum - should produce an appraisal with integrity. The recording of that risk assessment has more than one benefit:

It remains as a working do***ent for others to build on (gaining the experience and knowledge of those conducting the first RA)

It encourages openness and forces any contributors with an 'agenda' to explain that train of thought (sometimes you have to point this out to some)

It becomes a written record which does force some 'decision-makers' to think twice about what they are recommending.

Common sense and basic seamanship will beat risk assessment by a mille
I see the Risk Assessment process as being built upon those qualities/attributes. It doesn't replace them, but your "common sense and basic seamanship" was/is not sufficient.

I posted a photo on this site of a deck cadet, climbing over a crane jib about 15ft above deck level. No PPE. Several 'experienced' seafarers commented that it was admirable - "one hand for the ship" etc. But - any risk assessment would highlight that the probability of a fall was 'possible' and the result 'death or severe injury'? Apparently the use of a fall-arrestor was deemed to be 'nanny'.

Things had to change.

"Risk Assessment" has always puzzled me. It appears to assume that we were all taking wild and unconsidered risks before it was introduced.
Not "all" - that is ridiculous. But - sufficient to demand a change in the MO.

One question I meant to ask is in the dark ages when I was a tug master we had to have a 'towage certificate' issued by a Department of Transport Marine Division surveyor before the tow started. Do they still as I saw no nmention of it in the report? This accident would not have happened had their been some experiencen somewhere in the decision making train.
Towing Approval is generally demanded by the underwriter for the operation. The procedure is reviewed by a warranty survey company (e.g. Noble Denton etc), and any shortfalls identified and asked to be addressed. From that - they will produce a checklist for the Warranty Surveyor to complete when he attends the towing vessel(s) prior to the tow commencing. A good Warranty Surveyor - will use the checklist as an aide-memoire and look at more than the checklist - lists.

It just formalises a process that most people have been going through since the year dot. Look on it as being a useful tool, a memory jogger, what you will, but it has stopped the routine taking of many stupid risks, which are usually put down to 'we have always done it like that'.
That is it - in a nutshell. It also assists others in the future, when carrying out 'similar' operations.

The final words of the conclusion tell us a lot:

''In fact, the risk management system instead tends to facilitate the carrying out of risk prone operations''
It can- if you let it. I have sat on many HIRAs, HAZIDs and Task Risk Assessments, and there are often project personnel who do not approach the process with the 'integrity' required. But - there is the opportunity to steer it back on course. One thing is certain - the Risk Assessment process beats the 'Ad Hoc' method any day. I have also carried out Towing Approvals on behalf of the operation underwriters.

In the days when we were taught seamanship we were also taught to think and to avoid stupid risks. More thought than could be put on paper in many hours would pass through the mind. Risk assessment is meant to place the responsibility on those carrying out the orders and to leave those giving the orders free of all blame should a mishap occur.

It must be obvious from the case in hand that a written risk assessment can also permit unacceptable risks to be taken.
I can't agree with that sentiment. The Risk Assessment isn't the final visit to the task - the Toolbox talk allows for the explanation of all the risks identified and the proposed mitigation and for the work party to contribute their experience/knowledge and also to question the assessment.

Yes, sometimes Risk Assessments can be lacking in integrity - some people continue to take shortcuts, and in a previous generation - would have been the cowboys, I reckon. I sense that a lot of the responses above are 'latching on' to the occasions when Risk Assessment fail - as if to prove a point.

Back to the Maersk operation - without going back to the report which I have just skimmed over - I am not sure if the operation had any external indemnity - it may have been self-insured by Maersk, who would naturally be more interested in the operation going ahead than "challenging" every aspect.

Al
 
#9 ·
It just formalises a process that most people have been going through since the year dot. Look on it as being a useful tool, a memory jogger, what you will, but it has stopped the routine taking of many stupid risks, which are usually put down to 'we have always done it like that'.
 
#8 ·
One question I meant to ask is in the dark ages when I was a tug master we had to have a 'towage certificate' issued by a Department of Transport Marine Division surveyor before the tow started. Do they still as I saw no nmention of it in the report? This accident would not have happened had their been some experiencen somewhere in the decision making train.
 
#12 · (Edited)
These days lack of practical experience seems to be the rule rather than the exception. Look at the MSC Napoli screw up.
We seem to be run either by academics with liberal arts degrees or morons with MBAs. 'Uneducated' practical folk and their opinions are ignored and this incident is just another symptom.

Rant over !! (Cloud)
 
#13 ·
I read this report on 4th September already being aware of the incident .
The final paragraph on page 37 of the report sums up the situation and highlights the failings of the so called " Risk Assessment " where it appears the intention was to " reverse engineer " the assessment to
ensure targets were met . This additional to the personnel movements, the " desk top " level of the planning , possibly the level of expertise of some involved , the final selection of the equipment to be used , in particular the fenders etc. etc . It appears to have been a catalogue of errors from the start .
Not what would have been expected from MAERSK
 
#17 · (Edited)
#15

Thank you, Ian.

My reference to the fact that it is now possible to acquire a Class 1 STCW Certificate applicable world-wide without going beyond Ushant should more accurately have said that it is now possible to hold the modern equivalent of the former Foreign Going Master's Certificate without ever going beyond Home-Trade limits (the Elbe and Brest). There has very clearly been a significant reduction in standards in maritime matters at UK governmental level, whereby experience beyond those limits is no longer required in order to claim world-wide qualification.

Does the general public appreciate the point? Of course it doesn't. Should the point be well known? Of course it should, particularly when clownery of this kind arises.
 
#18 ·
#11 and #10

#11 speaks up for the philosophy of "Risk Assessment" whereas #10 (and the Report in the present case) speak the truth that reliance upon a new-fangled philosophy is highly dangerous when rational experience warns against it.

It would appear that worship of the philosophy of "Risk Assessment" in all things was a harbinger of what is now becoming known as the "post-truth" era. Far more sensible is the ancient folk-lore that "If it looks like a duck and quacks like a duck, it probably is a duck."

To cross the English Channel with bow-doors wide open never did look right, did it? (Herald of Free Enterprise, 1987.)
 
#19 ·
A further basic thought on Risk Assessment is that most of us here in SN will recall the obligation to ensure that hatch-beams were in place before even crossing any harbour. Today, many mariners might ask "What are hatch-beams?"

I might well be wrong, but I'd guess that such things had disappeared long before any jargonist coined the term "Risk Assessment".
 
#23 ·
I thought that the herald only went round the zeebrugge breakwater with the bow doors open-end that was a error on the duty bosuns part, he should have closed the doors but fell asleep.\
On townsends one of the duty mates stayed on the vehicle deck until bow and stern doors were closed and secured before proceeding to the bridge.
 
#25 · (Edited)
Thanks for posting that.

It's comprehensive and, I think, very good, apart from the "calculation of bollard pull section", which is a bit iffy I think. The horsepower of tugs is a Dark Art, and their Bollard Pull doubly so...

Edited to add: I see - after reading to the end - that it's largely the work of Chris Spencer. Well done, Chris.

Pity Maersk didn't read it!
 
#27 ·
It became clear to me that some of the motivation, at least, behind a switch from type approval to risk based 'shipbuilding' (ie from sheer strake to masthead lantern) is to avoid proving the gadgetry or technique as far as possible before it gets approved. This was over the course of two presentations by LR to IMarEST branch here.

I don't know about the body of SN (especially as it seems content to rely on GPS - ALONE - for navigation) but I would be considerably more content if the kit I was tasked to supervise was tried, tested and its foibles already discovered than simply chewed over on paper.

Perhaps not when I was at sea when the more and more complicated the kit the more fun it was to play with. But certainly from behind a desk.

Tried and tested safe but expensive. Risk assessed, cheep, until proven unsafe.
 
#29 ·
In sixteen years at sea and twenty five years in aviation I never carried out a risk assessment and I never had a serious accident although there was plenty of opportunity for such. I guess my experience replicates that of many others on this site.
IMHO the main purpose of risk assessments is to provide a 'get out of jail card' for management.
 
#30 ·
#28

Nobody appreciates more than I do the benefits of learning from the experiences of other people; and I do not question for a moment the good intentions of the philosophy of preparing a written risk assessment. A risk assessment, however (by definition) precedes the running of any risk; and if the proposed event then proceeds and occurs without incident then it seems unlikely that any of us will ever see the preceding risk assessment or gain any benefit from it.

As to giving (or gaining) benefit from the experiences of others, it seems quite clear that MAIB Reports and Law Reports (both of which are reports ex-post facto) are of far greater benefit than any preparatory risk assessment, based largely on wishful thinking. I have been present at the taking of evidence for more MAIB reports than I care to remember and can confirm without hesitation that they are based on hard fact rather than supposition, however expert the supposition might or might not be.

As to the Law Reports, their records bind us all, precisely because their contents are factual and not merely estimated or assessed.
 
#33 ·
On major project or constituent parts - the task is reviewed upon completion, where lessons learned are explored (on a well-run project, at least)

In a system using Task Risk Assessments - there are "usually" the requirement for the TRA to remain in the system, to be utilised as a framework for future similar tasks (with the caveat that it must be reviewed to ensure that the cir***stances are the same - and adjusted to suit). Of course - there are some who will shortcut the process, by grabbing a TRA and thinking "this will cover it" - and wade in.
Most companies will require within their SMS that a TRA can only remain valid for a period of 12 months, after which it must be reviewed by the appropriate disciplines.
TRAs also have the facility for review after the task has been carried out - for issues or any additional safeguards which have been noted as being worthwhile.


"A risk assessment, however (by definition) precedes the running of any risk"

Every task has a risk, albeit (hopefully) the risk is 'negligible' or 'zero'. The RA allows operators to see the steps involved in the task, in a tabular fashion - which to me is of great assistance to ensure that the whole task is considered f- prior to commencement.

I've seen a few operations where I would be very surprised if the formalising of the risk assessment - didn't bring the operators to their senses.

Acting on Law Reports and MAIB reports - Yes, when severe incidents occur- then quite rightly, there may be a requirement for a whole industry to change, but I am a firm believer that the Risk Assessment Process assists in minimising the LRs and MAIBRs.

I fully recognise that the experience and knowledge are principal inputs to the RA process, but I've seen too many cases of "We've always done it like that" and "It'll be alright".......... Often with disastrous consequences.

Al
 
#31 ·
However one views 'risk assessments' and other manifestations of managementese, I think we can all agree that experience and awareness are the most valuable assets for any seafarer. It is a source of great concern that there is such a headlong rush to be the first to introduce 'autonomous' or unmanned ships, that if there are to be no seafarers, how can anyone get the required experience?
 
#36 ·
I agree that we are trying to replace expertise and experience with operational procedures however in the case of risk assessments I do not see why one should shy away from demonstrating one's common sense by recording it.

No one else is going to blow your trumpet for you (and it gives the Coroner something to read in your absence if one is too short of the rare commodity in question).
 
#41 ·
But a risk assessment is something we all do do. That does not necessarily sitting down with a checklist but perhaps just simply thinking about the task and making sure one has the tools and instruments required to hand, certainly if one might inconvenience another (killing the galley for instance), considering if one should poll others on what one is doing and potentially moving on to a more formal RA or even permit to work. It DOES mean to some "auditable **** cover" however it can certainly serve a useful purpose as well.
 
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