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Saturday, November 25, 2017

Safety Management System or a Checklist for Negligence?

September 10, 2008

Does your company have a safety management system (SMS), a safety program, or internal safety policies?  Are there problems with implementation or making sure that all policies are consistently complied with?  Are there items in the manual which do not apply to your vessels or operations?  Does the manual call for unrealistic work practices?  If you answered "yes" to these questions, rest assured you are not alone.  Unfortunately, however, your company could also be in danger of severe financial penalties, and/or litigation.  In some case, such as a serious accident, individuals, depending upon their position in the company, might even face imprisonment.

The latest trend in regulatory schemes is performance based regulations.  This type of regulation usually requires the regulated entity to come up with a plan or system which will meet the performance based criteria in the regulations, such as International Safety Management (ISM) and the impending towing vessel inspection regulations.  Some organizations also require member companies to implement an SMS such as the American Waterways Operators (AWO) Responsible Carrier Program (RCP).   Regardless of the source, not fully implementing and complying with these plans can have serious consequences in the event of an accident. 

Unfortunately, for some companies, their SMS remains just another book on the shelf.  Some company personnel may not know what is required by their company's SMS, but are successful in passing audits by convincing auditors that what they do traditionally for safety checks and procedures comes close enough to what is required in the SMS.  While this may be enough to pass an audit, it may not be enough to satisfy investigators and attorneys following a serious accident.

A conversation I had with an attorney after a serious accident really drove home the importance of "saying what you do, and doing what you say."  I discussed my concerns with some SMSs which can never be complied with due to the way they are written.  I explained that some companies seem to have brainstormed with a bunch of "old salts" and came up with every possible thing that could ever go wrong during any one evolution.  While this is never a bad idea, and produces excellent training material, it was how the information was incorporated into the SMS which created the problem.  After the comprehensive list had been compiled it was entered into the SMS and labeled, "The following items must be checked prior to conducting the following evolution…."  I explained that the problem I have found as an auditor is, despite the SMS mandating that the entire extensive comprehensive list be completed every time, the crewmembers can only explain the two or three items they actually check.   The attorney was well aware of this problem and explained that is why a company's SMS manual can serve as a "checklist for negligence" during litigation.

In writing an SMS it is important to distinguish between training items, maintenance items, and essential operational checks.  Deciding which items must be mandated to be checked every time in the SMS manual should only be done after careful risk assessment.  Mandating that the entire comprehensive list be checked every time may just be setting the company up for failure.  If it is an unrealistic goal which can never be complied with, it will give cause for the crew to dismiss the entire manual as unrealistic and not applicable. 

The manual must also be realistic and customized for a particular vessel and operation.  There are off-the-shelf SMS manuals which are hundreds of pages long, written by individuals who have no practical vessel experience.  These manuals, while comprehensive, most likely contain sections which are not applicable or are unrealistic. These are the types of manuals which are most likely to become just another book on the shelf. 

There are some processes and procedures which are required by regulation.  These should be identified first and foremost to ensure compliance. The SMS should only include what is required to ensure compliance and safe operations, and it must be able to be implemented.  If something in the manual cannot be complied with, the manual should be amended immediately and the requirement changed or removed.  The best way to ensure success when developing an SMS is to start by finding out what procedures are currently done by the captain and crew, and then build on those procedures.  Whatever procedures the company deems appropriate to mandate via the SMS manual, they must be done consistently, and must be enforced regularly by the company.  A checklist can be a good tool to implement once the proper risk assessment has been conducted and the mandatory checks have been determined.  However, it is not realistic to expect a vessel operator, to use a written checklist for every operation that they conduct.  Entering these types of requirements in an SMS just invites "gun-decking" and gives reason for the crew to disregard the entire program which they may perceive to be nonsense. If the company thinks a checklist is necessary, but the use of one is impractical, the solution is quality intensive training. Another common oversight regarding safety management systems is their purpose.  They are intended to be management systems, not just safety manuals.  For instance, if a vessel lost power and a serious accident resulted, and during the investigation it is found that the loss of power was due to and automatic main engine shutdown which occurred due to a malfunctioning piece of newly installed equipment.  Upon further investigation it may be uncovered that this malfunctioning piece of equipment automatically shut down the main engine twice before, and that the crew had reported it to the port engineer, but because they were able to get the main engine restarted and there were no other obvious problems, they assumed it was a "fluke." Given this real-life example, a safety manual might say what to do in case of loss of power, or to report machinery casualties to the port engineer, but a safety management system is suppose to be designed to ensure that the issue is thoroughly resolved so that the accident doesn't happen. 

 Even with a comprehensive system in place, it is only as effective as the decisions which are ultimately made by management.  For example, during an inspection a captain was very proud of his safety management system and showed how his discrepancies had been identified, documented and carried over from the monthly reports, to the quarterly reports, and to the semi-annual reports.  The problem was that one of the discrepancies was a hole in the hull ten inches above the waterline.  The company had decided to keep operating the vessel, continuously pumping out the compartment until the next drydock.  There must be a system, not only for reporting, and tracking of discrepancies, but also for risk based decision making to resolve issues in accordance with regulatory requirements and prudent industry practices.  The intent is not to have a manual and a system to track everything.  The intent is to design a system which ensures the best possible decisions are made by the company, captains and crews, regarding safe operations. By now most have heard of the tragic ferry disaster which occurred in October of 2003.  One lesson to take away from that tragic accident was that not only was the captain of the ferry sentenced to prison, but so was the ferry manager.  The ferry manager, who failed to enforce the city's own internal policy of having two captains in the wheelhouse at all times, was also sentenced to a year and a day in prison. Remember, whatever you put in the SMS manual must be complied with at all times. Close enough, is really not, good enough.

About the author

Kevin Gilheany is a maritime industry consultant and a retired Coast Guard marine inspector. His company is , He can be reached at 504.319.3229, or

(Reprinted from the September 2008 edition of MarineNews)

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