Accident Reporting and Investigations
Fostering a ‘No Blame’ Culture
‘Blame culture’ has become very prevalent in maritime accident reporting and investigations, prohibiting effective problem solving and the advancement of the maritime industry.
When accidents happen onboard ships it is typically the seafarer who pays the price – first by suffering injury or death in the accident, and second by being blamed for the incident.
The maritime industry does itself, and those who work in it, a great disservice by pointing fingers in this simplistic way. This phenomena has been deemed “blame culture” by many in the industry, and it must not continue.
The goal of this working group is to improve the maritime accident investigation process, with the goal of ending ‘Blame Culture.’ Through its activities, this Working Group aims to propose improvements to the investigation process to foster better communication, improve safety within the shipping industry, and improve the relationship between shore and ship.
The absence of personal blame encourages employees to explore new ways of problem-solving and experimentation. The hope is that the work developed by this Working Group will aid in fostering an environment that promotes innovation and creativity in problem solving.
Our Objective is to change the Accident Investigation Codes of Conduct. We aim to achieve this by digging deeper into investigations, asking questions such as:
- Why was it done that way?
- Who was responsible for employing this person?
- Who was responsible for supervising this person?
- Who was responsible for training this person?
- In order to check where are the system shortcomings.
- Is the Environment Safe?
- If not, why not?
Upon answering the above questions, an additional set of questions should also be asked:
- Was risk assessment done?
- Why did it failed?
- Was there a standard Working Procedure in place?
- Did it fail?
To end ‘Blame Culture’ by improving the maritime accident investigation process, fostering better communication, improving safety within the shipping industry, and improving the relationship between shore and ship.
Proposed Activity Items
The proposed plan for this group is to carry out reviews of investigations carried out by different flag states. The aim of these reviews is to identify the shortcomings of investigations to help us better understand what is preventing the shipping industry from moving forward. From these reviews, members of the working group will propose improvements to the investigation process.
The proposed efforts of this working group have been broken up into three steps:
Re-investigate latest accidents with ‘No Blame’ approach.
Identify road blocks.
Create Management of Change compatible procedure which would allow abandonment of ‘Blame Culture.’
Existing Protocols & Procedures
Checklist for Considering Human Element Issues by IMO Bodies
Marine Casualty Investigation: Investigators’ In-the-field Job Aid
IMO: Implementation of Instruments Support, Casualty
Capt. Kuba Szymanski
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