Presentation to the Canadian Shipowners' Association & Lake Carriers' Association
75th International Joint Conference
Ian MacKay, Member
Transportation Safety Board of Canada
Traverse City, Michigan
June 5-7, 2011
Check Against Delivery
Slide 1: Title Page
Slide 2: Outline
Today I'll be talking about:
- About the TSB
- Safety Management Systems (SMS): What it is, why it matters, what's required
- Bridge Resource Management (BRM): what it is, why it matters, what's required
- Summary, Questions and Answers
For SMS and BRM, I will use TSB investigations as case studies, to go into greater detail with the issues.
Slide 3: About the Transportation Safety Board
The TSB is an independent government agency. We are not the regulator, and we have no legislative power — that's Transport Canada. Our mandate is to advance transportation safety in the air, marine, rail and pipeline modes of transportation that are under federal jurisdiction by:
- conducting independent investigations
- identifying safety deficiencies
- identifying causes and contributing factors
- making recommendations
- publishing reports
Who We Are: Approximately 230 employees in 8 regional offices nationwide.
In 2010, we received notice of roughly 3000 occurrences, and just over 20 per cent of these were in the Marine mode. When that happens, we deploy, assess the situation and, if we feel there is a safety lesson to be learned, we launch an investigation.
Slide 4: Watchlist
Just over a year ago, in March 2010, the TSB released a safety Watchlist, which highlights nine critical issues posing the greatest risk to Canadians. The Watchlist originated when TSB investigators began reporting troubling patterns in their work. In fact, what happened was that far too frequently they would arrive at the scene of an accident only to see the same set of persistent safety issues. We therefore developed it as a "blueprint for change" — a way to restate the TSB's safety messages, stimulate discussion, and generate further action on the part of regulators and industry.
Underpinning the nine issues in the Watchlist are a series of 41 recommendations, along with findings from our investigations. For each issue, regardless of the status of the associated recommendations, action taken to date has been inadequate, and concrete steps must be taken on the part of industry and the regulator to eliminate these risks.
Today, I'll focus on two issues, one of which is on the Watchlist, and one of which is not … at least not yet.
Slide 5: Definition of SMS
SMS is an internationally recognized management tool designed to build safety into everything a company does. It is generally defined as a "formalized framework" for integrating safety into an organization's daily operations, including the necessary organizational structures, accountabilities, policies and procedures.
In simple terms, SMS can help organizations find trouble before trouble finds them.
On screen is a definition of SMS by James Reason, an expert in the study of human factors in accident causation. Reason calls SMS "a systematic, explicit and comprehensive process for managing safety risks," one that, done properly, becomes "part of that organization's culture, and of the way people go about their work." (J. Reason 2001)
That part about becoming "part of that organization's culture" is key, because it's the organization as a whole that creates the operating environment:
The benefit, then, is obvious:
"Implemented properly, SMS allows transportation companies to identify hazards, manage risks, and develop and follow effective safety processes."
However, there's a problem — two of them, actually. First, although SMS is a great tool, it still needs oversight to be effective. And second, right now not everybody's required to use it.
Let's look at a marine example that perfectly illustrates this.
Slide 6: TSB Investigation Report M09W0141 (North Arm Venture)
On 19 July 2009, the tug North Arm Venture was towing the barge North Arm Express, loaded with fuel and deck cargo, from Toba Inlet to Sechelt Inlet, British Columbia. The tug girded and capsized while making a turn to port at the entrance to Sechelt Rapids.
The four crew members on board were rescued, and the overturned tug and barge were subsequently towed to Killam Bay, B.C.
To explain what happened a little more clearly, the tug was girded — that is, pulled sideways by the towline on the much larger barge until the tug eventually capsized. Girding, as it turns out, is a well-recognized phenomenon in the towing industry. Deck officers receive instruction on how to deal with it, including how to manipulate the forces involved for operational purposes.
Slide 7: SMS
As far as Safety Management Systems go, the purpose of an SMS is to try to identify as many potential risks as possible, so that mitigating measures could be found in advance. (Again, "finding trouble before it finds you.")
Now, is it reasonable to assume that you can think of every single possible disaster that can befall an operation? No. That's not realistic. But is it reasonable to identify at least some risks in advance, particularly the most common ones for which mitigation strategies are already known? You bet.
But in this case, the TSB's investigation revealed that the operator considered girding to be so common that it assumed masters and mates would have previous experience with it and could be expected to know what to do. As a result, even though the company had an SMS, it contained NO specific procedures, instructions or guidelines relating to unintentional girding.
Furthermore, when the SMS was reviewed by the external auditors (Lloyd's Register and Transport Canada), this absence of procedures regarding girding was NOT identified.
Slide 8: SMS (cont'd)
In the marine community, the value of SMS has long been recognized. Since July 2002, all vessels over 500 gross tonnage that sail in international waters have had to meet the requirements of the International Safety Management Code and implement an SMS. However, this requirement does not apply to vessels that operate domestically, including the hundreds of passenger and commercial vessels over 500 tonnes.
The TSB has repeatedly emphasized the advantages of safety management systems in the marine industry, citing numerous deficiencies in various occurrences over the last 12 years. In fact, the TSB has previously made a recommendation that Transport Canada (TC) ensure small passenger vessels have an SMS, too.
So, this is what we'd like:
- All commercial shipping operations should have an SMS.
Slide 9: BRM
Now let's look at BRM: Bridge Resource Management. (In aviation they call it CRM: Crew Resource Management.)
It's generally defined as "The effective management and utilization of all resources available to the bridge team, to ensure the safe completion of a vessel's voyage."
Let's look at part of that phrase again: all resources.
Clearly, that's a broad term. "All resources."
Sometimes in our reports, we'll modify that phrase a little, to make the point even more clear.
Slide 10: BRM (cont'd)
"The effective management and utilization of all resources — human and electronic/mechanical — available to the bridge team, to ensure the safe completion of a vessel's voyage."
Here's an example.
Slide 11: Case Study TSB Investigation Report M09C0051 (Federal Agno)
On 05 October 2009, the bulk carrier Federal Agno had completed loading at Côte-Sainte-Catherine, Quebec. The vessel was docked facing upbound and, in order to proceed downbound, was to turn around in the anchorage at the west end of Lac Saint-Louis, Quebec. While executing the subsequent starboard turn, the vessel grounded. The vessel was refloated three days later. There were no injuries or pollution.
Slide 12: Federal Agno (cont'd)
Here's a picture of the area where the grounding took place.
One key element of BRM is monitoring of both the vessel's progression and the performance of bridge team members in order to trap and mitigate errors. To do this, best navigating practices dictate that all members of a bridge team should have the same understanding of how the voyage will progress. This allows for multiple checks from different points of view, reducing the possibility of single-point failure.
In this occurrence, the pilot was the only person who knew all the details of the planned manoeuvre. The master and pilot agreed on the general plan for the turn, but the pilot did not make the detailed plan explicit in advance.
This proved problematic: once the vessel was turning to starboard, the master became concerned that the manoeuvre had been started too soon. He reviewed the situation in the chart room and then queried the pilot but was subsequently "reassured."
The subsequent TSB investigation report found that:
- The pilot's main focus was [not] on the exact position of the vessel and … the vessel subsequently did not have enough room to complete the manoeuvre as intended.
- The absence of a detailed plan and a shared mental model … prevented the pilot and bridge team from effectively trapping the error of turning early.
This is not an uncommon issue, nor is it new. As far back as 1995, the TSB completed A Safety Study of the Operational Relationship between Ship Masters/Watchkeeping Officers and Marine Pilots. In this safety study, the Board noted that a pilot's decision making "can become the weak link in a system prone to single-point failure; i.e., in the absence of effective monitoring, there is little safety backup for the pilot in the navigation of the vessel." [TSB Safety Study SM9501]
Slide 13: BRM: The goal
The whole point of BRM is to give you as many tools as possible to achieve success. If you were in a car, you wouldn't drive with one eye deliberately closed. Nor would you drive without occasionally checking the speedometer, or the mirrors. And if the person beside you said, "Hey, I know you're thinking of changing lanes, but there's an 18-wheeler in your blind spot," would you ignore them?
Ultimately, BRM is pretty simple, and if done well it accomplishes two things:
- Everybody knows what the plan is
- Everybody can verify the plan and catch any errors
Slide 14: BRM in other transportation modes
This issue isn't limited solely to mariners. As I said, in aviation, they call it CRM — crew resource management — and failure to utilize it properly can be deadly there, too.
On 12 March 2009 a Cougar Helicopters' Sikorsky S-92A on a flight to the Hibernia oil production platform had a total loss of oil in the transmission's main gear box. The flight crew descended to 800 feet, turned around, and headed back toward St. John's. Approximately 35 nautical miles from St. John's, the tail rotor failed and the helicopter crashed. Seventeen people drowned.
In that occurrence, there was no one single cause; rather, our investigation found a complex web of factors that ultimately brought down the aircraft. However, BRM — or in this case, CRM — played a role. Here's how:
The captain was an experienced and confident pilot with a more directive style of leadership. The first officer was a relatively new company pilot with a non-assertive personality.
Following the initial warning of a problem with the oil pressure, the two crew members began consulting the emergency procedures, during which time the first officer provided several very relevant pieces of information to assist the captain. Moreover, after consulting this emergency checklist, it became clear to the first officer that the recommended course of action was to land immediately. The pilot, however, was determined to reach St. John's — he was fixated on it — and his communication style became more directive in nature. As the situation unfolded, he did not actively seek out or encourage input from his first officer, who was likely reluctant to assert himself because of a combination of inexperience and the steep "trans-cockpit authority gradient."
That's a fancy phrase to describe an age-old problem.
That "authority gradient," however, interfered with the decision-making process.
As a result, we made three findings:
Slide 15: Cougar Flight 91 Findings (TSB Investigation Report A09A0016)
1. The captain's fixation on reaching shore combined with the first officer's non-assertiveness prevented concerns about CHI91's flight profile from being incorporated into the captain's decision-making process. The lack of recent, modern, crew resource management (CRM) training likely contributed to the communication and decision-making breakdowns which led to the selection of an unsafe flight profile.
That's a big finding. There were 2 others:
2. Under the current regulations … operators are not required to provide CRM. As a result, there is an increased risk that crews … will experience breakdowns in CRM.
3. The current CRM regulation and standard [has] not been updated to reflect the latest generation of CRM training … [creating] a risk that flight crews may not be trained in the latest threat and error-management techniques.
So, whether you call it an "authority gradient" or a power dynamic, it's vital to recognize that it can happen anywhere, and that it does happen. Every day, whether it's in a helicopter or on the bridge of a fifty-thousand ton vessel.
So here's our take-home message: The term "bridge team" means exactly that. All crew are on the same team, working toward the same goal. The "old days" of single point failure — the cliché of "the master being the master" — are behind us. Safety is everybody's job. That means all members of the bridge team need to listen, and they need to be able to question everybody. And it's the responsibility of the ownership/management to make sure that culture/atmosphere is created.
Slide 16: Summary
At the TSB, we do not "assign blame," nor do we "determine civil or criminal liability."In other words, we're not here to point fingers. Rather, our job is to identify a problem. That's the whole point behind our Watchlist. The 9 issues it identifies are all recurring problems — problems where action to date has been insufficient to reduce the risks to Canadians.
That's why we're looking for solutions, and why we're working with industry "change agents" to make that happen.
With respect to SMS:
- It's about being proactive — finding trouble before it finds you. But to be truly meaningful and effective, an organization's commitment to and investment in safety must permeate day-to-day operations.
- No SMS is perfect, and as I said, an SMS isn't supposed to identify every single possible risk in advance. Therefore, the absence of a procedure or guideline in itself is not necessarily a sign of a deficient SMS. However, once a risk or hazard is identified — in advance or following a hazardous occurrence or accident — a well-functioning SMS mitigates it through corrective action. This highlights the importance of thoroughly and objectively identifying key hazards when developing, implementing, revising and auditing a SMS.
- We want Transport Canada (TC) to require domestic commercial shipping operations to adopt SMS
With respect to BRM:
The old days are over. The new paradigm is all about using all available resources — equipment and crew. This accomplishes two things:
- Everybody knows the plan and can follow it
- Everybody can effectively challenge one another, to verify the plan
None of this, however, can be accomplished without your help. And that's why I am here today: because even if Transport Canada makes BRM mandatory tomorrow morning, for everybody, it'll still need to be implemented. And the people here in this room are the ones who can make that happen.
Thank you. I'd now be happy to take any of your questions.
Slide 17: Questions & Answers
Slide 18: End
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