Ism Code-r Nijjer

7/25/2019 Ism Code-r Nijjer

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Critique of the International Safety

Management (ISM) Code

Nautical Institute Command Seminar

Sydney16 June 2014


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Rena, Costa Concordia & Sewol


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Safety Management System

(SMS)

Themain purpose of a SMS is to

prevent a large scale accident


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Safety Management Systems (SMS) - History

1950sNuclear Power Industry challenge of developing

safety standards in a totally new industry with extremeset of hazards

Existing safety standards inadequate and a new approach

had to be developed from the ground up with the goal of

zero accidents

All hazards were carefully identified in advance by domain

experts and systems built-in to manage all aspects of risk

and safety at the design stage from construction, and

operation to decommissioninglifecycle of the project

This proactive systematic approach to safety became

known as the Safety Case


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SMS Chemical Plants

Seveso disaster in 1976 which involved a

large scale release of highly toxic dioxin from

a small chemical plant in Italy giving rise tothe Seveso I IDirective.

The Directive mandated systematic safety

management systems across facilities inEurope that handled dangerous substances.


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SMSOffshore Industry

Piper Alpha was a North Sea oil productionplatform. On 6 July 1988 an explosion and the

resulting oil and gas fires destroyed it, killing 167

men. (Total insured loss was about US$3.4 billion).

The subsequent inquiry headed by Lord Cullen made

106 recommendations

Most significant of these recommendations was that

operators were required to present a safetycaseformanaging safety.

Safety Case implies a proactive approach


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Safety CaseLord Cullen

Asafety case regime provides a comprehensive frameworkwithin which the duty holders arrangements andprocedures for the management of safety can bedemonstrated and exercised in a consistent manner. Inbroad terms the Safety Case is a document, meant to bekept up-to-date, in which the operator sets out its approachto safety and the safety management system, which itundertakes to apply. It is, on the one hand, a tool forinternal use in the management of safety and, on the otherhand, a point of reference in the scrutiny by an external

body of the adequacy of that management system, ascrutiny which is considered to be necessary for maintainingconfidence on the part of the public.


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SMS - Shipping

Herald of Free Enterprise - 06 March 1987 capsized and sank afew minutes after leaving Zeebruge resulting in the deaths of193 passengers and crew

Scandinavian Star - On 07 April 1990 a fire broke out andrapidly spread through the ship resulting in the deaths of 158persons

Development of International Safety Management (ISM)Code for the Safe Operation of Ships and for PollutionPrevention1990 - 1995 Gestation period1998 - 2002 Staggered compliance in shipping industry

Large emphasis on closing the gap between the boardroomand the bridge). Prior to ISM it was felt that some risks werecreated in the boardroom and carried by the shipspersonnel - Herald of Free Enterprise

Accidents such as the Costa Concordia indicate inadequateidentification and classification of risk in the ISM Code


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SMS - Ports

On 15 February 1996 the tanker Sea Empress under

pilotage became grounded at the entrance of Milford

Haven spilling 72,000 tons of crude oil into the sea

In March 2000 the Port Authority was found guilty

under the strict liability Water Resources Actfor not

having a safety management system. This judgement

bypassed the civil immunity of the pilot and port that

had withstood many challenges since 1913


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SMS - Ports

Theport authority created and then operated a system

which resulted in Sea Empress attempting to enter the

Havenat a time as late or later, in terms of proximity to

low water, than any comparable vessel had attemptedpreviously. It thereby put (the pilot) in a position where as

a direct consequence of the management system

operated by the port he could make an error*of

navigation..Justice Steel2002 U.K . Port Safety Code introduced. (Mirror image

of ISM Code)

*Error seen as a consequence rather than a cause


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Basis of ISM Code

The ISM Code is based on a Quality Management(QM) and Quality Assurance (QA) approach and

hastily adopted by the shipping industry after the

high profile 'Herald of Free Enterprise' and

Scandinavian Starincidents

The ISMCodeuses the same terminology, tools,

techniques and clauses as QM

Main difference:- QMhas focus on the Customerand Service

- ISMCodehas focus on Safetyand Environment


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Aims of ISM Code

To provide an international standard for the

safe management and operation of ships and

for pollution prevention

To minimize the scope for poor human

decisions that contribute directly or indirectly

to a casualty or pollution incident through

better management


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ISM Code - Deficiencies

QA/QM based safety management systems such as theISM Code take an engineering approach to safety

More suitable for manufacturing and other processdriven industries

Limited application on a moving ship operating in adynamic environment

In a dynamic environment safe outcomes are achievedthrough the timely interventions and adjustments of

skilled human operators to changes in an uncertainenvironment

(Many operations in shipping particularly in pilotage aresituated in the operational chain where activefailuresoccur)


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Implementing a SMS in different Industries

A safety management system can be defined as a planned,

documented and verifiable method of managing hazards and

associated risks(Bottomley,1999).

Proper identification and classification of risk is a critical factor in

the protection encompassed in a safety management system

In the nuclear power industry SMS built in at design stageidealsituation. Hazards and risks clearly defined.

Relatively simple to transfer the concept to the process based

chemical and offshore industries

In shipping the industry to be managed:- is up and running.

- has its own strong traditions and culture

- involves a moving platform and incorporates a large element of dynamic risk

which is much more difficult to assess.


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In shipping it was very difficult to identify and classify risksand hazards with the same level of clarity as the processbased industries

It is also possible that existing risk controls in such areas as

bridge operations were considered sufficient It appears that no appraisal was done to check if existing risk

controls were adequate in meeting contemporary communitystandards in regard to acceptable risk and that availableknowledge and concepts on safety were taken into

consideration The practical solution was to consolidate existing practices as

a standard and amend the system after failures and accidents


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ISM Code Viewed as a Safety Case

But what the ISM Code seeks to do is tosuperimpose a safety case regime which isregulatory in the sense that it is compulsory

and is intended to be fully enforceable, whilstbeing specific only in its generalrequirements

The ISM Code: The Road to Discovery ?

By Lord Donaldson of Lymington, Cadwallader Lecture 26 March 1998

Ship safety, and the consequences of the lack of it, is a topic which is asfascinating as it complex also by Lord Donaldson


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In practical terms this has made the ISM Code

a normative, top down and reactivesystem

With the level of safety required for shipping

the SMS must be proactive

Also the dynamic nature of bridge operations

demands a proactive approach


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ISM Code - Decision Making, Human

Factors & Error Management

Aim of ISM code to minimize the scope for poorhuman decisions that contribute directly or indirectlyto a casualty or pollution incident through theapplication of better management

Decision makingis a process thoroughly permeated byhuman factors

QA based Safety Management System (SMS) such asthe ISM Code is not properly informed by humanfactors knowledge

In SMS context human factors implies errormanagement


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Error Management (EM)

Human error is inevitable (Part of the humancondition). The most dedicated, conscientious,experienced and professional person can make theworst error (Fundamental)

Error Management (EM) must be a vital part of a properSMS for shipping

EM is bottom-up

Errors fall into recurrent patterns: the same situationkeeps on producing the same error in different people

QM based SMS is reactive. For something as dynamic aspilotage a SMS must be proactive

An SMS without human factors/error management hasbeen likened to a car without an engine (JamesReason)


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Error ManagementRaising awareness of the types of individualhuman and teamwork errors that commonlyoccur and how we might prevent, trap and

mitigate these before they lead to an accidentis error management

The issue is not that an

error occurred, but how itfailed to be corrected


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SMS and Risk A safety management system can be defined as a planned,

documented and verifiable method of managing hazards andassociated risks(Bottomley,1999).

Proper identification and classification of risk is a critical factor inthe protection encompassed in a safety management system

The demands of managing risks of workplace injury are very

different to the risks associated with a Low Probability/HighConsequence/High Profile (LP/HC/HP) transportation accidents. Yeta study concludes Even given the very different demands ofmanaging the risks of workplace injury compared to the risksassociated with LP/HC accidents, the overarching structures,individual components and major functionality of safety

management systems have remained very similar regardless ofindustrial context.

*Matthew J W Thomas (2012) A Systematic Review of theEffectiveness of Safety Management Systems (ATSB TransportSafety Report)


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Risk AssessmentIACS Approach

Proper Risk Assessment is critical for the development of aSMSAccording to the International Association of Classification Societies IACS

There is no universally accepted definition of risk, but the one commonlyapplied and regarded as authoritative in most industrial contexts is:

Acombination of the probability, or frequency, of occurrence of a defined

hazard and the magnitude of the consequences of the occurrence. (ISO8402:1995/BS 4778)

From AGuide to Risk Assessment in Ship Operations- IACS No 127 (June2010)

IACS response to new requirement for risk assessment added as anamendment to the ISM Code 2010

How valid is this approach for assessing risk inshipping operations such as pilotage that involvedynamic risk?


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IACS - Risk Assessment (Shipping)

The IACS approach to risk assessment issuitable for managing the type of risk inherent

in situations with a potential for personal

injury and death. The ISM Code does not address the risks

inherent in bridge operations beyond

mentioning a passage plan as a risk control.


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Costa Concordia

The Costa Concordia (2012) accident occurred a decade after theintroduction of the ISM code. In terms of the IACS risk assessmentapproach it is a 1 in a 100 year accident and was therefore notincluded in the organisationsrisk matrix. [The cause of the accidentwas that more compartments were breached as result of theallision than the ship was designed to withstand. (Titanic - 1912)]

In all the post Costa Concordia analysis and discussion the role ofthe ISM Code in preventing/reducing the risk of such an accidentis conspicuous by its absence

The main purpose of a SMS is to prevent a large scale accident


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Risk Assessment & Due Diligence

The combinationof probability, frequency, of occurrence of adefined hazard and the magnitude of the consequences of the

occurrence approach to risk assessment does not provide a

legal defence in case of an accident in Australia

The courts in Australia tend to take a very harsh view of safety

management systems based on methodologies backed by risk

experts but contrary to common sense.

Only a Safety Management System underpinned by a due

diligence approach can provide a credible legal defence

against negligence after an accident


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Due Diligence - Negligence

Where it is possible to guard against aforeseeable risk, which though perhaps notgreat, nevertheless cannot be called remoteor fanciful, by adopting a means which

involves little difficulty or expense, the failureto adopt such a means will in general benegligent

High Court of AustraliaJustices Gibbs, MurphyBrennan, Deane


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ISO 31000 versus Due Diligence

Costa Concordia

According to ISO 8402:1995/BS 4778 Standardfor Risk Assessment the Costa Concordia was a1 in a 100 year accident

In terms of due diligence what would haveguarded against the Costa Concordia accident?

Application of Bridge Resource Management(BRM/Error Management (EM) techniqueswould have greatly reduced the risk of an

accident(What is the cost and effort involved inimplementing BRM?)


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Due Diligence

Legal basis of Risk and Liability:Are all reasonably practical precautions in place basedon the balance of the risk versus the effort required?

Two questions relating To Due Diligence- Does the way we operate meet contemporary

community standards in regard to acceptablerisk?

- Are we using all available knowledge in our

approach to safety or is it restricted to industrypractice?


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Need for a Reappraisal

The criminal indictment and jailing of seafarersindicates the need for a reappraisal of the ISM Codeand consideration given to:

- taking into account a seafarers practical perspective (too much

emphasis on process and paperwork)- adopting a DueDiligence approach in developing resilience inregard to Low Probability/High Consequence/High Profile(LP/HC/HP) shipping accidents

Under Workplace, Health and Safety Actsdemonstrating Due Diligence is the only credibledefence


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