There is an important free resource available to the whole of the shipping industry that makes a major contribution to safety and that surveyors can help to improve. This is the Mariners Alerting and Reporting Scheme (MARS) operated by The Nautical Institute. MARS is a free resource and The Nautical Institute hopes that surveyors will help to make its existence known to the maritime world. The Nautical Institute wants as many mariners and, indeed, as many in shipping as possible, to benefit from lessoned learned from accidents and near misses. Surveyors can spread the word to let mariners and companies know the resource is there.
The background to MARS is known to all; across the major transportation modes and in many other fields, human error looms as the leading cause of both accidents and incidents. In recent years, the definition of human error has been expanded to include concepts such as unsafe supervision and organisational influences (e.g. resource management and operational processes). In the maritime industry approximately 90 percent of accidents can be traced to human error despite the promotion of regulations, training and quality management systems.
As onboard systems become ‘smarter’ and more heavily used, the fear is that human operators will fall behind in their training and ability to safely operate the new technology. These and other technology changes, coupled with greatly increased numbers of operations, increase the risk that incidents and accidents will occur. The feedback from incident reporting systems is a vital early-warning tool for decision makers and planners tasked with improving safety margins. So MARS was devised. It is now a substantial database from over 25 years of reporting to The Nautical Institute.
How can surveyors help? We all know that reporting of incidents goes against our natural instincts; pride and prejudice are strong influences and it is human nature to want to hide such events rather than broadcast them, especially if there were no severe consequences. Since nothing bad happened, who will be the wiser? And why tell anyone, anyway? Surveyors with their multiple visits to vessels are well placed to help promote a reporting culture. We all know this is not easy and that it takes firm leadership and commitment to the principle of continued improvement. Masters need support in establishing such a culture.
Without data, nothing can be analysed. Trends cannot be identified and the unsafe conditions lurking just below the surface cannot be corrected. Creating a ‘just’ or ‘no-blame’ culture is one of the single biggest factors in encouraging and enabling a widespread reporting culture.
Reporting in the marine industry is accomplished on many different levels and marine surveyors are in a unique position to help. Their employment takes them on board many different vessel types. This means they can observe generic problems across the industry – problems such as preparations (or lack of) for entering into enclosed spaces; hydrostatic release systems wrongly attached; markings/warning notices obscured and poor procedures.
Reporting these experiences can contribute to the database of common trends in the industry and alert others to take preventative action. As Captain Zarir Irani AFNI FIIMS, of Constellation Marine Services in Dubai says: “MARS is an extremely important initiative. It benefits the entire maritime industry by enabling us to learn from one another’s mistakes and avoid accidents. Recollecting the details of a published MARS report can mean that someone somewhere, at sea or ashore in the management office, could take avoiding action in a similar situation.” At The Nautical Institute we understand surveyors are employed for a specific purpose, but the industry would value reports of a generic nature which would not compromise the confidentiality that surveyors need to adhere to.
Clearly, it is just as important to report violations of procedure as it is to report close calls, or actual casualties. Not only do violations of procedure tend to increase risk, these ‘rogue’ acts are a symptom of a malaise that must be addressed. And that is not the only bad news. If violations become prevalent yet due to luck, no major accident ensues; the risky behaviour will be validated.
The only way to sustain a state of intelligent and respectful wariness is by creating a safety information system that collects, analyses and disseminates the knowledge gained from incidents, near misses and other ‘free lessons’. To achieve this, it is first necessary to engineer a reporting culture – not an easy thing, especially when it requires people to confess their own slips, lapses and mistakes.
So how can surveyors help? They can become correspondents and send MARS confidential reports on incidents, no matter how small. A confidential report provides the opportunity to alert colleagues in the industry to potentially dangerous situations without fear of incrimination. The reporting scheme creates awareness of trends and potentially dangerous minor occurrences leading up to major accidents.
Those making reports are asked to pass information on confidentially but not anonymously, which ensures reports are not manipulated by those promoting a particular issue, or that a series of reports are filed by an individual purporting to be several reporters. Anonymous reports would make the scheme unreliable and generate grave doubts about its credibility. Confidentiality is maintained at all times. Reports are received by the editor, who works independently of NIHQ, and who may contact the reporter if further details are required. Ship and personal names and any identifying characteristics are then removed from the report before publication as a supplement in The Nautical Institute’s monthly journal Seaways. The original report is then deleted. The only information kept by The Nautical Institute is the published report.
MARS is open to all and differs from accident reports to flag state authorities and international organisations in that it provides an information service; whereas an official report may be the result of investigations by authorities. These authorities are perceived to be enforcers and prosecutors by mariners and there is reluctance to submit reports where they may be incriminated. They need have no such fear about MARS.
Surveyors could also help to ensure that MARS reports are used widely throughout the industry so the lessons learned can be disseminated. This is, after all, their purpose. Reports are available for free through The Nautical Institute’s website and can be analysed and linked to other reporting systems to create reports of meaningful data for use in understanding causes and trends of marine accidents.
The MARS database is fully accessible to the general public and can be searched by key words or phrases, by subject, by year and by the report number. Official reports from accident investigation boards such as UK Marine Accident Investigation Branch (MAIB), Australian Transport Safety Bureau (ATSB), Transport Safety Board of Canada (TSB), and USCG, are also included as well as reports from P&I Clubs and from sail training vessels. MARS reports are used by a number of organisations throughout the shipping industry – P&I Clubs, shipping companies and shipping journals all regularly publish MARS reports as a matter of routine.
The system has now been going for long enough that it is recognised by most seafarers as a forum to raise awareness of hazards and to bring them to the attention of others without fear of reprisal. Reports are read by seafarers and used in discussions at safety meetings onboard ships. Companies study MARS reports to see if there is a requirement to alert ships in their fleet and a number of companies are now submitting safety management system reports to MARS with the added advantage of a ‘lessons learned’ section within them.
Confidential incident reporting systems are not a foolproof method of data acquisition. They are subject to the biases and fears of the humans who use them. Voluntary incident reports also cannot be considered a representative sample of the underlying population of events they describe. But as MARS has demonstrated for many years that, if the people at the ‘sharp end’ of day-to-day operations are encouraged to report safety problems they encounter to a programme they can trust, safety goals will be reached much sooner than if stories of those lessons learned go untold.
All sectors of the marine industry are invited to make the best use of this resource, to promote the contribution of reports to the scheme, and to use the published reports to improve safety. We urge surveyors to take the message to the ships they visit and help us all to make those vessels safer for all who sail on them.