BY

CHARLES BARBEE & DAVID DEAVER

Marine investigators shall keep the following fundamental principles in mind when explaining how a specific incident occurred:

　

Principle #1: Shipping, diving, oil exploration, fishing, towing, fuel transfers, passenger operations, and recreational boating are complex production systems. These production systems do not create new cars or refrigerators; instead they produce intangibles such as safe passenger voyages, timely delivery of oil, and so on. Because maritime transportation is a production system, it shares the elements common to every complex production system.

Principle #2: All incidents (including even the most minor) are failures of the system, not simply the human or equipment directly involved.

Principle #3: No human error is entirely to blame. Human error is a naturally occurring, intrinsic part of human performance. While holding mariners accountable for their actions and taking steps to reduce human errors, marine investigators should bear Principle #2 firmly in mind. The human error could not have resulted in an incident unless conditions in the system (especially the system's defenses against human error) were already ripe for it.

Principle #4: System incidents have their primary origins in the fallible decisions made by the high-level corporate, underwriter, regulatory, or plant managers. These fallible decisions are an inevitable part of the decision-making process, and the process of improving systems involves making fallible decisions harmless as opposed to eliminating high-level error.

Principle #5: The whole point of analyzing the causes of an incident is to improve the system and prevent reoccurrence. Accordingly, the marine investigator's job is to identify system failures and propose fixes.

Many psychologists view all organized human or technological systems as production systems. These production systems make energy, a chemical substance, a mechanism, or the mass transportation of any commodity (including people) by road, rail sea, or air. In this view the many maritime operations, once thought independent, are just "pieces" rolling off the maritime transportation system. In this system, there are many factors, that include the charts and publications that mariners use, the aids to navigation on waterways, vessel traffic systems, the laws and regulations in place, safety inspections, the navigation equipment and all the other systems on vessels, and even mariners standing the watch. When these factors come together in precise synchronization, the product is the safe and timely transit, fuel transfer, or use of our nation's waterways. As a complex production system, the maritime transportation system can be described in terms of the elements of any production system.

　

In order for a system to operate, it must have an initial direction. At the organizational level, decision makers respond to the pressures, demands, and opportunities in the outside world and set the goals for the system. They also direct, at a strategic level, the ways in which the system will reach these goals. In practice, decision makers take limited financial and other resources (equipment, people, talent, expertise, and time), and direct how they will be spent in order to get the most productivity with the highest degree of safety (a process of balance). In the simplest of terms, decision makers provide the money to begin an operation, and the shell building (or vessel) which, when properly equipped and staffed will become an operating plant. Organization elements are those that set the goals and provide the means to reach them.

　

Below the decision makers, line managers must create specific plans to carry out operations, including the hiring of personnel, the training of these personnel, the purchase and deployment of exactly the right type of equipment, systems for managing ongoing operations, and finally, means for reacting to all the foreseeable problems that will arise. Again, in simple terms, line managers take the money and empty shell, provided by the decision maker, and transform it into a plant filled with managers, workers, and equipment. Workplace elements are those personnel, buildings, equipment, vessels that manage operations.

　

Although the line managers and decision makers have provided a system, that system cannot be considered ready to operate until both the workers and the equipment they use are properly prepared to "run the line." To be ready, the system must possess certain attributes:

　

Precondition elements are those conditions that make people and machinery ready to go to work.

　

Once the system is properly manned, equipped, and managed, the line can be turned on and product can be created. Production is the precise synchronization of human and mechanical activities to produce the right product at the right time. Production elements are the actual operation of the system.

　

In any system, there are natural and man-made hazards. Where they can reasonably be foreseen, the system should have safeguards that protect people and equipment from injury, damage, or production-damaging losses. Defenses may be human (procedural), such as a buddy system, plotting fixes; or mechanical, such as guards, life jackets; or a combination of both. Defensive systems perform the following functions:

　

The various elements in the model of production relate in very specific ways. This relationship can be represented as below:

Any complex production system contains defenses against foreseeable threats. Incidents, which can loosely be defined as the occurrence of an unwanted outcome (event), come to pass when there are holes in the system's defenses through which an unanticipated threat penetrates.