Dangerous liaisons..(Just an idle twiddle).
Every once in a while you start a project with good intentions; do your homework and begin to piece together the 'whole'. Just like a jig-saw puzzle, eventually, with patience and determination, the picture emerges. My jig-saw puzzle began when P2 dropped a link in my mail box to - “Chapter 9 & 10 of the 'Special Commission of Inquiry into Ferries” (2007).
“Read Chapter Nine” wrote our inveterate research Guru (dustbin specialist) and; dutifully, I did. Three times; then I found a pencil and a sheet of paper to make a 'flow chart' you know the kind of thing – that which clearly lays out who does what, to whom and who pays for it all. Mission impossible – so paper abandoned for the large white board on the workshop wall and 'round two'. This time I was determined to 'sort it out'. Well, I got my 'mud map' - a confused abstract of disconnections, blurred lines and a total shemozzle in the 'safety training system' (for want of a better descriptor).
The analysis did however define one stand out item – the 'safety' of the travelling public, in practical terms, came home well to the back of the pack. Ministerial safety won by a handy margin, closely followed home by 'legal' safety, with fiscal safety' running home in the minor placing. There seems to be a great confusion within the ranks of those who 'prescribe' safety procedures as what the ultimate purpose of a 'safety system' actually is; in practical terms. Bear with me, I shall endeavour (in my clumsy way) to illuminate the dark places. To business then:-
“Still, he figured, sometimes you've got to do what you've got to do, and then sometimes you've just got to run like hell after it's done.”
'Fire' for example in one form or another is something most people can relate to. So there we are, fine Sunday afternoon, coming back to town from Manly on the ferry. Where on the boat is the most likely place for a fire to kick off? There are options here, so choose carefully. The ingredients for 'fire' are what? Oxygen, Heat and fuel: correct. Plenty of good rich oxygen on the harbour; so we now need a heat source and fuel. Where on the ferry is the most likely place for a 'heat' source? Plenty of those, there is a large engine driving the boat, where fuel, oxygen and heat are combined to provide the power needed. To get that fuel to the engine there must be storage (tanks) pumps to provide the motive flow; pipes to deliver the fuel to the combustion chamber. There are some pretty hefty rules in place to almost guarantee, beyond reasonable doubt, that if the 'system' is properly inspected and maintained, then the risk factor is reduced to a very, very low percentage probability.
“Human beings, like plans, prove fallible in the presence of those ingredients that are missing in manoeuvrers - danger, death, and live ammunition.”
Any 'safety system' associated with 'fire' management and control on the ferries is heavily dependent on the 'human' element. This reliance begins in the most unlikely place; the head man (or woman) in the head office and his (or her) masters; the money men (or women). They must manage the cost and maximise the profits; 'tis their task in life and much depends on 'the numbers'. Here, the first potential obstacle emerges from the heart of darkness – Costs.
“Any order is a balancing act of extreme precariousness.”
The 'money' factor features throughout this story and there must be a 'balance' struck between the ridiculous and the 'cor-blimey'. This is where the 'standards' crew join in. For example; to use say garden hose to deliver fuel to the engine is out of the question; the notion of using gold plated space age pipes is 'off the planet'. So somewhere in between a serviceable, affordable medium must be found, tested, installed, secured and certified as meeting the 'standard' demanded, this is applicable across the whole 'system'. So far, So good. Item next falls into the routine inspection bracket; this must be clearly defined – documented – and demonstrable. At grass roots level the 'Engineer' or his mate probably do an inspection of the fuel delivery system - “nothing hanging – nothing dripping” - signed off as good to go. But, what if? Say there is a minor leak; what then? This is where it becomes subjective and the 'pressure' is turned on.
The Engineer has several options here: much depends on the 'human factor' – some will stop the service until the leak is fixed; or, some will let it run on with only a bucket underneath until the service has finished, depending on how they see it. No matter; whatever action is taken must be able to satisfy the questions in the worst case scenario. This is where the Safety Management System' (SMS) fits into our puzzle and once again, bumps into human frailty, where both daemon and detail reside. The man who 'grounds' the ferry until repairs are made expects there will be questions to answer; management will want to know the why and the how of it, 'justify the expense and loss of service'; may even be taken to task and have his card marked for future attention (it happens). Unless he's smart and passed the problem up the line and someone else makes the decision and cops the incoming managerial flack. The man who fixed the problem 'on the run' is at a higher level of risk; this once again is subjective. A quick twist of spanner and screwdriver and all is well is great – back on the road – but; should this end up in a coroners court, the basics of liability will be clearly demonstrated, in Spades. The fellah who just shoved a bucket underneath the leak is in a much higher risk bracket again. Ramble over; the point follows.
There are four risks involved in my ramble; to wit:- Fiscal, legal, operational and human; all have consequences.
The whole point of a SMS is to reduce or nullify those risk elements. This is achieved (in theory at least) by clearly defining the basic structure; and ensuring that the basic is not cast in stone, put in a cupboard and ignored. Now, I don't imagine that the Skipper of a ferry would simply hop on board and start her up like he does the Falcon and roar off down the highway to work. Is there a clearly defined 'daily inspection' and a reporting process – a check list – so the Engineer can report his leak? Yes, great; does the Skipper have clear guide lines for decision making, is he qualified and authorised and 'arse covered' to make that decision? If not then who?
So, the Deckhand spots a fuel leak, reports to the Engineer, he takes a look and reckons it needs to be fixed, he calls the Skipper and reports. Here we bump into the perennial problem of 'command'. The service needs to run; passengers expecting it; revenue lost and a potential expense to be met for repairs. All of this does, (it should not – however) have a bearing on the 'command' decision. You see, this is one of many scenarios where it is not 'crystal clear' and these are the most dangerous – across the board. Damned if you do; damned if you don't. “Can you fix it Charlie?” asks the Skipper - “I can patch it up to keep us going, but its a yard job when we get back” says Charlie. There is the proverbial 'rock and hard place'. Charlie may well be able to work his magic and keep 'em going; but – (big one) Charlie doesn't know 'why' the leak has revealed itself – does he. So he patches it up and off they go – all is well until someone yells “FIRE”. This is the part when it all turns to worms. You can guess the rest, history will repeat (again). Sods law of the ocean is appropriate and highly applicable.
The first and probably the most important 'rule' of any SMS is to clearly define the lines of 'responsibility' – all the way back to the 'head of power' – Managing director, chairman, minister etc from the lowliest deckhand. It must also unequivocally define the 'command prerogative'. Skippers says 'No Go' that should be the end of it – no questions asked. Why – well, when the other boot lands – it lands on the Skippers neck – always. History is full of parallels; time and time again the governing 'agency' walk away with more money and a larger work force to fiddle and twiddle with the mountain of paper work they generate, reams of fine words and oodles of obfuscation and elegant exits; all care but little responsibility and well able to afford serious legal counsel.
You see the problem – 400 passengers stood in the rain at Manly waiting for their ferry to work – highly pissed off because the boat has not arrived on time have a much bigger voice than the Skipper who declared the boat not serviceable. Should the Skipper have decided to 'run' and the wretched thing caught fire – what then M'lud?
SMS – daily inspection – clearly defined decision making rules and support for the decisions made is an imperative. It is almost as important as 'training': not in the way the current load of cobblers stands, but real training; twice a year. Bring in the Fire brigade to teach how to manage a fire; bring in the Navy to teach survival at sea – properly; make absolutely certain that the ships are as serviceable and as well maintained as possible. For no matter how trained and prepared the crew are – their ultimate safety depends on the absolute reliability of the ship and the systems used in daily operations. The SMS is NOT an arse covering tenet, it must be clear, concise and definitive.
Final note before I shut up; if an aircraft Skipper had to put up with the stuff the ferry Masters have to live with there would be Hell to pay and the Devil to dance with. That's it...
Toot toot.
Every once in a while you start a project with good intentions; do your homework and begin to piece together the 'whole'. Just like a jig-saw puzzle, eventually, with patience and determination, the picture emerges. My jig-saw puzzle began when P2 dropped a link in my mail box to - “Chapter 9 & 10 of the 'Special Commission of Inquiry into Ferries” (2007).
“Read Chapter Nine” wrote our inveterate research Guru (dustbin specialist) and; dutifully, I did. Three times; then I found a pencil and a sheet of paper to make a 'flow chart' you know the kind of thing – that which clearly lays out who does what, to whom and who pays for it all. Mission impossible – so paper abandoned for the large white board on the workshop wall and 'round two'. This time I was determined to 'sort it out'. Well, I got my 'mud map' - a confused abstract of disconnections, blurred lines and a total shemozzle in the 'safety training system' (for want of a better descriptor).
The analysis did however define one stand out item – the 'safety' of the travelling public, in practical terms, came home well to the back of the pack. Ministerial safety won by a handy margin, closely followed home by 'legal' safety, with fiscal safety' running home in the minor placing. There seems to be a great confusion within the ranks of those who 'prescribe' safety procedures as what the ultimate purpose of a 'safety system' actually is; in practical terms. Bear with me, I shall endeavour (in my clumsy way) to illuminate the dark places. To business then:-
“Still, he figured, sometimes you've got to do what you've got to do, and then sometimes you've just got to run like hell after it's done.”
'Fire' for example in one form or another is something most people can relate to. So there we are, fine Sunday afternoon, coming back to town from Manly on the ferry. Where on the boat is the most likely place for a fire to kick off? There are options here, so choose carefully. The ingredients for 'fire' are what? Oxygen, Heat and fuel: correct. Plenty of good rich oxygen on the harbour; so we now need a heat source and fuel. Where on the ferry is the most likely place for a 'heat' source? Plenty of those, there is a large engine driving the boat, where fuel, oxygen and heat are combined to provide the power needed. To get that fuel to the engine there must be storage (tanks) pumps to provide the motive flow; pipes to deliver the fuel to the combustion chamber. There are some pretty hefty rules in place to almost guarantee, beyond reasonable doubt, that if the 'system' is properly inspected and maintained, then the risk factor is reduced to a very, very low percentage probability.
“Human beings, like plans, prove fallible in the presence of those ingredients that are missing in manoeuvrers - danger, death, and live ammunition.”
Any 'safety system' associated with 'fire' management and control on the ferries is heavily dependent on the 'human' element. This reliance begins in the most unlikely place; the head man (or woman) in the head office and his (or her) masters; the money men (or women). They must manage the cost and maximise the profits; 'tis their task in life and much depends on 'the numbers'. Here, the first potential obstacle emerges from the heart of darkness – Costs.
“Any order is a balancing act of extreme precariousness.”
The 'money' factor features throughout this story and there must be a 'balance' struck between the ridiculous and the 'cor-blimey'. This is where the 'standards' crew join in. For example; to use say garden hose to deliver fuel to the engine is out of the question; the notion of using gold plated space age pipes is 'off the planet'. So somewhere in between a serviceable, affordable medium must be found, tested, installed, secured and certified as meeting the 'standard' demanded, this is applicable across the whole 'system'. So far, So good. Item next falls into the routine inspection bracket; this must be clearly defined – documented – and demonstrable. At grass roots level the 'Engineer' or his mate probably do an inspection of the fuel delivery system - “nothing hanging – nothing dripping” - signed off as good to go. But, what if? Say there is a minor leak; what then? This is where it becomes subjective and the 'pressure' is turned on.
The Engineer has several options here: much depends on the 'human factor' – some will stop the service until the leak is fixed; or, some will let it run on with only a bucket underneath until the service has finished, depending on how they see it. No matter; whatever action is taken must be able to satisfy the questions in the worst case scenario. This is where the Safety Management System' (SMS) fits into our puzzle and once again, bumps into human frailty, where both daemon and detail reside. The man who 'grounds' the ferry until repairs are made expects there will be questions to answer; management will want to know the why and the how of it, 'justify the expense and loss of service'; may even be taken to task and have his card marked for future attention (it happens). Unless he's smart and passed the problem up the line and someone else makes the decision and cops the incoming managerial flack. The man who fixed the problem 'on the run' is at a higher level of risk; this once again is subjective. A quick twist of spanner and screwdriver and all is well is great – back on the road – but; should this end up in a coroners court, the basics of liability will be clearly demonstrated, in Spades. The fellah who just shoved a bucket underneath the leak is in a much higher risk bracket again. Ramble over; the point follows.
There are four risks involved in my ramble; to wit:- Fiscal, legal, operational and human; all have consequences.
The whole point of a SMS is to reduce or nullify those risk elements. This is achieved (in theory at least) by clearly defining the basic structure; and ensuring that the basic is not cast in stone, put in a cupboard and ignored. Now, I don't imagine that the Skipper of a ferry would simply hop on board and start her up like he does the Falcon and roar off down the highway to work. Is there a clearly defined 'daily inspection' and a reporting process – a check list – so the Engineer can report his leak? Yes, great; does the Skipper have clear guide lines for decision making, is he qualified and authorised and 'arse covered' to make that decision? If not then who?
So, the Deckhand spots a fuel leak, reports to the Engineer, he takes a look and reckons it needs to be fixed, he calls the Skipper and reports. Here we bump into the perennial problem of 'command'. The service needs to run; passengers expecting it; revenue lost and a potential expense to be met for repairs. All of this does, (it should not – however) have a bearing on the 'command' decision. You see, this is one of many scenarios where it is not 'crystal clear' and these are the most dangerous – across the board. Damned if you do; damned if you don't. “Can you fix it Charlie?” asks the Skipper - “I can patch it up to keep us going, but its a yard job when we get back” says Charlie. There is the proverbial 'rock and hard place'. Charlie may well be able to work his magic and keep 'em going; but – (big one) Charlie doesn't know 'why' the leak has revealed itself – does he. So he patches it up and off they go – all is well until someone yells “FIRE”. This is the part when it all turns to worms. You can guess the rest, history will repeat (again). Sods law of the ocean is appropriate and highly applicable.
The first and probably the most important 'rule' of any SMS is to clearly define the lines of 'responsibility' – all the way back to the 'head of power' – Managing director, chairman, minister etc from the lowliest deckhand. It must also unequivocally define the 'command prerogative'. Skippers says 'No Go' that should be the end of it – no questions asked. Why – well, when the other boot lands – it lands on the Skippers neck – always. History is full of parallels; time and time again the governing 'agency' walk away with more money and a larger work force to fiddle and twiddle with the mountain of paper work they generate, reams of fine words and oodles of obfuscation and elegant exits; all care but little responsibility and well able to afford serious legal counsel.
You see the problem – 400 passengers stood in the rain at Manly waiting for their ferry to work – highly pissed off because the boat has not arrived on time have a much bigger voice than the Skipper who declared the boat not serviceable. Should the Skipper have decided to 'run' and the wretched thing caught fire – what then M'lud?
SMS – daily inspection – clearly defined decision making rules and support for the decisions made is an imperative. It is almost as important as 'training': not in the way the current load of cobblers stands, but real training; twice a year. Bring in the Fire brigade to teach how to manage a fire; bring in the Navy to teach survival at sea – properly; make absolutely certain that the ships are as serviceable and as well maintained as possible. For no matter how trained and prepared the crew are – their ultimate safety depends on the absolute reliability of the ship and the systems used in daily operations. The SMS is NOT an arse covering tenet, it must be clear, concise and definitive.
Final note before I shut up; if an aircraft Skipper had to put up with the stuff the ferry Masters have to live with there would be Hell to pay and the Devil to dance with. That's it...
Toot toot.