UK MAIB: The role of human in the digital marine environment needs careful consideration to avoid failures

In an exclusive interview to SAFETY4SEA, Andrew Moll, Chief Inspector of the UK Marine Accident Investigation Branch (MAIB), explains the challenges and priorities of investigating marine accidents and trends that have arisen through the branch’s work. Also, we discuss what he would like to see happen within the industry and his key messages for further enhancing safety on the sea and the need to not become complacent.

With many environmental issues and technological advances facing the industry and the need to adapt, he highlights how these challenges can be mitigated and how this could potentially impact the marine environment.

SAFETY4SEA: When it comes to incident investigation, what are the key challenges and what should be industry’s top priorities?

Andrew Moll: My answer comes in two parts in that there are tactical and strategic challenges. In terms of tactical challenges, what the MAIB sees year-on-year is accidents to people. Every year, the Branch investigates accidents that have had life-changing or even fatal outcomes, and these can include falls from height, man overboard fatalities, crush injuries and confined space fatalities. These present challenges that are routine and regrettably remain the same each year.

In terms of strategic challenges, I think there are two very significant ones facing the industry over the next decade. The first one, following the recent agreement at the IMO, is the drive towards net-zero. We are seeing a number of companies moving towards liquefied natural gas as a stop-gap measure, in the hope there will be a VHS/Beta Max sort of moment when the industry will coalesce around one new fuel type. The problem with delaying is that even if ships are built with new fuel propulsion, the infrastructure and training needed in support will not be in place. The smaller companies are waiting for the big players to commit, but there is little sign of that happening and so a mixed economy seems likely. This will probably result in a fractured support infrastructure in the years ahead.

The second strategic challenge is the drive towards autonomous vessels. Right now, we are in the era of computer aided humans, which is not going very well. Humans do not make good monitors, as they are easily overwhelmed by high volumes of low value data and they cannot sift through lots of cautions and alerts as well as computers can. We are already seeing cargo stows and passage plans prepared ashore and presented to the master, who still remains responsible for the vessel’s safety, but with diminishing ability to affect it. The role of the human in the digital marine environment needs careful consideration if some expensive mistakes are to be avoided.

S4S: From your professional experience, what are the most important factors to consider when investigating maritime accidents?

AM: From the MAIB’s perspective, we are looking at the underlying causal factors and the systemic safety issues. If an organisation is repeatedly having the same type of accident, they should be asking themselves why. For example, a few years ago, a towage company decided to focus on Lost Time Injury (LTI) accidents, expecting to find that most were occurring towards the end of an individual’s two-week shift pattern. Instead, they found that most accidents were occurring in the afternoon of their first day back on shift after a break. Simply telling people to slow down and take more care on the first day back helped reduce the number of LTIs to almost zero, showing a good way of using data.

At the other end of the spectrum, I asked the engineering supervisor of a large small-boat operator what spare part was in greatest demand. He responded he did not know, but would find out for me – this response had already answered my question, because how can you plan to improve something if you do not know what is going on? I think the most important factor is gaining a true understanding what is going on in your organisation and then you can start planning to improve it.

S4S: Following analysis of the last years, what are the most reoccurring factors that result to maritime accidents/incidents? Have you identified any alarming trends/topics?

AM: I think it varies significantly from sector to sector. The most challenging is the leisure sector, because we do not see a particular set of reoccurring trends. One year it might be single-handed sailors being lost over the side and another year it might be canoeists drowning; it is a very mixed bag. The small commercial fishing sector gives us a lot of work, as there are two things we see time and time again. The first, is a problem with small fishing boats as, quite often, a lone operator or small crew are trying to make a small boat do a big boat’s job. This can result in the boat carrying too much gear or simply being overloaded, either of which can create a stability problem. With larger fishing boats, the heavy gear presents a challenge. When the vessel is moving in a seaway, crew can be struck and injured by the gear, or even knocked overboard with often tragic consequences if they cannot be recovered quickly. The final sector is the merchant fleet, where the accidents we see vary dependent upon the trade. However, as a general comment, we are seeing a drop off in the quality of watchkeeping standards that correlates with the rise of electronic navigation. If there is not much to stimulate a watchkeeper and traffic is light, they can become bored or distracted and then accidents start to happen. This is something we are seeing on a routine basis and, too often, with catastrophic outcomes.

S4S: What is your wish list for the industry and/or regulators and all parties involved for the shipping industry to enhance safety culture onboard?

AM: I think this is reasonably simple – with a few exceptions, margins are tight in the shipping industry and some sectors, over time, have developed a compliance culture where just enough is good enough. However, safety has its own rewards in reduced downtime and fewer lost days due to injuries. It also makes the workforce feel valued, which they repay in return with better engagement, taking better care of the ship and a desire to do a good job. A good safety culture can be a virtuous thing with the potential to really spiral an organisation upwards in terms of its performance.

S4S: Do you have any projects/plans that you would like to share with industry stakeholders?

AM: The MAIB has over 42000 occurrences on its database, which is a huge resource. We answer information requests from researchers when they come in, but we are working to make an anonymised data set available to anyone. This would allow the public to access our website, put their queries in and download good quality statistics as analysing what has gone before can help point towards areas where lessons can be learned. If we can make our data available to researchers and industry, I think that is a good thing. We are about to start the alpha phase of a project looking at ways this can be done, and I am reasonably hopeful that at the end of this financial year we will have a beta version available that people can trial.

S4S: What is your key message to industry stakeholders to enhance safety at sea?

AM: From my simplistic perspective, there are three parts to every accident. These are the period prior to the event, which is usually when the pre-conditions for the accident are set; the trigger event itself, when it all goes wrong; and, the aftermath or how it was dealt with. Many accident investigators focus on what happened, but we find our best safety learning often comes from looking at the ‘before’ and ‘after’ of an event; it is too late to notice that your car has bald tyres after it has skidded off the road. Solid maintenance, good risk management and effective training are amongst some of the things that come together to create a well-run organisation and help prevent accidents. Unfortunately, these are also some of the first things to suffer when budgets get tight.

With the aftermath, one of my favourite phrases is that ‘fortune favours the prepared mind’. Better still, not just thinking about what to do in an emergency but practising for one can help prevent a drama becoming a crisis. When things start to go wrong, wishing you had done more emergency training is not going to help; that should have happened well before the crisis occurred. In the accident investigation profession, we call it ‘precautionary thought’, which is about considering carefully what you are going to embark upon. This includes thinking it through properly, understanding your role, the risks or hazards you could encounter, and how those can be mitigated.


The views presented hereabove are only those of the author and do not necessarily reflect those of SAFETY4SEA and are for information sharing and discussion purposes discussion purposes only.


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