According to the EU-funded SAFEMODE project, it is useful to consider the accident ‘iceberg’, when considering causality and Safety Learning. The events and facts – who did what, when and where, are the surface layer, relatively easy to document. But they don’t tell the whole story.
Below the waterline are the Human Factors that can lead people into error. Deeper still are the factors affecting how we get the job done on a day-to-day basis, when workarounds might be necessary, or when someone – whether the individual seafarer or their senior officer or captain – has to make a judgment call concerning trade-offs between risk and productivity.
This is where we have to admit that we don’t live in a perfect world, that procedures will not cover every possible situation. Procedures must therefore always remain open to improvements that better reflect the reality of working conditions / work as done.
At the deepest level are the organizational and cultural factors that can affect safety. These are usually only detected when looking across a number of incidents, or else are raised to the surface and brought into the daylight following a major accident.
The accident iceberg: Factors hidden below the surface
Thinking out of the box
Investigating differently…
- goes hand-in-hand with a taxonomy but encourages simple narratives
- contributes to identifying deeper levels of factors beyond the surface causes
- focuses on learning, throwing blaming overboard
