Anything sexier than the word ”procedure”? Yes, I believe so. The word ”procedure” probably ranks amongst the lowest rated words when it comes to catching people’s attention:
”Buy 3 procedures, get the cheapest one for free”, ”Crazy procedure fest - low prices, get yours before it’s too late” or ”Homemade procedures – like grandma made them” - a marketing manager would probably have nightmares if she should try to sell this concept.
So what is a procedure?
Our dear old Wikipedia tells us that: ”Standard Operating Procedure, a step-by-step instruction to achieve the desired result (efficiency, quality output, uniformity, reducing miscommunication and failure), used in industry and military.”
Easy - you follow the procedure and you get what you want. You press the button the engine starts, you press another and it stops.
How are procedures actually used today?
Inspired by the latest report from the Danish Maritime Accident Investigation Board (Den maritime havarikommision) and the event held last week by the Danish Shipowners Association and EMUC in cooperation – it’s time to give some thought to how we use procedures.
Until the introduction of the ISM code, procedures were more or less of an internal matter for shipping companies and was not really regulated. The ISM code gave rise to safety management systems and thus also policies and procedures setting out guidelines on how to run your operation. The code sets specific requirements for what is to be covered by the company’s system and in addition, the company optionally chooses to include one or several other codes, guidelines or standards in their system.
So – in order to fulfill the above, what kind of procedures do we see in a safety management system (just some examples)? If could be:
- A procedure to regulate or forbid the use of alcohol or drugs
- A procedure specifying guidelines for performance appraisal
- A procedure for cargo handling
- A procedure specifying how you should compose your bridge team
- A procedure for anchoring
- A procedure for updating charts and other publications
- A procedure for ensuring watchkeeping in port for the engine room
- A procedure for handling garbage
And so on.
Well - maybe some of these situations that the procedures covers could fall well under the above definition of a procedure: a step-by-step instruction that ensures a desired outcome/result. The case is - as DMAIB points out: that our world is dynamic not static - and thus a static step-by-step instruction will not do the job in many of the cases. I would assume that the way charts and publications are updated (being that electronic or paper) that it is pretty similar every time you do it. But how you compose your bridge team depends on a lot of factors you have to take into consideration in the specific situation. Same with cargo handling for example.
So, a step-by-step instruction will most likely get you a success with updating your charts and publications. But will a step-by-step instruction get your cargo safely loaded? A newly graduated officer - or a cadet - would probably succeed with the charts and publication update by following the procedure, but most likely not with the cargo loading if he/she stands with the procedure manual in hand and have to manage the cargo operation. Something else is needed. The procedures do not do the job. They are static and do not take into considerations all factors that emerge during an operation.
Procedures are seen as a barrier to creating safety. Similar to a fence or a rail limiting the risk of you falling down in the cargo hold. Procedures should prevent you from doing something unsafe.
As Erik Hollnagel describes safety: Safety is the absence of unwanted events. So does procedures ensure unwanted events stay away from your ship? And taking into consideration that a procedure is a safety barrier he [Hollnagel] concludes in his paper “Risk + Barriers = Safety?” that:
“Barriers are an effective means against known risks, a way to prevent unwanted events from taking place and to protect against their consequences. Yet barrier design must not become entirely reactive since in that case safety will become a game of constant firefighting or catching up. Safety cannot genuinely be improved only by looking to the past and taking precautions against the accidents that have happened. Safety must also look to the future. It must be proactive, although that requires taking a risk – the unwanted outcome being that nothing untoward happens and that the investment, therefore, is not matched by tangible results.”
So from the above, we have that a procedure is a safety barrier, it can do some simple job - but also that barriers always work in hindsight and are not proactive.
So what do we do - here is a step-by-step guide which is definitely static and not fulfilling:
- Review your procedures and delete those that do not make sense
- Should you use another word instead of a procedure, a policy? An instruction?
- In case you need to set up safety barriers - look at barriers that actually work and stop people from falling, instead of writing a procedure: “that you should not fall, and if you do it’s your own fault”
- Consider the way you make the procedure, the format, the receiver, who should provide input, should it be in writing as always or should it be as a video?
- Work with your safety culture to create resilience in your organization - the ability to be robust and come out strengthened from incidents
Well - in the end maybe procedures will be more sexy and attractive in the future?
Mikkel Hansen, September 8th 2016