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Human errors and system variability in safety investigations of maritime casualties: an expression of systemic concerns

KT Ghirxi


The International Maritime Organization has achieved a milestone by the adoption of the new Casualty Investigation Code, which is now mandatory as prescribed in regulation XI-116 of the Safety of Life at Sea Convention, 1974, as amended. Until OJ January 2010, the IMO Code for casualty investigation was annexed to an Assembly Resolution and therefore enjoyed only the status of soft law. However, whilst the legal status then was different, the philosophy of safety investigations remains the same i.e. an investigation should not apportion blame and/or determine civil/criminal liabilities. In a strict academic sense, not mentioning the term 'blame' in an accident investigation report does not suffice. Unless paying particular attention to the collection of evidence and its analysis, blame may nevertheless be inferred. A safety investigation which doesnot take into consideration the realities of socio-organisational systems and constituent sub-component interactions may still lead to the inference of blame. Such an approach may lead to the isolation of the liveware from the wider context that influenced any decisions taken, and eventually leads to the conventional labeling of human error and violations as the cause of an accident. This paper, which is not based on empirical data, discusses the operation of maritime socio-organisational systems within a safety envelope, and the concept of performance variability rather than human error. It also explains how performance variability may be the result of necessary, if not vital, adaptations that need to be done as a result of internal and external pressures imposed by the wider environment; deviations made during the course of normal work.

Keywords: accidents, blame, investigations, human error, performance variability, violations