Light bulbs, red lines, and rotten onions

I’ve talked about the MV Hoegh Osaka incident before. A huge ship that left port out of balance and soon was grounded on the Bramble Bank sandbar off the Isle of Wight. The official British Marine Accident Investigation Branch (MAIB) report determined that a “fundamental principle of seamanship appears to have been allowed to drift, giving rise to potential unsafe practices.”

Hoegh Osaka

Today I read an excellent analysis of the accident report and what it means for Safety Management Systems and safety/production balance in the real world. It’s titled Light bulbs, red lines, and rotten onions, by Nippin Anand. It was originally published in The Seaways of the Nautical Institute June 2016 Edition, and is online at the Safety Differently website. It’s well worth a read.

It has paragraphs titled:

  • Light bulbs and the myth of compliance
  • Crossing the red line
  • The proceduralisation of everything
  • “No blame” myth
  • A new view of safety management system
  • Purposeful compliance
  • Approximate adjustments
  • The equivalence of success and failure
  • Business is safety

Astute observations include:

Within the 83 page Hoegh Osaka incident report, the term ‘chief officer’ appears  132 times, and Master 89 times. By contrast, the organisation responsible for the safety management system appears in the report only on 60 occasions.

Where is the root cause of the accident? This shows how approximate adjustments and routine practices can sometimes emerge as disproportionate, non-linear outcomes.

And if you read the whole thing, you’ll understand the safety meanings of light bulbs, red lines, and rotten onions!

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