{"id":1199,"date":"2016-09-01T16:13:54","date_gmt":"2016-09-01T23:13:54","guid":{"rendered":"http:\/\/www.innerairmanship.com\/blog\/?p=1199"},"modified":"2016-09-01T16:13:54","modified_gmt":"2016-09-01T23:13:54","slug":"light-bulbs-red-lines-and-rotten-onions","status":"publish","type":"post","link":"https:\/\/www.innerairmanship.com\/blog\/2016\/09\/01\/light-bulbs-red-lines-and-rotten-onions\/","title":{"rendered":"Light bulbs, red lines, and rotten onions"},"content":{"rendered":"<p>I&#8217;ve talked about the <a href=\"http:\/\/www.innerairmanship.com\/blog\/2016\/03\/30\/procedural-drift-and-the-bramble-bank-sandbar\/\">MV Hoegh Osaka incident<\/a> before. A huge ship that left port out of balance and soon was\u00a0grounded on the Bramble Bank sandbar off the\u00a0Isle of Wight. The official\u00a0<a href=\"https:\/\/assets.digital.cabinet-office.gov.uk\/media\/56e9a7afe5274a14d9000000\/MAIBInvReport6_2016.pdf\">British\u00a0Marine Accident Investigation Branch (MAIB) report<\/a>\u00a0determined that a &#8220;fundamental principle of seamanship appears to have been allowed to drift, giving rise to potential unsafe practices.&#8221;<\/p>\n<p><a href=\"http:\/\/www.safetydifferently.com\/light-bulbs-red-lines-and-rotten-onions\/\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-full wp-image-978\" src=\"http:\/\/www.innerairmanship.com\/blog\/wp-content\/uploads\/2016\/03\/sandbar.jpg\" alt=\"Hoegh Osaka\" width=\"1024\" height=\"576\" srcset=\"https:\/\/www.innerairmanship.com\/blog\/wp-content\/uploads\/2016\/03\/sandbar.jpg 1024w, https:\/\/www.innerairmanship.com\/blog\/wp-content\/uploads\/2016\/03\/sandbar-150x84.jpg 150w, https:\/\/www.innerairmanship.com\/blog\/wp-content\/uploads\/2016\/03\/sandbar-600x338.jpg 600w, https:\/\/www.innerairmanship.com\/blog\/wp-content\/uploads\/2016\/03\/sandbar-768x432.jpg 768w, https:\/\/www.innerairmanship.com\/blog\/wp-content\/uploads\/2016\/03\/sandbar-200x113.jpg 200w\" sizes=\"auto, (max-width: 1024px) 100vw, 1024px\" \/><\/a><\/p>\n<p>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&#8217;s titled\u00a0<strong><a href=\"http:\/\/www.safetydifferently.com\/light-bulbs-red-lines-and-rotten-onions\/\">Light bulbs, red lines, and rotten onions<\/a><\/strong>, by Nippin Anand. It was originally published in\u00a0<em>The Seaways of the Nautical Institute June 2016 Edition, <\/em>and is online at the <a href=\"http:\/\/www.safetydifferently.com\">Safety Differently<\/a> website. It&#8217;s well worth a read.<\/p>\n<p>It has paragraphs titled:<\/p>\n<ul>\n<li>Light bulbs and the myth of compliance<\/li>\n<li>Crossing the red line<\/li>\n<li>The proceduralisation of everything<\/li>\n<li>\u201cNo blame\u201d myth<\/li>\n<li>A new view of safety management system<\/li>\n<li>Purposeful compliance<\/li>\n<li>Approximate adjustments<\/li>\n<li>The equivalence of success and failure<\/li>\n<li>Business is safety<\/li>\n<\/ul>\n<p>Astute observations include:<\/p>\n<blockquote><p>Within the 83 page\u00a0<i>Hoegh Osaka<\/i>\u00a0incident report, the term \u2018chief officer\u2019 appears \u00a0132 times, and Master 89 times. By contrast, the organisation responsible for the safety management system appears in the report only on 60 occasions.<\/p><\/blockquote>\n<blockquote><p>Where is the root cause of the accident? This shows how approximate adjustments and routine practices can sometimes\u00a0<i>emerge<\/i>\u00a0as disproportionate, non-linear outcomes.<\/p><\/blockquote>\n<p>And if you read the whole thing, you&#8217;ll understand the safety meanings of <a href=\"http:\/\/www.safetydifferently.com\/light-bulbs-red-lines-and-rotten-onions\/\">light bulbs, red lines, and rotten onions!<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>I&#8217;ve talked about the MV Hoegh Osaka incident before. A huge ship that left port out of balance and soon was\u00a0grounded on the Bramble Bank sandbar off the\u00a0Isle of Wight. The official\u00a0British\u00a0Marine Accident Investigation Branch (MAIB) report\u00a0determined that a &#8220;fundamental principle of seamanship appears to have been allowed to drift, giving rise to potential unsafe practices.&#8221; 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&#8217;s titled\u00a0Light bulbs, red lines, and rotten onions, by Nippin Anand. It was originally published in\u00a0The Seaways of the &hellip; <a href=\"https:\/\/www.innerairmanship.com\/blog\/2016\/09\/01\/light-bulbs-red-lines-and-rotten-onions\/\" class=\"more-link\">Continue reading Light bulbs, red lines, and rotten onions<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[6],"tags":[56,157,104,57,77,64],"class_list":["post-1199","post","type-post","status-publish","format-standard","hentry","category-link-to-articles","tag-accident","tag-compliance","tag-drift","tag-safety","tag-seamanship","tag-sms"],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.innerairmanship.com\/blog\/wp-json\/wp\/v2\/posts\/1199","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.innerairmanship.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.innerairmanship.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.innerairmanship.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.innerairmanship.com\/blog\/wp-json\/wp\/v2\/comments?post=1199"}],"version-history":[{"count":1,"href":"https:\/\/www.innerairmanship.com\/blog\/wp-json\/wp\/v2\/posts\/1199\/revisions"}],"predecessor-version":[{"id":1200,"href":"https:\/\/www.innerairmanship.com\/blog\/wp-json\/wp\/v2\/posts\/1199\/revisions\/1200"}],"wp:attachment":[{"href":"https:\/\/www.innerairmanship.com\/blog\/wp-json\/wp\/v2\/media?parent=1199"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.innerairmanship.com\/blog\/wp-json\/wp\/v2\/categories?post=1199"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.innerairmanship.com\/blog\/wp-json\/wp\/v2\/tags?post=1199"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}