Safety Systems and Processes for Safe Navigation. Capt Kunal Nakra 21 June Singapore

Transcription

1 Safety Systems and Processes for Safe Navigation Capt Kunal Nakra 21 June Singapore

2 2

3 TSIB SINGAPORE Director Transport Safety Investigation Bureau (TSIB) Deputy Director Air Safety Investigation Advisor Transport Safety Investigation Bureau (TSIB) Deputy Director Marine Safety Investigation Capt. Kunal Nakra Senior Investigator and Head/Operations Senior Investigator and Head / Technical Support Senior Investigator and Head / Training Senior Investigator Capt. Jamaludin Jaffar Investigator Capt. Xiao Shouhai Mr Yeo Lee Chuan Senior Investigator Senior Investigator Senior Investigator Investigator Senior Investigator Snr. Exec Exec Exec

4 Displayed at MPA s VTIS Control Centre Navigational Safety is our Culture! 4

5 COLREGs What to do STCW How to do Safe Navigation Principles of bridge watch keeping and Bridge Resource Management ISM Code Remote VDR audits - monitor what is being done COMPETENCY TRAINING INTERVENTION STCW Skills Knowledge Attitude / BBS 5

6 Ship Factors People factors Accidents External influences Environment Human Performance Organisation onboard Shore-side management Working and Living conditions

7 Hardware LL Physiological conditions, knowledge, skills H workstation, seats, displays, controls Software S L E Environment procedures, manuals, checklists personalities, relationships, communication styles L Central temperature, noise, vibration, air quality, weather Liveware Peripheral

8 Hazard identification ISM Code requires, and allows for, identification of hazards and assessment of risks, for e.g. Bridge watch composition Bridge layout both Radars clustered on the same side of the Bridge ECDIS on the other side of the Bridge OOW making bell book entries on chart table because location near telegraph console does not (have a light) and allow him to place the book properly Is the VTS an INS, TOS or NAS

9 Formation and Limitations Mental Models Formed by unique experience of an individual and group think of how it is normally done Are limited by assumptions about oneself and how one understands others (and the world) Intra - bridge Inter - bridge Ship - Shore authority Ship - Shore office

10 The solution! Shared Mental model is essential By monitoring what is happening and can happen By communicating those observations To gain a high level of trust To demonstrate that we live and breathe safety To ensure processes and technology are aligned

11 What s up there..that isn t down here! The 3 Phases of the Support Process in the Aviation industry Source: TSIB 1.Guidance phase 2.Procedural phase 3.Emergency phase

12 1. Guidance Phase 2. Procedural Phase 3. Emergency Phase Express your concern about consequences SOLUTION STATEMENT EMERGENCY STATEMENT TAKE ACTION Question their understanding Give information others may not be aware of INCREASING CONCERN FOR SAFETY OF THE AIRCRAFT Source: TSIB

13 #Navigator #NI publications highlight the key points on BRM BRM can be a vessel s greatest strength or its weakest point Navigator must be able to filter relevant information, use good oldfashioned common sense, and keep in mind the most important screen onboard the window! BRM is never over. It must be part of a continuous improvement process underpinned by mentoring, open discussion and debriefing at the end of the voyage

14 #Navigator #NI publications highlight the key points on Communication Share information by any means, i.e. talk and electronic exchange Body language, tone and verbal communication can have an impact on the bridge team Speak the mind Observe and verify the actions of the listener COLREGs is a rule-based system Avoids inherent risks with voice communication

15 #Navigator #NI publications highlight the key points on VTS VTS has reliable and accurate coverage of the traffic situation in the area but don t forget to use your own eyes as well Clear communication depends on proper use of both technology and language The professional relationship with VTS operators is as important as those among the crew onboard

16 Key takeaways Seafarers do not come onboard with an Agenda to be involved with accidents Accidents do not happen by themselves There is no wrong place or wrong time in shipboard accidents Safety Barriers can fail and it is our responsibility to implement redundancies Behaviour of and Habits in an individual = Attitude can improve the safety culture on-board Safety is not the responsibility of the HSE(Q) department It is everyone s ALL Inclusive

17 TSIB (Marine) 24 Hr. Accident Notification No.: