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Safety Systems and Processes for Safe Navigation
Capt Kunal Nakra
21 June 2018
Safety@Sea 2018
Singapore
Director Transport Safety Investigation Bureau (TSIB)
Deputy Director Marine Safety Investigation
Capt. Kunal Nakra
Senior Investigator and Head / Technical Support
Deputy Director Air Safety Investigation
Senior Investigator
Senior Investigator and Head / Training
Snr. Exec
Senior Investigator
Senior Investigator
Senior Investigator
Investigator
TSIBSINGAPORE
Senior Investigator
Capt. Jamaludin
Jaffar
Exec
InvestigatorCapt. Xiao Shouhai
Mr Yeo Lee Chuan
Advisor Transport Safety Investigation
Bureau (TSIB)
Senior Investigator and Head/Operations
Exec
Safe Navigation• COLREGs – What to do
• STCW – How to do
– Principles of bridge watch keeping and Bridge Resource Management
• ISM Code
– Remote VDR audits - monitor what is being done
5
COMPETENCY
Skills
Knowledge
TRAINING INTERVENTION
STCW
Attitude / BBS
Human Performance
Accidents
People factorsShip
Factors
Externalinfluences
Environment
Organisation onboard
Shore-side
management
Working and Living conditions
L E
L
S
H
Software Environment
Hardware
Liveware
Central Peripheral
workstation, seats,
displays, controls
procedures,
manuals, checkliststemperature, noise,
vibration, air quality,
weather
personalities,
relationships,
communication
styles
LL – Physiological conditions,
knowledge, skills
• ISM Code – requires, and allows for, identification ofhazards and assessment of risks, for e.g.
– Bridge watch composition
– Bridge layout – both Radars clustered on the same sideof the Bridge
– ECDIS on the other side of the Bridge
– OOW making bell book entries on chart table becauselocation near telegraph console does not (have a light)and allow him to place the book properly
– Is the VTS an INS, TOS or NAS
Hazard identification
Mental Models
• Formed by unique experience of an individual andgroup think of how it is “normally done”
• Are limited by assumptions about oneself and howone understands others (and the world)
– Intra - bridge– Inter - bridge– Ship - Shore authority– Ship - Shore office
Formation and Limitations
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
The solution!
What’s up there..that isn’t down here!
1.Guidance phase
2.Procedural phase
3.Emergency phase
The 3 Phases ofthe Support Process in the Aviation industry
Source: TSIB
Question their
understanding
Give information
others may not
be aware of
Express your
concern about
consequences
SOLUTION
STATEMENT
EMERGENCY
STATEMENT
TAKE
ACTION
INCREASING CONCERN FOR SAFETY OF THE AIRCRAFT
1. Guidance
Phase
3. Emergency
Phase
2. Procedural
Phase
Source: TSIB
#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 old-fashioned 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
#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
#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
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 cultureon-board
• Safety is not the responsibility of the HSE(Q) department It is everyone’s – ALL Inclusive
TSIB (Marine) 24 Hr. Accident
Notification No.:
+ 65 - 96283593