Safety Systems and Processes for Safe Navigation

Capt Kunal Nakra

21 June 2018

Safety@Sea 2018

Singapore

2

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

Displayed at MPA’s VTIS Control Centre

Navigational Safety is our Culture!

4

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