Deviation from procedure is a frequently used factor in accident causation. This exemplifies the belief that safety can be created by means of formalisation. The ISM Code is based on this principle and is the main regulatory tool for ensuring the formalisation of safety and for promoting a safety culture. However, it is rarely discussed how procedures perform as a safety measure.
The Danish Maritime Accident Investigation Board has prepared a report on the proceduralisation of marine safety with the purpose of pointing to problematic issues that occur structurally in the process of moving from the idea of formalising safety to the implementation of this idea in practice.
In the report, the DMAIB concludes that safety management systems mitigate several types of risk besides the safety-related risk, inducing goal conflicts and making the system complex. Furthermore, it is concluded that procedures is a static tool to be used in a dynamic situation. This creates a discrepancy for seafarers to bridge on an everyday basis. In the wake of an accident this will be perceived as an anomaly and a causal factor. Rather than pointing to the seafarers' abilities and will to follow procedures, the DMAIB suggests taking a critical look at the performance of the procedures as a safety measure.
Report can be downloaded in PDF format here.