- the proposed changes would not have affected the accident with Combat boat #848
- the proposed rule to implement was neither understood nor analysed by the Swedish Accident Investigation Authority, and
- the proposed changes most likely affect safety culture negatively, as the changes prescriptive nature of safe and unsafe sea areas contradicts the general need to develop the crews’ risk understanding.
Friday, 13 April 2018
Safety on board naval vessels – does the specific operational conditions make safety efforts and safety lessons based civilian maritime work irrelevant?
Today, the safety work on military vessels is influenced by civilian approaches, regulations and codes. This influence introduces important civilian lessons into naval vessel design, but can also potentially be in conflict with military task solving. One regulation, which is largely influenced by IMO codes, is the Swedish Military Ship Code formulated by the Military Safety Inspectorate. Risk management could present an approach for investigating if the civilian influence on the code leads to decisions and solutions that hinder military task solving. IMO’s Formal Safety Assessment (FSA) is a risk-based approach for such an investigation.
The effect of using IMO and classification society-based codes for the design of naval vessels has been found to assist in the engineering process and to guarantee a basic level of safety. However, the civilian naval engineering practices are not sufficient for guaranteeing survivability and thus safety in military cases. However, there could be a potential conflict between the rules that prescribe aspects of vessel use, and military task solving.
In 2010, the Swedish Navy introduced a new rule re-defining the sea area of safe operation for respective classes of vessels. The new rule is based on an EU directive developed for European passenger vessels. The Swedish Military Ship Code is not intended to limit military (wartime) operations. However, a Swedish naval vessel does (as most naval vessels do) always operate under a basic readiness level and therefore under military conditions. The potential conflict between rules that limit vessel use (rules for areas such as operations) and military task solving have not, so far, been investigated.
The objective of the published article was to describe the investigation performed and to focus on the meta lessons identified by applying the FSA structure to a military maritime safety case. The investigation analysed the safety level in the Swedish navy as a result of the regulation on sea areas of safe operation. The objective of the described investigation was to investigate the safety impact of the new sea areas given the Swedish Navy’s concept of operation, staffing structure, and competence. An additional objective was to determine if the rule is cost effective, and whether, if needed, sufficiently low risk can be achieved by an alternative rule, which has less impact on the Navy’s operations.
The investigation identified that it in the period studied there have been safety issues leading to risks higher than negligible. For the studied severe accidents, the identified risk levels are a result of decisions made on-board when solving military peacetime tasks. However, the quantitative analysis of the nine severe accidents shows that not only the human element affect the probability of an incident. Thanks to the military education, training, organization and personal safety equipment severe incidents that involve high speeds, cold water and vessels lost or severely damagedalso often result in relatively low levels of consequences. Such incidents would typically lead to multiple fatalities for a civilian vessel.
The less severe incidents leading to injuries were most often a result of maintenance work performed on-board independent of the vessel operation. Therefore, in the material, there is a low number (<1) of accidents per year related to the vessel operation with potentially severe consequences and a higher number (>5) of accidents per year related to work on-board leading to injuries.
An investigation in accordance with the FSA, as performed in the described investigation, in qualitative terms analyses both the effectiveness and the effects of the rule. Therefore, an analysis
can show if a regulation affects safety in the manner intended and if there are other means by which the regulation affects the operations. However, in order to reach high validity, the FSA approach needed to be supported by more explicit support on uncertainty treatment and propagation and by a peer review with strong contextual knowledge. The quantitative risk estimated was not, and should not, be in focus.
The investigation particularly highlights the need for an approach for analysing proposed safety changes both in terms of effectiveness and in terms of suitability. In 2008, after the accident in which Combat boat #848 was lost, the Swedish Accident Investigation Authority recommended 11 changes. One of those changes was to implement new sea areas of safe operation according to the civilian regulation; in addition, there were several regarding strengthening the crews’ risk understanding. In this investigation, the recommendation to implement new sea area limitations is shown to be problematic in several ways:
From this example, it can be identified that the effectiveness of the proposed changes must be analysed by the Accident Investigation Authority or by the Armed Forces. The result of an accident investigation is a set of recommendations; however, these recommendations must be analysed before they lead to new rules, particularly if the recommendations affect operation types that the Accident Investigation Authority have limited insight into. It must be ensured that new rules have the intended effect on safety; this responsibility must be taken by the organization deciding the new rules.
This investigation has shown that the recommendations to change the sea area rule led to a rule that has very limited positive effects, possible far-reaching negative effects and substantial operational costs.
The safety level for a vessel is a complicated relationship between several factors including the vessel type, the quality of the vessel’s maintenance and the vessel operation (seamanship). This finding is also identified in this investigation. It is stated in earlier studies using the FSA approach that “human error problems” can and must be included. However, this study shows that human element strengths also can and must be included, as they had an important impact on the link from incident to consequence and are an important part of the seamanship. The study identified that the high level of safety training of the persons on-board was important to making sure that severe incidents often lead to relatively limited or minor injuries.
An approach in accordance with the FSA structure is suitable even for areas outside the IMO’s typical scope. The FSA structure does not limit the approach to operational conditions as defined by civilian ships. However, the analysis needs to incorporate operational knowledge suitable for the area under study.
The military vessels’ concept of operations differs from civilian ships in such way that civilian safety rules can become irrelevant.
The case examined also raises many questions such as about how to articulate the actual difference between civilian and military contexts, especially in peace time; about how risk to individuals should and could be compared to national security risks as a result of operational limitations put on armed forces; and about how different types of hazards combine to create risk. These types of questions that are dependent on the connections between the organizations and technology under study and the Swedish society in general are largely here left unanswered. However, answering such questions without concrete examples easily becomes abstract and will therefore not affect decision makers. The hope here is that the case studied and described can be used as one example that together with other suitable and complementing examples can assist in making future conclusions that assist decision makers and increase the understanding of applicability and validity of risk management in state safety and security issues. However, it is unlikely that the perspective on risk presented by the FSA alone can answer such important and complex questions. Compared to traditional risk analysis of technical systems the FSA covers more aspects of the socio-technical system studied. However, the analysis power provided is not, and not intended to be, an approach that can be said to fully represent risk and safety in socio-technological systems.
Also more specifically in relation to this case further work, both in regard to how central parameters should be measured or calculated and more overarching questions, is needed. In relation to the definition of central parameters, it is important that such definitions (such as how to calculate the number of ship years) are clear and communicated. Two overarching questions that need further investigation are how risk limits in relation to military tasks should be defined and how to define and assess operational costs in general and quantitatively.
The extra risk introduced by antagonistic threats is not assessed, and the crews have not been tested in relation to such conditions. Therefore, the negative effects of the rule (as a result of the civilian and commercial background), which reduce the crews’ need for continuous risk assessment on-board, could be even more harmful to war-like military operations than what is shown in the material studied.