Why Seafarers are Reliant on Procedure Manuals

When Captain John Rose, director (maritime) of the UK charitable trust CHIRP, reported on the lack improvement in the standard of Marine Operating and Maintenance Manuals after 10 years, he received this response from a doctorate student:

There are a number of contributing factors towards a seafarer’s reliance upon procedures in operating and maintenance manuals: failure of training and certification to keep pace with the rate of change of technology; rapid movement of Officers through ranks; reduced staffing levels; and the large breadth of technologies that seafarers (particularly engineers) are now expected to be fairly expert in, is another growing problem. These affect stress, fatigue and reduced retention as well as error. Such factors contribute towards a knowledge gap, the absence of a solution to such factors will ensure that procedures remain critical to safety throughout seafarers’ careers.

Industry reliance upon procedures emphasizes the need to properly understand the way in which seafarers utilize operating and maintenance manuals. It has long been established through academic research that operating and maintenance procedures need to serve three primary functions: selection, inference and switching (from instruction to task). These basic functions are underpinned by complex processes which either promote or mitigate human error.

Operating and maintenance manuals are often pre pared by non-seafarers working for manufacturers, they may perhaps have an in-depth knowledge of their own equipment but have little understanding of technical communication, task analysis and level of seafarers’ prior knowledge [STCW]. This leads to a failure of both user navigation and comprehension of the procedure. There is no immediate communicative feedback to the writer, so procedures are always a negotiated meaning and don't necessarily translate to what the writer thinks is being communicated. 

Alternatively, there are manuals produced by specialist technical authors with little system knowledge other than that passed to them by the manufacturer (often in a foreign language). These manuals tend to be very aesthetically pleasing with a high degree of graphic design but of poor technical content.

My current Doctoral research was triggered by the earlier CHIRP report, “Marine Operating and Maintenance Manuals – Are They Good enough?” Commencing research in 2010, it became clear quite quickly that although standards and guidance exist, none address the critical questions of supporting systematic thinking (filling the knowledge gap) and the mitigation of human error. The answers lie within an eclectic body of research spanning risk analysis, technical communication, philosophical theories of semiotics, cognitive loading, constructivism and many other such subject matters considered outliers within the maritime professions. 

In early 2013, a pilot study was conducted using two groups of seafarers to validate two rule-based error-provoking markers identified through literature review. These results proved promising and with the main study scheduled later this year, it is hoped that 2015 will add some clarity to the issue.

Standards of operating and maintenance manual content is one issue, regulatory failure is another. The IMO Maritime Safety Committee circular MSC.1/Circ.1253 “Shipboard
Technical operating and Maintenance Manuals” states that the enforcement of accurate and up to date operating and maintenance manuals could be achieved through the mechanisms of the ISM Code. This is a wholly reactive measure and without a clear regulatory foundation, burdening shipping companies with such a responsibility is an unfair and ineffective strategy of self-regulation.

There are currently very serious issues of control associated with regulators failing to ensure that operating and maintenance manuals are fit for purpose when issuing machinery certification. The 2012 NOMAD project com - missioned by 14 EU member states examined the noise related content of instructions supplied with machinery offered for purchase in the European Economic Area (EEA). The project reviewed 1,500 sets of instructions within 40 machinery groups from 800 manufacturers. 

The information in these instructions was analyzed to determine compliance with the European Machinery Directive, and assess the quality of information. The report concluded that the general state of compliance of machinery instructions was found to be very poor: 80 percent of instructions did not meet legal requirements. In fact, the report further stated that 8 percent of the documents surveyed were not even in an official European Community language. 

One may be forgiven for questioning the competence of EU authorizing bodies for presiding over such an industrial level of failure. To supply inadequate operating and maintenance manuals is as dangerous as supplying faulty tools. Incidents such as the Isle of Arran, P&O SL Aquitaine, CSL Pacific and the Arco Adur are testimony to this. However, with a lack of validated submissions for the IMO to consider and failure to regulate the current standards of operating and maintenance manuals, perhaps we need to accept that (from seafarer to delegate) there is a need for collective responsibility to bring about change.

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The aim of CHIRP is to seek out root causes, identify the lessons learned and to consider how best this information can be used to prevent reoccurrence elsewhere in the maritime industry. CHIRP does not seek to apportion blame to any company or individual(s). The term ‘whistleblowing’ is not one used in CHIRP as that is often used to cast blame on an organization or an individual.  

A report can be generated either online (through a secure website), as a written report (via post/Freepost), or by telephone to the Charitable Trust’s office in Farnborough England.