WEAK SIGNAL – A TREACHEROUS DANGER by Capt. Michalis Fragkias
On the very big issue of accident prevention on merchant ships, in recent years, another dimension has been introduced in the Heinrich triangle which, for those who do not know, condemns that for one death corresponds to 10 serious injuries, 30 lighter, 600 near misses and 300,000 unsafe acts. The number of weak signals included in this new dimension cannot and has not been determined.
There is a big difference in the definition of weak signal, compared to near miss.
Near miss is something that has already happened and was treated effectively so as not to end in an accident.
Weak signal is an almost imperceptible indication of a possible or lurking situation that could develop into a near miss or even an actual accident in the near or distant future.
Weak signals may exist for some time, in the space around us, before they develop into an event, if not addressed. This is because they are quite difficult to determine or estimate.
We can feel the weak signal as a small change in the surroundings, such as a strange noise that did not exist, a special smell, a strange vibration in a machine, pump, ship movements, an instrument with a strange indication or even practices such as decisions that do not comply with regulations or procedures or even stewardship that allow unsafe situations to develop.
In all Safety Management Systems (SMS), a procedure must be included that determines the identification, investigation and management of weak signals.
Officers and crew should be informed and trained to effectively deal with any weak signals they sense, or any change that makes them worried.
There are many cases (case studies) where near-misses were prevented because the weak signals related to them were perceived and their causes were investigated and managed effectively.
We should take into account that weak signals are directly related to the concept of Situational Awareness, a key element of which is to never be complacent but always to be vigilant, alert and worried about what is happening around us and about situations that could create problems or unsafe conditions.
This is achieved using all our senses, available technology and that sixth sense that causes concern that something is wrong or that something is not as it should be.
This concern or instinct based on knowledge, experience and responsibility can help us recognize and understand the environment and potential hazards including weak signals.
According to SHELL’s “Maritime Partners in Safety” scheme, Chronic Unease, it is a permanent state of vigilance to identify potential hazards on board ships.
Chronic Unease is the creation of a culture in which individuals are suspicious of weak signals and manage them effectively.
The tendency to downplay a risk, which we are somehow used to, is defined by SHELL as a “mind trap”. This is a mental state of complacency, perfectly linked to frequently repeated processes without the slightest incident (Normalization – Routinization).
Unfortunately, in quite serious shipping accidents, the pre-existing weak signals were either not noticed or ignored. In the process of investigating the sinking of the Titanic, in which 1500 people died, it was reported that the bridge was informed by the engine room of a sharp drop in seawater temperature. This happened a few minutes before the impact with the iceberg but no one paid attention (the sudden drop in water temperature had to do with the presence of the iceberg near the ship).
In general, there is a tendency to ignore something disturbing that we perceive, finding an explanation that satisfies our mental model at this point in time!
In general, the cycle from the identification of a weak signal to its positive management includes 3 stages.
1. The weak signal must be observed and reported. This means that there is a relevant procedure in the company’s Safety Management System.
2. The weak signal should be investigated and the possibility of developing into an undesirable or dangerous situation should be assessed. At this stage the investigation and decision on what to do should not be by the person who reported the weak signal.
3. After reporting the relevant weak signal to the decision-making level, those responsible undertake the investigation, depending on its importance and make decisions for effective response.
There are many studies and reports related to weak signals from which useful conclusions or lessons can be drawn. Several companies include in SMS statistics with reports and related weak signal management, in addition to reports of accidents, injuries and near misses reporting
It should be mentioned here that weak signals do not exist only on ships. They exist in all organizations, businesses, in phases and activities of life, at home, in the car and in people’s personal health. In all these cases, what makes us worry must be taken seriously in mind and managed effectively. And let it turn out that we were unfairly concerned or that it was not something that would cause a problem.
But let’s get back to the maritime reality. I’m sure most of the traveling (or sea-going) readers will have many examples of detecting and managing weak signals on the ships they served.
In the modern transition from re-active Safety I to pro-active Safety II, the reporting and management of weak signals play a key role in preventing accidents and unsafe conditions.
To make it more understandable to those who do not have maritime experience, I will mention a personal (one of many) case study:
“Almost 50 years ago, I was serving as Able Seaman on a 26,000-ton bulk carrier of the Stavros Livanos Company (in which, for those who don’t know, I worked for 58 years). The ship was sailing across the Pacific Ocean from Japan to the west coast of the United States. I was a Look-out during the night shift 00.00 – 04.00. Officer on the bridge was a good and educated young Second Mate from the Aspropyrgos Maritime Academy. It was a quiet evening, good weather and very good visibility. The watch at that time for the skapoulos, (i.e. the A.B look-out), was done on the shelter wing outside the bridge area! At some point I noticed a strange smell of oil. I immediately reported it to the Officer of the watch. Capt……., outside I smell of oil. “Let me go Michael,” he told me. Oil in the middle of the ocean; Are we a tanker ship? He did not get off the wheelhouse and paid no further attention. But I was smelling oil. I asked permission to go down to smoke. I stepped out from the left side on the main deck. There was something going on in the deck’s side. I put my hand in and took it out pitch black from FUEL oil. What’s next? Chaos. The fuel had overflowed from the bows bunker tanks, in which the engineers had turned on heating but forgot to turn off. The weather began to deteriorate and with the ship slightly rolling the deck, became pitch black. Two days we were cleaning. Fortunately the fuel oil did not spill out of the ship. Otherwise? Tanker are we Michael?”
Conclusion and advice: Never, ever ignore that “little bell” that tells you that something is wrong! And not only don’t ignore it, but make sure it manages effectively.
