SAFETY MANAGEMENT
SYSTEM
2008
CANADIAN
CANADIANCOAST
COASTGUARD
GUARDAUXILIARY
AUXILIARY- -PACIFIC
PACIFIC
International Safety Management
Code
as amended 2002
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Development of the ISM Code
• A number of very serious accidents which
occurred during the late 1980's, were
manifestly caused by human errors, with
management faults also identified as
contributing factors.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Herald of Free Enterprise
• One of these accidents was the capsize of
the ferry “Herald of Free Enterprise” on the
6th March 1987, killing 193 passengers and
crew.
• The prime reason for the accident was that
the bow doors were left open when the ships
sailed.
• The water rushed in, made the vessel
unstable and she rolled over.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Herald of Free Enterprise
• The crew member who was expected to close
the doors was asleep during his break, and
the First Officer who was supervising the car
deck, was ordered to the bridge for sailing.
• The bow doors could not be seen from the
bridge, and there were no indicator lights, so
the Captain assumed the doors were closed.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Herald of Free Enterprise
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Herald of Free Enterprise
• Lord Justice Sheen in his inquiry into the loss
of the Herald of Free Enterprise, famously
described the management failures as "the
disease of sloppiness” and identified
negligence at every level of the corporation's
hierarchy.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Development of the ISM Code
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Development of the ISM Code
• At its 16th Assembly in October 1989, IMO
adopted resolution A.647(16), Guidelines on
Management for the Safe Operation of Ships
and for Pollution Prevention.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Development of the ISM Code
• The purpose of these Guidelines was to
provide those responsible for the operation of
vessels with a framework for the proper
development, implementation and
assessment of safety and pollution prevention
management in accordance with good
practice.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Development of the ISM Code
• The objective was to ensure safety, to prevent
human injury or loss of life, and to avoid
damage to the marine environment, and to
property.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Development of the ISM Code
• The Guidelines were based on general
principles and objectives so as to promote
evolution of sound management and
operating practices within the shipping
industry as a whole.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Development of the ISM Code
• The Guidelines recognized the importance of
the existing international instruments as the
most important means of preventing maritime
casualties and pollution of the sea and
included sections on management and the
importance of a safety and environmental
policy.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Development of the ISM Code
• After some experience in the use of the
Guidelines, in 1993 IMO adopted the
International Management Code for the Safe
Operation of Ships and for Pollution
Prevention (the ISM Code).
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Development of the ISM Code
• In 1998, the ISM Code became mandatory,
for deep sea vessels.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
ISM Code
• The Code establishes safety-management
objectives and requires a safety management
system (SMS) to be established by "the
Company", which is defined as the shipowner or
any person, who has assumed responsibility for
operating the ship.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
ISM Code
• The Company is then required to establish and
implement a policy for achieving these
objectives. This includes providing the
necessary resources and shore-based support.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
ISM Code
• Every company is expected "to designate a
person or persons ashore having direct access
to the highest level of management".
• The procedures required by the Code should be
documented and compiled in a Safety
Management Manual.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Non Conformances /
Observations
• Major Non Conformance – Issues where
corrective action must be carried out
immediately to meet the ISM Code, failure to
do so would result in the withdrawal of the
Safety Management Certificate and/or the
Company Document of Compliance.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Non Conformances /
Observations
• Non Conformances – Issues where
corrective action must be made to meet the
ISM Code and/or ensure that the Procedures
in the Safety Management System onboard
are being followed correctly.
• Time limited.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Non Conformances /
Observations
• Observations – Issues where improvements
in the Safety Management System and
procedures are recommended.
• These do not have to be complied with,
however they should be considered.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Has ISM worked
• It is hard so say precisely whether ISM has
worked. However it certainly has contributed
to the fact that the number of ships over 100
GRT lost at sea has reduced year on year,
and the number of seafarers lives that have
been lost annually has dropped since 1996.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
The reduction in the number of
vessels losses
• Relatively few vessels actually sink at sea. The
vast majority of the following "losses" simply
refer to ships which are damaged and "written
off" by the hull insurers as being beyond
economical repair - described by underwriters
as "total constructive losses".
CANADIAN COAST GUARD AUXILIARY - PACIFIC
The figures below cover the entire global
industry and indicate the steady improvement in
safety performance since the 1990s.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Lives lost at sea (1995 - 2004)
• As in all transport sectors, lives are sadly lost
as a result of accidents. However, the loss of
life in shipping is in fact relatively modest, and
the overall trend is one of reduction in the
number of fatalities, which is all the more
impressive in view of the growth in the number
of ships in the world fleet.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
• The figures below relate to lives lost on cargo
vessels and cover the entire international industry,
which employs over one and a quarter million
people, plus many more employed in coastal
trades.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
How Does This Affect the
CCGA P?
CANADIAN COAST GUARD AUXILIARY - PACIFIC
How Does This Affect the
CCGA P?
• Whilst the International Safety Management
Code only applies to ships on international
trade, various ship operators in Canada have
voluntarily adopted, either because it is seen
as a good idea, or because events in those
companies have made it expedient to do so.
• As a result, for example, both the Canadian
Coast Guard and BC Ferries have their own
Safety Management Systems.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Queen of Oak Bay
Auxiliary
1
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Queen of the North
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Canadian Coast Guard
• The Fast Rescue Craft "G.R.1", dispatched in
response to an urgent SAR call, struck a rock
at about 0140 at a speed of approximately 30
knots.
• All three crew were thrown from the boat and
projected over the rock, landing in the water
on the opposite side. The boat, carried by
momentum, flew through the air some 18m
and came to rest at the water's edge also on
the other side.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Canadian Coast Guard Auxiliary
• The CCGA (P) are not immune from
accidents, and recently have had:
– two persons fall overboard.
– one of our vessels went aground due to
loss of situational awareness by the entire
crew.
– one of our vessels suffered a cockpit
window break when stuffing the bow in bad
weather, flooding the cockpit
CANADIAN COAST GUARD AUXILIARY - PACIFIC
The Safety Management System
CANADIAN COAST GUARD AUXILIARY - PACIFIC
The Safety Management System
• We have been requested by Canadian Coast
Guard to put in place a Safety Management
System.
• The system documents are to be found on
our web site, under Document Library, and
Safety Management http://www.ccga-
pacific.org/ccga-p/library/?action
=category&lcid=15
CANADIAN COAST GUARD AUXILIARY - PACIFIC
The Safety Management System
• The basic requirement for a Safety
Management System is “write down what you
do, and then do what is written down”.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
The Safety Management System
• The CCGA (P) already had many of the
policies, procedures and standing instructions
required for a Safety Management System,
but just not formalised in one suite of
documents.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
The Safety Management System
• The system covers the following subjects
Policy and Procedures
SAR
Operations
Contingency
Plans
Human
Resources
Training
Environmental
Protection
Maintenance
Purchasing
Communications
Non Conformances
& Observations
Personal
Safety
Forms &
Checklists
CANADIAN COAST GUARD AUXILIARY - PACIFIC
The Safety Management System
The biggest changes are:
• Use of checklists to minimise errors by
omission, whether during routine operations
or during emergencies to own vessel.
• The active encouragement to report
accidents, and non conformances to promote
continuous improvement.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Accident Reporting
• Accidents to our personnel and vessels can
often be caused by mistakes or errors which
can reveal omissions or mistakes in operating
instructions, training procedures.
• By encouraging stations to report these in a
“no blame” environment, we can find those
omissions or mistakes and put in place
improvements, and promulgate them to
reduce the chance of a future re-occurrence.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Record Keeping
• Formalise the keeping of records.
• This is a large part achieved by the SAR
Management System, which keep records for:
– the training and certification of our
volunteers.
– the operation of the vessels
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Lessons Learned
• Part of the system is a section online on
Lessons Learned.
• This is a summary of accidents that occur,
and identifying procedures that could have
prevented that accident, including new
recommendations that may be necessary.
• Whenever possible the station is not
identified, (although the accident report may
reveal this) and names are never to be used.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Audits
• Periodic audits of stations, station personnel
and vessels by CCGA (P) staff will be
required to ensure that the policies,
procedures and standing instructions are
being followed.
• There will also be audits by an approved
external agency.
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Results and Benefits
CANADIAN COAST GUARD AUXILIARY - PACIFIC
Results and Benefits
• The result and benefits of the proper
operation of the system will be:
– increased reporting of accidents
– detailed investigation of accidents and
publication of lessons learned
– reduction of accidents (and insurance?)
– improved and formalised record keeping
– consistency of operations across the
region
CANADIAN COAST GUARD AUXILIARY - PACIFIC