Imbalances that develop between production and protection have been driving forces in causation of many previous disasters such as those of the Piper Alpha platform, the Exxon Valdez tanker, the Deepwater Horizon, the El Faro, and the NASA Columbia shuttle. Explain what is meant by an ‘imbalance between production and safety’ and why and how do such imbalances develop?
You are the Health, Safety & Quality manager for CMA CGM, the owners of the vessel, Ville de Mars. The executive committee of CMA CGM has requested you submit an executive summary of the Ville de Mars investigation findings (and actions taken) prior to their next meeting. The report is to be 1000-1250 words. You received an email from the Director of Operations (who serves on the committee) ‘requesting’ you to include the following in your report;
Summary of investigation findings and key causal factors of the incident.
Actions taken against the Master who failed to ensure the safety of his vessel and crew. [For the purposes of this assignment assume that the company subscribes to a ‘just culture’ policy]
Key corrective actions proposed and the timeline for these actions.
The rationale for the proposed corrective actions.
How you plan to measure the effectiveness of the proposed corrective actions.
Assurances, based on the corrective actions proposed, that this type of incident will not occur again in any vessel in the CMA-CGM fleet.
Note 1: The executive committee consists of former Masters & Chief Engineers as well as non-technical persons (who have a good understanding of the shipping industry).
Note 2: For the purposes of this assignment assume you have just recently completed the investigation. The MAIB report on the Ville de Mars will be your primary source of information, however, some of your responses will be based on your own analysis (as HS&Q manager) of the MAIB investigation findings.
The link to the MAIB report is
A useful representational perspective that can be applied to many incidents is James Reason’s ‘Swiss Cheese’ model. James Reason describes major system organizational accidents as a penetration of hazards through the system’s defenses or barriers.
a) Explain James Reason’s theory of organisational accidents.
What are the strengths and weaknesses (limitations) of his theory?
b) Using Reason’s ‘Swiss Cheese’ model, explain how the Ville de Mar accident developed and how the major hazards confronting the safety management system were able to successfully penetrate the barriers. In your answer describe what the relevant barriers (defences) were and why they failed.