Assignment 2

Business and Law for the Shipmaster

Module Code: NAUT 8016
Programme Code: SNASC_8

The ISM Code

The ISM Code, in force since 2002, has been described as a paper tiger,
toothless and super bureaucratic. Others suggest that it has contributed to a
reduction in casualties at sea.

Word Count
2102

Submitted by
Dominik Muller-Tolk
National Maritime College of Ireland
April 2015

Contents
Introduction.......................................................................................2
The ISM Code.....................................................................................2
Safety Management Systems............................................................3
Checklists...........................................................................................4
Standard Operating Procedures.........................................................5
Company Attitude to ISM...................................................................6
Conclusion.........................................................................................6
References.........................................................................................8
Appendix............................................................................................9

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Introduction
The ISM code was adopted into SOLAS in 1998 in response to the
sinking of the Herald of Free Enterprise. It was intended to bring
about a fundamental change in seafarers attitudes towards safety
and pollution prevention. By 2002 almost all internationally trading
ships were required to be compliant. 13 years on and there are
widely ranging views on the code and how it has changed the
industry. Some have described the code as a paper tiger, toothless
and super bureaucratic, others suggest that it has contributed to a
reduction in casualties at sea. I think that, in a sense, both are true.
The principle of ISM has the potential to revolutionize safety at sea,
however the resulting Safety Management Systems (SMS),
implemented by companies, are often totally missing the point and
giving rise to the aforementioned paper tiger. It is sad to think that a
system with as much potential as ISM has been violated to such a
degree that, in my opinion, it is only a matter of time before we
witness the total constructive loss of a vessel, as a direct result of
the on board Safety Management System. This report aims to
consider what I feel are some of the main issues with the manner in
which ISM is currently implemented.

The ISM Code

The ISM code was adopted by the IMO through resolution A.741(18),
and became mandatory in 1998 by virtue of adsorption into the
SOLAS convention. There followed a fazed implementation, and
since 2002 the code is effectively mandatory for all ships.
One of the first things stated within the code is that it is based on
general principles and objectives and is expressed in broad terms
so that it can have a widespread application. (IMO, 1993) Hence
the code lays down a set of objectives that must be achieved, but
leaves it to the individual company to decide how they will go about
achieving said objectives. Section 1.4 of the code requires
companies to establish a Safety Management System (SMS), which
lays down a structured manner in which the company intends to
achieve compliance with the code.
Once a company has established an SMS, compliance with the ISM
code must be verified by the administration and a Document of
Compliance is issued to the company. Company vessels are also

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inspected to verify compliance and issued with Safety Management

Certificates. These certificates are both subject to periodic surveys.
(IMO, 2001)

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Safety Management Systems

The broadness of the ISM code, and lack of specific guidelines made
it somewhat challenging for companies to establish an SMS
satisfactory to the Administration. Certain specialists/consultants
quickly latched onto this as a business opportunity and began
selling off the shelf SMS systems. Unfortunately this necessitated
a one size fits all attitude to certain matters, which would better
have been established on a ship specific basis. The result is an SMS
system designed with the company in mind rather than the seafarer.
When these early SMS were developed someone somewhere
realized that a system of Standard Operating Procedures (SOPs) and
checklists is an easy way to satisfy the code and is particularly easy
to audit and inspect. This principle spread quickly and developed
into the mantra say what you do, do what you say, record it. This
further spiraled into the attitude, adopted by some authorities, that
procedures and checklists should be developed to such a degree
that anyone could walk onto the ship and carry out any job, simply
by following procedures. (Vallance, 2015) It seems to me that this
attitude is now becoming the new mantra of ISM. It is worth noting
that the word checklist only occurs once in the entire ISM code, in
section 7, where it refers to key shipboard operations concerning
the safety of the ship. In fact IMO resolution A.913(22), in offering
guidelines to administrations in the implementation of ISM, states
that Administrations are recommended to limit the development of
criteria in the form of prescriptive management system solutions.
This indicated to me that companies are encouraged to develop a
unique SMS specific to their own needs and circumstances.
Unfortunately too few companies seem to be doing this, preferring
to stick to the tried and tested checklist approach.

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Checklists
I am not suggesting, by any means, that checklists are a bad thing.
They are used extensively in the airline industry, and increasingly in
the medical profession, to great effect. A study published in the New
England Journal of Medicine showed that the use of a simple
checklist (appendix 1) during surgery could reduce mortality rates
by up to 50%. (Haynes, 2009) There are several important things to
note about this checklist; which in my experience, are often not the
case in shipboard checklists.
Every point on the checklist is critical and appropriate to the
operation and must be carried out every time.
Points are laid out in a logical sequence in the order in which
they will be carried out in the theater.
It is short and to the point, serving to draw a competent
surgeons attention to critical points s/he may have missed. It
is not an idiots guide to surgery.
Such a checklist is inviting to use as it is clearly intended to assist
the person using it. In fact it could be referred to as an aid de
memoirs rather than a checklist in the traditional sense. Critically,
there is nothing to be lost in using such a checklist. It cannot be
used as a stick to beat you with later on, and still allows for the use
of professional judgment.
In contrast, many of the checklists I have encountered at sea are far
more, an idiots guide than an aid de memoirs. They contain an
endless list of points to be covered encompassing every possible
eventuality; the completion of each point is indicated by a tick.
Many companies operate a policy where every point must be
ticked when completing the checklist. Even when this is not the
case every point must at least be read to ensure that nothing
important is left un-ticked. This does not sound unreasonable until
one is doing the reading and ticking for the Nth time, at which
point it feels totally pointless and stupid. Most people do not enjoy
tasks they consider pointless and stupid and are apt at finding ways
around them. What results is a tick the box attitude, which may lead
to a very tidy paper trail that looks great to auditors and inspectors,
but it has completely failed in its practical objectives on board ship.
Another problem with the inappropriate use of checklists is the
potential for hindering/removing a persons professional judgment.

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When people are forced to follow idiots guides there is a real

danger of them starting to act like idiots. A classic case I
witnessed on a ship was that of a seaman working aloft. He had a
permit to work and had completed the associated checklist, which
included ensuring that the safety line was securely attached to a
strong point on the vessel. In his case a pad eye on the bulkhead, in
such a location that he was free to move up and down the ladder
without having to adjust the safety line. When I pointed out the
shortcomings of this arrangement the seaman argued that it was OK
because he was complying with the checklist. Research done in the
airline industry in 2000 cited the improper use of checklists as a
primary of contributing factor in 15% of accidents. (Nicolalde, 2000)

Standard Operating Procedures

Another cornerstone of many SMS systems are Standard Operating
Procedures (SOPs). These generally go hand in hand with checklists
and would appear to stem from Section 7 of the ISM code. It would
seem to make sense that if someone has figured out the best way to
do a job, that others should be encouraged to adopt the same
procedure. If such procedures are written up and compiled in a
folder on board then this can clearly be of great benefit to the crew.
A problem arises when procedures are written up in the office and
enforced upon the crew without consulting them. Such was the case
on the, Dutch registered, MV Azoresborg. The vessel was alongside
in Bilbao, Spain, preparing to load cargo. The crew, under the
direction of the chief mate; were moving tween deck pontoons into
position when the chief mate fell overboard and subsequently died.
Amongst other things, the Dutch Safety Boards investigation into
the accident found that the working practice on board did not
coincide with the SOP laid down in the SMS, as this was found to be
unworkable by the crew. Although the company was aware of this
the SOP had not been changed. (Dutch Safety Board, 2013) It is a
tragic failing on the part of the company SMS that a life had to be
lost in order for the crews practical knowledge to be considered in
producing the SOP.
An industry with a long-standing history in the use of SOPs is the fire
service. (Fire SOPs, 2014) In recent years the shortfalls in their use
have been brought to light and a new approach has been adopted to
give the officer in charge more freedom to exercise professional
judgment. All SOPs have now been replaced with Standard
Operating Guidelines SOGs. The Fire Authority SOG Policy Document

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states SOGs are intended to assist fire service officers in dealing

with an emergency incident in an efficient, effective and safe
manner. SOGs underpin the officers approach to incident
management and decision making, building on his/her own
knowledge, skill and experience and should not be read or
interpreted as restricting the officers power to exercise judgment/
take such action as he/she sees as appropriate in light of the
circumstances prevailing at the emergency All SOGs are
underpinned by a risk assessment, but officers and crews are also
trained in dynamic risk assessment which is carried out on a
continuous basis and facilitates a safe deviation from the SOG as is
deemed necessary. (National Fire Council of Ireland, 2014) Although
this system may not translate directly to the shipping industry, I do
feel that we can learn from it and that considerable improvements
can be made to our current use of SOPs.

Company Attitude to ISM

The cornerstone of good safety management is commitment from
the top down (IMO, 1993)
I feel that a major stumbling block of ISM is the attitude of shipping
companies. Many companies seem more concerned with passing
audits than with improving safety for seafarers. This seems starkly
evident from the Global Marine Insurance Report 2014 (Seltmann,
2014) which indicates clearly that the insurance cost of marine
causalities has not significantly dropped since the introduction of
ISM. If ISM were doing what it says id does one would have expected
these figures to slope downwards as safety standards improve. The
ISM code requires companies to show that corrective action has
been taken in response to incidents on board. This action tends to
be in the form of issuing more Checklists, SOPs and fleet standing
orders, telling the seafarer not to do that again. Rarely do
companies consider actively training crew to increase competence
and the standard of seamanship, or changing a ship schedule to
make it possible for seamen to comply with SMS requirements, such
as hours of rest. In my experience the feeling amongst seafarers is
that once the paperwork looks good, and the job gets done, the
company do not really care too much about what happens on board.
I do not think that ISM will have any real impact at sea until this
attitude changes both ashore and at sea.

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Conclusion
I feel that ISM was a much-needed system with commendable
targets. I do not feel that the manner, in which companies have
chosen to implement ISM, in producing their SMS, has been very
conducive to achieving those targets. The manner in which SOPs
and checklists are used, to mitigate risk, itself risks reducing rather
than increasing standards of seamanship and therein causing a
whole new range of potential accidents. In this regard I feel that the
shipping industry is guilty of trying to re-invent the wheel. Many of
the problems we face today have already been faced and overcome
by the aeronautical and medical professions and by the fire service
and we should take the opportunity to learn from their mistakes.
Otherwise I suspect it is only a matter of time before we, like the
airline industry, find an increasing number of accidents caused by
our own Safety Management Systems.

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References

Dutch Safety Board. (2013). Fatal fall overboard during loading

operations. Dutch Safety Board.
Fire SOPs. (2014). About fire SOPs. Retrieved 03 12, 2015, from Fire
SOPs.com: http://www.firesops.com/about-fire-sops/
Haynes, A. B. (2009, 01). A surgical safety checklist to reduce
morbidity and mortality in a global population. The New
England Journal of Medicine.
IMO. (1993). ISM Code. IMO.
IMO. (2001). Revised guidelined on implemintation of the ISM code
by administrations. IMO.
National Fire Council of Ireland. (2014). Fire Authority SOG Policy
Document. National Fire Council of Ireland.
Nicolalde, R. (2000, 03 15). Improper chechlist use as a factor in
aircraft accidents and incidents. Retrieved 03 11, 2015, from
flightdeck.ie.orst.edu: www.flightdeck.ie.ost.edu/Electronic
Checklists/HTML/accidents.html
Seltmann, A. (2014). Global Marine Insurance Report. Hong Kong:
IUMI.
Vallance, K. (2015, 03). When ticking the fight boxes is not enough.
Telegraph, p. 26.

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Appendix

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