Learning from error
Governing: MCA The Human Element, 'Making mistakes'; SI 2012/1743 (MAIB); REG Yacht Code Part A Chapters 23A and 23B.
From blame to just
The MCA guide describes a shift in safety-critical industries from a blame culture to a just culture, founded on two principles applied to everyone at once:
- Human error is inevitable. Policies, processes and interfaces must be continually monitored and improved to accommodate errors.
- Individuals are accountable for their actions if they knowingly violate safety procedures or policies.
The first needs a reporting system people trust enough to disclose to. That trust grows, or dies, according to how the second is applied: how the organisation defines, investigates and attributes accountability for what people report.
Honest mistake or negligence?
The guide cautions that the line between an 'honest' mistake and 'negligence' is hard to draw, because experienced people break rules or get distracted for organisational reasons. It warns that hindsight bias:
- oversimplifies causality;
- overestimates how obvious the outcome was;
- overestimates the role of rule violations;
- overestimates the relevance of information available at the time.
Its recommended approach is to investigate how the actions made sense to each person at the time, and what the organisation could change. Blaming and prosecuting honest error produces fear, discourages reporting and drives unsafe behaviour underground.
A practical sorting
| Behaviour | Response |
|---|---|
| Honest error (slip, lapse, mistake) | Support, learn, fix the system |
| At-risk behaviour (a shortcut that became normal) | Coach; find out why the shortcut exists |
| Knowing violation for personal gain or with reckless disregard | Accountability, proportionate discipline |
Reporting systems on a yacht
| Level | Requirement |
|---|---|
| Vessel under 500 GT | SMS under REG Yacht Code Chapter 23A |
| Vessel 500 GT and over | ISM Code under REG Chapter 23B (SOLAS IX) |
| Accidents | Report to the MAIB (for UK yachts) under the 2012 Regulations, and preserve evidence |
Within the SMS, near misses and hazardous occurrences are reported, analysed and acted on. A yacht with no near-miss reports is not a safe yacht; it is a yacht where people do not report.
Making it work
- Lead by example: report your own near misses.
- Thank reporters, publicly where they are comfortable with it.
- Investigate systems, not just people.
- Feed back: show what changed because of a report.
- Be consistent about genuine violations, including by senior crew and the captain's favourites.
WARNING — The owner's reaction Owners and management companies sometimes want someone blamed after an expensive incident. The master and HoDs need to defend a fair process, or the reporting culture dies with the scapegoat.
TIP — Debrief format What happened? What did we expect? Why was there a difference? What will we keep and what will we change? No names in the minutes unless needed.