How to Read DP Incident Reports
Introduction:?I was once shocked by an industry statesmen proclaiming in a private dynamic positioning (DP) conference that DP incident reports were useless.?I was so shocked that I couldn’t reply, as I was trying to figure out what he meant.?I used the IMCA DP incident reports extensively in training myself and others, so how were they useless??Perhaps he meant that they were so generic and abstracted that lessons could not be learned from them.?Perhaps, he was referring to the sometimes large difference between the real incident and its report. Or perhaps, he was frustrated that we keep making the same mistakes over and over.?All these problems are real, but I think that the DP incident reports are still useful for learning problems and avoiding them.?They just can’t be taken at face value.?Let’s look at what DP incident reports are, and how they can be used.
Info Gathered:?DP incident reports have been collected and published by IMCA, and its predecessors, since at least 1994.?The idea is to capture and document problems, so the industry can learn to avoid those problems.?This noble motive competes with vessels trying to demonstrate good operation to customers and maintain a good reputation, so the reports are voluntary and anonymous.?The magnanimous sharing of valuable information is in competition with the selfish accumulation of competitive advantage and hiding of faults, so very few vessels actually report their DP incidents, and the faults and findings need to be made generic to prevent identification of specific vessels and manufacturers.?Historically, only a fraction of 1% of DP vessels provide such reports, and even on these vessels, most DP incidents are not reported.?This creates a bias toward major and unusual incidents that are not the report writer’s fault.?Worse, the people who write and submit the reports may not have been part of the investigation, may not have the background to understand the problems, and are often censored in internal and external findings.
Info Provided:?Annual incident reports were put out covering from 1994 on, and supplemented with occasional warning bulletins.?These reports provided a page per incident that usually included event trees, commentary, and evaluation of causes.?Each report tried to parse industry trends based on this very limited and random data.?In 2014, IMCA started putting out abbreviated spreadsheet summary reports and started issuing a few DP Event Bulletins each year looking at new incidents of significance.?So, the industry has IMCA DP information notes, annual incident reports, annual summary sheets, and event bulletins to learn from.?These are occasionally supplemented by other sources such as MTS and the informal network of DP professionals.??
What It Isn’t:?Some industries have statistically significant, objective, verified, failure data that can be used as a trusted source for decision making and process improvement.?When I was a reliability engineer for GE, I had access to the knowledge derived from large and long lasting industry databases and studies.?DP incident data is above the level of hearsay, but it isn’t unbiased, verified, or a significant sample size.?Many of us know DP incident reports that are very different from the actual problems, and DP incidents that were never reported.?Client confidentiality means that the errors and omissions will never be reported from us - that’s the vessel operator or owner’s responsibility.?That is preferred by the industry and safer for us.?The USCG probably thinks they are getting full DP incident reports, but that is unlikely.
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Mystery:?DP incident reports are not objective facts, but mysteries with unreliable narrators and missing facts.?They are not whodunits (who did it) or howdunits (how it was done), although those can be significant questions, they are whatdunits (what did it).?What went wrong, and what part of the overall DP risk management system needs updated to reduce this risk??These questions cannot be definitively answered by reading many of these reports, but encountering each problem and thinking through it increases the overall understanding of risks and potential solutions.??
Benefits:?Readers encounter problems that they have not experienced and should ask themselves how they would detect each problem, how they would avoid it, and how they should handle it, if it occurs.?The incidents aren’t objective data to be skimmed through, although they do contain objective data in unknown proportions, they are mysteries to be solved.?What is most likely??Why didn’t something occur??What statements might be mistaken??Why were they operating like that??How can I apply these lessons to my work??Read, ask, think, learn, apply, repeat.
Hazards:?While extracting additional information from limited data can be very useful for recognizing possibilities, it does not prove their existence and should not be taken as doing so.?The additional system and operational knowledge that a reader can apply to each problem can only be useful if the report is sufficiently complete and correct.?Sometimes the event, the summary, and the analysis lead to different conclusions.?So, if you really want to know what happened then you are out of luck, but if you want to learn about important potential risks that happen again and again, the reports are useful, if you are willing to look past the surface and think them through.??
Use:?I used to talk trainees through the incident reports, have them analyze incidents, and reviewed the annual DP incident reports for lessons learned for my colleagues.?If they cross-connected the power supplies, used non-redundant references, or DPed in heavy environments, beyond their redundant capability, was equipment failure the real cause of their incident? We would discuss the difference between known events and the reports, and keep this in mind when using the information.?They are important reminders and tools that can be used to keep our DP thinking sharp.?In another private DP conference, an incident report came in and I was so ashamed of my first thought (“Reports from the field are never 100%, so what is most likely?”) that I added little to the discussion.?None of us are 100% accurate or capable of perceiving the most important factors at a glance, especially when under stress, but good practice that is grounded in reality improves ability.?This knowledge, practice, and grounding is the value of DP incident reports.
Conclusion:?My mother loved murder mysteries and I’ve been interested in how things really work for most of my life, so this approach may not work for everyone.?The DP incidents can’t be bulldozed through, because they aren’t fully reliable.?Application and database use of the findings needs to be careful and grounded.?The DP incident reports are useful reminders of lessons that most of us should already know, and useful training tools.?We all forget, or get distracted by other priorities, and then another incident happens again.?Use the incident reports regularly to help avoid this tendency.?Share DP incidents with IMCA, when possible, so we can all learn together.
Advisor at Petrobras
2 年Very good!
A career path diverted by essential roadworks
2 年I have heard it say that IMCA Incident reports are over sanitised to the extent that it is not possible to arrive at the true root cause of reported incidents. Whilst I tend to agree with that sentiment, it has to be acknowledged that this is largely due to providing anonymity in order to encourage operators to provide reports. Yet IMCA's own statistics show less that 5% of the world DP fleet reports. This seriously impedes statistical analysis of incident causes. I have read incident reports issued by major national authorities which are obviously inadequate in their reporting and erroneous in their conclusions - likely due to a lack of understanding of DP Principles and the necessity to be seen to act. At least IMCA's technical expertise can help remedy the errors of the uninformed. Secrecy is a barrier to enlightenment; in misguided attempts at reputational protection internal safety reports can sacrifice veracity. I once read a complaint by a CEO that his company had lost out on a contract because a competitor did not count death as a lost time incident. The more people can be encouraged to submit incident reports to IMCA, the better the body of knowledge that can be drawn on, and the safer the industry can become.