At the start of this consideration, I would like to bring you up to date on our current investigation into the approach to the Corona crisis. From the point of view of the Safety Board, I would then like to reflect on the very current theme of ‘countervailing power’. Finally, I would like to draw your attention to a field of work of the Safety Board that does not always receive the attention it deserves: the Dutch shipping industry, a sector where there is certainly room to achieve safety improvements.
For the Dutch Safety Board, too, COVID-19 has been the overriding factor, since March 2020. It has influenced our work as an investigation body in many respects. However, it is also affecting us all, on a personal level. It has had direct consequences for our health. Right from the start through to the present day, it has led many of us to work from home. The same home to which other family members have also been forced to move their school and work activities. It has led us to seek safety by locking ourselves up in own our homes; a situation we could never have imagined would last so long. It is however astonishing how much of our work could be continued from home, with such success. In 2020, we spent less time on the road visiting accident locations, and were unable to speak to the persons involved in the various occurrences whom we wished to interview, live on location; but our work has nonetheless continued. Our staff deserve considerable praise for their efforts.
The COVID-19 investigation
The agenda of the Safety Board has been heavily influenced by COVID-19, over the past year. In the spring of 2020, the Cabinet asked us to evaluate the approach to the COVID-19 crisis in the Netherlands. This request tied in well with the initial investigation we had already launched, and on the basis of which the Safety Board decided to carry out this investigation. We also added a number of our own footnotes. For example, we have opted not to restrict ourselves to the Cabinet's approach. After all, the pandemic was tackled in many different places by very many different parties. ‘The Hague’ was certainly an important player, but was not all-decisive. In addition, we opted to carry out an investigation rather than an evaluation. The term evaluation inherently includes an ‘appreciation of the result’, and that is not a task for the Safety Board. Our aim is to learn lessons from occurrences in order to improve ourselves as a society, in managing risks. We hope to contribute to protecting the population in areas in which they are dependent for their safety on government, businesses or organizations. Our COVID-19 investigation is therefore focused on learning lessons for future (health) crises.
Right from the start, we also made it clear what we would not be investigating. We will for example not include the medical actions taken in tackling COVID-19 in our investigation. The economic consequences and the support measures aimed at mitigating those consequences will also not be part of our investigation. Both of these aspects are clearly beyond the scope of operation of the Dutch Safety Board.
"Our COVID-19 investigation is focused on learning lessons for future (health) crises."
The COVID-19 investigation currently in progress is divided into several phases. There are two separate sub investigations. The investigation into phase one considers the preparations for a pandemic and the first wave of COVID-19 in our country. The investigation into phase two considers the second wave that emerged after the summer of 2020, and continued through to April of this year. In both sub investigations, the most important events and decisions from each phase will be closely examined. Our aim is to complete the first sub report this year.
To date, we have enjoyed excellent cooperation from many parties and actors that have played a role in the overall COVID-19 approach. We are still in the process of holding interviews with many of them, but the open attitude of the interviewees clearly assists us in our work. It is of huge importance that the culture of openness in government remains at the forefront, and that our investigation is welcomed as a learning opportunity.
Countervailing power?
In a period in which the discussion of ‘power and countervailing power’ occupies such a central position at the heart of Dutch Government, the question arises whether the Safety Board is part of that ‘countervailing power’. Whether or not justified, many independent institutions are seen as occupying just such a position. The Board is not a countervailing power in the sense of an institution that takes up a position in opposition of the three powers. At the very least, the Dutch Safety Board aims to contribute to the checks and balances that help keep a system vital. It is our social task to encourage the learning of lessons from ‘occurrences’. In the Dutch Safety Board Act, occurrences are defined as events that result in personal injury or fatalities, or damage to property or the environment. In all our investigations, we go in search of the direct and underlying causes of the occurrence, in order to learn from them, and to reduce the risk of recurrence or to mitigate the consequences. Wherever necessary and meaningful, we also issue recommendations, often addressed to members of the national government, but our recommendations can also be addressed to other levels of government or organizations or businesses. From our independent position, we aim to be a constructive power that contributes to greater understanding and improvement. We must prevent institutions that are seen as holding power from adopting behaviour aimed at avoiding risks, so that the willingness to speak openly about their mistakes and to learn from them starts to disappear, almost before we know it. That risk is always present. Against that background, at least let the ‘new culture of government’ be a learning culture, in which openness is encouraged and rewarded. This is a theme that is often reflected in our reports, for example in the report published last autumn ‘Wrong-way driving accident on the A73 motorway: learning from road traffic accidents’.
"From our independent position, we aim to be a constructive power that contributes to greater understanding and improvement."
Contradiction
Although independent investigation is not designed to represent a countervailing power, it is based on contradiction. Undertaking careful, independent investigation means that in our work, we must at all times remain alert to the risk of prejudice, tunnel vision or drawing conclusions too quickly. We have taken various structural measures to bring this about. Firstly within the Board itself, where the (associate) members, with their diverse backgrounds and knowledge, reflect critically on investigations at every stage of the work. In 2021, the Board will welcome four new members, each with a fresh new look and a range of areas of expertise.
Within the investigative teams, in addition to the necessary technical knowledge, we also consider diversity in terms of experience and background. Over the past few years, we have brought on board new expertise in such areas as administration, culture, finance and the digital society. The Research & Development team advises on investigative methods and assists us in monitoring our quality. For our larger investigations, we first establish a supervisory committee, with external experts who observe critically at various points throughout the investigation process. Prior to the publication of an investigation report, there is a consultation procedure in which anyone involved in the occurrence and the investigation is given an opportunity to issue comments. Together with the report, we also publish the consultation comments including an overview of the way in which any comments and criticisms were dealt with. This approach means that from both inside and outside the Dutch Safety Board, there is room for contradiction and criticism of our work.
Underexposed: shipping
The Dutch Safety Board investigates occurrences in which safety is threatened, in practically every sector of society. Prior to the establishment of the Board, now more than 15 years ago, there were sectoral investigation committees, in particular for the transport sectors. Our investigations into occurrences in aviation almost without exception enjoy considerable media attention. The numerous occurrences in the shipping sector receive clearly less attention. Based on international treaties, the Dutch Safety Board has a statutory obligation to investigate accidents involving sea shipping. In 2020 we carried out 93 such investigations. The figures show that almost half of the statutory sea shipping accident investigations relate to industrial accidents. Some of these accidents lead to limited but permanent injuries. In other occurrences there is not only a potential for fatalities, but sadly in truth also a fatal outcome.
Shipping accidents rarely hit the headlines. This may be because many of the occurrences take place out at sea, or in far away ports, or perhaps because many of the crew members on board Dutch ships are not Dutch nationals. Nonetheless, all these developments deserve our attention. The shipping sector is facing considerable international competition. Time is a major cost factor. As a consequence, there is often huge time pressure to complete the various tasks, such as loading and unloading, as quickly as possible. Shipping routes are sometimes not adjusted according to severe weather conditions, even if such a route change would be preferable from the point of view of safety; instead, making the time slot in the port of destination receives more priority. Faced by this unrelenting pressure, safety is sometimes neglected.
A great deal is laid down in international laws and regulations, but this constant economic pressure is imposed from shore. At the same time, the regulatory task that has been entrusted by the SZW Inspectorate of the Ministry of Social Affairs and Employment to the Human Environment and Transport Inspectorate (ILT) offers limited possibilities for checking compliance for example with compulsory break times. Another worrying development is the ‘outflagging’ of ships by Dutch shipping operators, a term that refers to the gradual transfer of all their ships to the flag of other countries where supervision is less strict.
In other words, attention for safety is under pressure from economic interests. The Safety Board considers it its task to constantly demand further attention for safety. Over the past year, the Safety Board has attached more recommendations to its investigations in the shipping sector. By means of these recommendations, we offer suggestions to the Minister, the inspectorate, shipping operators or the sector organizations for improving safety. In addition, over the past two years, we have on two occasions issued an early warning in connection with acute risks to shipping. Once in the context of the investigation into the container ship MSC ZOE, and once again during the investigation into the capsizing of two beam trawlers. We plan to continue this active approach over the coming year.
Serious accidents occasionally do not receive the attention they deserve because ‘it all turned out all-right in the end’. One example was the collision between the river cruise ship Viking Idun and a chemical tanker during the night, while sailing on the Westerschelde. Despite suffering serious damage, both vessels were able to be towed to a nearby port, and the 171 passengers were taken into safety. Our report into this investigation appeared at the end of 2020. Although the river cruise sector has grown rapidly, it is very doubtful that the understanding of safety has grown at the same pace. The safety of inland shipping deserves greater attention, also from us. The Safety Board is under no legal obligation to investigate accidents in this sector. Many issues remain unreported, or are not notified by the relevant inspectorate. Nonetheless, over the past few years we have been involved in a number of major inland shipping investigations, including the collision with the weir on the Meuse river near Grave, in dense fog. Over the past few years, Rijkswaterstaat (Directorate-General for Public Works and Water Management) has recorded around 700 accidents each year, of which around 100 can be labelled ‘significant’, but itself admits that the figures are far from complete. Our efforts at present are aimed at ensuring that we are immediately informed of any serious occurrences in inland shipping. Such notification will enable us to carry out investigations more often, where necessary.
COVID-19 has made life particularly difficult for ships’ crews. Due to travel restrictions and other COVID-19 measures, many were forced to remain on board their ship for sometimes up to six months longer than permitted by the rules. This fact could represent a serious threat to safety on board. My eye was recently drawn to a news report that ‘seafarers are to be offered their own vaccination programme’. All crew members sailing on vessels operating under a Dutch flag, or managed by a Dutch ship management organization are to be vaccinated, irrespective of their nationality. A move that serves social, economic, health and safety interests, all at once. A positive and wise initiative.
Jeroen Dijsselbloem
Chairman