Laureline. One training assessment scored 100%.
CCTV told a different story.
Laureline. Purfleet. 13 July 2024.
A trailer stopped.
An AB moved behind it.
Then it moved again.
He was crushed against the vessel’s structure.
The easy conclusion is obvious.
He entered the danger zone.
Procedure not followed.
Case closed.
Except MAIB did not stop there.
The procedure was new.
Eight pages.
Three core rules.
Stay outside danger zones. Stay on the same side of the trailer. Monitor each other.
On paper, reasonable.
On deck, something did not fit.
The tug driver had to watch the trailer. The lane. The vessel’s structure. His mirrors.
To see someone between the trailers, he had to lean outside.
The available gap was 20.6 cm.
That changes the question.
This was not only about whether somebody followed a rule.
It was about whether the rule could survive the job.
The terminal expected the driver to stop when the marshaller disappeared.
The vessel procedure defined where people should not stand.
But neither system gave both men positive confirmation that the movement was finished.
So assumptions filled the gap.
The crew member believed the trailer had stopped.
The driver believed the crew member was clear.
And there is the management problem.
Training had been completed.
Assessment had been passed.
The procedure existed.
Yet historical CCTV still showed routine danger-zone entries.
Those three facts can sit comfortably together in an SMS.
That should worry every DPA.
Because completion is not assurance.
A signed training record proves somebody attended.
A score proves somebody answered questions.
A procedure proves somebody wrote a control.
None proves the control works at 1711, between steel, trailers and blind spots.
For a DPA, the test should be brutally practical.
Take the new procedure to the workplace.
Run the task.
Watch where people lose sight of each other.
Watch what happens when the sequence changes.
Watch what each person assumes.
Then identify the feedback that closes the loop.
Because if both sides cannot positively confirm that movement has ended, the procedure still contains an assumption.
And assumptions move faster than paperwork.
Where in your SMS does “he will know” replace positive confirmation?
