CMA CGM Ville de Mars Investigation and Healthcare Imbalance Report

This report addresses the critical issue of imbalances between production and safety in the healthcare industry, drawing upon real-world examples such as the Piper Alpha platform and the Ville de Mars incident. It defines the concept of imbalance, explaining its development through market competition and political factors, impacting environmental and global safety. The report then examines James Reason's Theory of Organisational Accidents, utilizing the Swiss cheese model to analyze system failures, along with its strengths and weaknesses and how it can be applied to a real-world scenario. Finally, the report provides an analysis of the Ville de Mars accident, offering an executive summary of the investigation findings, key causal factors, and corrective actions, including the application of a 'just culture' policy. The report highlights the importance of safety regulations, industry practices, and organizational compliance in preventing accidents and ensuring safety within the healthcare and maritime sectors. The assignment is based on a final end of term major assignment.

Running head: HEALTHCARE 1
Healthcare
Name
Institution

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Healthcare
Introduction
An imbalance between production and safety is a scenario in which companies tend to
focus on too much production of a given product for example vessels (Sætrevik, Ghanonisaber &
Lunde, 2018). Companies do this with an aim of meeting a particular demand in an
overstretched market as a means of capitalizing on company gains but not realizing that this
might interfere with the safety of this product while in use. Some of the causes of imbalance in
maritime include; when there is excessive supply of vessels while there is surge in fleet growth,
an instance when there is sustenance in the consolidation and increase in container shipping
against the performance of the port, countries over relying on import demands, high rate of
container shipping. All these imbalances are important to sustainability of environment together
with maritime industry (Casagrande et al. 2020).
Imbalance between production and safety arise due to market competitions when
companies compete to deliver supplies. As a result of the competitions, there is no much
concerns about the quality to be delivered but the quantity that brings money due to sales. When
companies smell increase in market demand, they tend to increase production of tankers. Due to
high demand of gas, there is a lot of production of containers which results to high level of
shipment to consumers across the world (Patterson, Bailleux, Chen & Zhu, 2019). When this
happens, a lot of energy clean and unclean is used in the productions. The unclean energy has
environmental repercussions that the producers do not want to care about.
There should be a reason for growth expansion in terms of production rather than just
popping up with productions that are not well thought of. For example UNCTAD has an
expectation that the average growth every year for the international, maritime should be at 3.5

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percent. This does not just come because production must be there, but necessitated. Some of the
products that are key and necessitate production of containers include transportation of gas and
bulk of dried items. As these are essential to humanity, the greatest question also lays on the risk
the production of such containers pose to the environment. Sometimes when tension escalates
between China and the United States of America, it largely affects growth in maritime trade by
developments in market segments that might have suffered previously. For example they include
disruptions to iron-ore trade that was caused by Cyclone Veronica in Australia and the worst
repercussions of the Vale dam incident in Brazil which largely affected the maritime transport.
The transportation of Crude oil from the Atlantic to Asia are expected yield increase of
tanker trade volumes, while sanctions affecting the Islamic Republic of Iran which is among
world producers of oil also dealt a blow to the production of containers and transportation
mechanisms. Another important aspect to consider is the compliance with production cuts put by
the Organization of countries that Export petroleum, which is most likely to jeopardize and put
further pressure on tanker trade. Encouraging developments in the lifting of some of these banns
and stability of affected countries might help reduce current pressure on maritime trade.
Technology has been overwhelmingly praised in playing a fundamental role in the field of
transportation and services in maritime industry. Maritime industry also comes with heightened
and more frequent natural disasters and disruptions that are climate related. These goes beyond
one country to the extent of affecting the entire globe and multiply beyond environmental
sustainability with much impact on global warming.
Environmental Safety has been a concern in the past as far as production and use of
vessels, containers is concerned in the maritime industry. This was evident when there were
temporary withdrawals of ships in the maritime to give room and time for installation of

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scrubbers. This happened in the year 2009, when there was compliance with the new 2020
regulation of the International Maritime Organization (IMO) about limits on sulphur fuel. This
had a great impact on market production of the transport essentials. With the increase in number
of ships carrying poisonous and noxious substances, with a lot of chemical trading taking place
every year, concerned countries whether developing or developed should come together and join
hands in signing an important trity to control water and environment pollution.
Quite a lot of changes have been enhanced by a number of vessels and ship building
companies towards incorporating new standards into the design and construction of ships. There
has also been a lot of Pressure on the industry to come up with better strategies and build cleaner
and energy efficient vessels which is on the rise now. With the introduction of Certification
schemes that will help ensure that considerable investment is going into the production of better
hydrodynamics, a good number of energy-efficient engines and vessels using low or non -carbon
fuels.
Reasons for development of imbalance between production and safety
The developments of such imbalance are as a result of economy, political power struggle
among other factors. Economy of states plays a crucial role in developing imbalance between
production and safety as outlined below;
World’s most techno developed countries who also have greater economies like America,
European nations and Asian tigers do everything to produce items and goods to help run their
economies. As a result of doing that, the whole world bears the burden of global warming which
adversely affect everyone including those who didn’t participate in the emissions.
World’s politics play integral role in developing imbalance between production and
safety. Countries with large militaries and most advanced weapons use substances like uranium

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among deadly minerals to make their weapons, some also explore on unclean coal in their
maritime to act as a source of energy and also used in making missiles in readiness for war.
These make them dominant and in control of the globe for their own stability.
In conclusion, many countries in the world are engaged in a lot of battles, the supremacy
battle that outlines who is dominant. As a matter of this, they jeopardize the rest of the earth’s
population by engaging in illicit behaviors that are tantamount to mass destructions as a result of
environmental degradation. Developed countries who engage in mass productions create a lot of
imbalance as they do not look at the consequences of their choices to the coming future
generation.
3) Explain James Reason’s Theory of Organisational Accidents.
James Reason suggested the image of Swiss cheese mainly to describe the occurrence of
failures of the system, for example, medical mishaps (Begum, McGregor, Kava, Tilsed & Rao,
2019). This metaphor of James claims that in a complex system, dangers remain prevented from
causing losses to human by a series of barriers. This model of accident causation, initially
suggested by James, likens people system defence to a randomly-holed Swiss cheese organized
vertically as well as parallel to each other with certain gaps in between every slice. James
hypothesizes that numerous accidents may be traced to four levels of failures: The four levels of
failures include organizational influences, preconditions for unsafe acts, the unsafe acts
themselves, as well as unsafe supervision (Fukuoka, 2016).
In this model, a firm’s defences against failure remain modelled mainly as a serious of
barriers, denoted as slices of the cheese. The cheese slices’ holes denote personal weaknesses in
individual parts of any system, and remain continually differs in position as well as size in all
slices (Fukuoka & Furusho, 2016). It is true that this model is mainly used in risk management

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and risk analysis, including engineering, aviation safety, emergency service institution, and
healthcare.
Weaknesses and Strengths of the Theory
Strength 1: Great Conceptual Model for Communicating the Ability Of The
Organization To Mitigate Risk
Within this model, the slices of cheese remain meant to indicate organizational defenses.
Conversely, the holes indicate opportunities as well as weaknesses as to breach the defence. This
model demonstrates that firms already have processes and systems in place that remain created to
stop large, high severity issues (Buist & Middleton, 2016). When such event occur, it happens
due to a breakdown within each of the defences; visually indicated when the holes align.
Strength Two: Demonstrates 2 Ways To Alleviate Risk.
Another advantage of this model is that it demonstrates two methods to prevent risk. To
start with, Risk = consequence x probability.
To reduce risk using this model, solutions may concentrate on reducing consequences or
reducing the probability (Kamoun & Nicho, 2018). Let us use the example of a driver hurt in a
car accident. Preferably we would prevent the damage by reducing the actual probability of
getting into that accident. This model indicates that the driver can reduce the accident by
practicing safe driving. A hole in James model might be distracted driving for example making a
phone call while driving. Clearly a solution is for the driver to stop making phone call while
driving. Nevertheless, even if an individual remains in the accident, we still reduce the risk of
damage with individual protective devices. For instance, that driver could reduce the injury by
wearing a seat belt.
Weakness One: Differentiating Causes Mainly By Imposing Labels.

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As we normally find, any time models and methodology impose terminologies, they often
create opportunities for disagreement and confusion. Within this model of James, accidents
remain the combination of latent conditions and active failures at that time of the accident. They
remain represented mainly as holes in this model. So, this model creates unnecessary terms and
arguments.
Weakness Two: The Ambiguity of the Hazard As Well As the Fact That the
Existence Of Hazard Remains Taken For Granted.
It is true that the ambiguity of the hazard label shows another major weakness of this
model in terms of application.
Lastly, it is true that this model remains not extremely effective at representing the clear
interrelationships among the causes. This might the result to be vague. The result may not
provide suitable solution for implementation
The Ville de Accident
The Ville de accident developed when the chief officer (CEO) began to descend into a
water ballast tank. It is true that the CEO was not wearing a fall arrestor when he entered the
ballast tank. This made him to slip as well as fell from a water ballast tank. According to the
model the accident would have been prevented mainly by wearing a fall arrestor.
Some of the barriers include: The industry put rules and regulation relating to the entry of
the tank at sea level. The organization also initiated the work permit system to reduce any
accident that might take place in the workplace. Even after the accident, the chief officer was
removed from the tank and was taken to the hospital to prevent further injury but he died on the
way to the hospital because he got a severe injury.

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The major hazards confronting the system of safety were capable of successfully
penetrate the barriers because the precautions taken in for the access of the tank failed to abide
by the requirements of the organization procedure or industry practice. Also, the organization
failed to issue permits to work at a higher height or to enter into an enclosed room. The chief
office did not abide by the rules and regulations of the industry practice and that of the
organizations. We also find that there has been non-compliance with the system of the permit to
work and the company has not taken any effective action to prevent it from taking place.

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References
Begum, F., McGregor, A., Kava, S., Tilsed, C., & Rao, G. G. (2019). A laboratory Brucella
exposure in a UK hospital: a Swiss cheese model?. Journal of Hospital Infection, 103(4),
477-478.
Buist, M., & Middleton, S. (2016). Aetiology of hospital setting adverse events 1: limitations of
the ‘Swiss cheese’model. British Journal of Hospital Medicine, 77(11), C170-C174.
Casagrande, F. V., Amadeo, A., Cartelli, D., Calogero, A. M., Modena, D., Costa, I., ... &
Pezzoli, G. (2020). The imbalance between dynamic and stable microtubules underlies
neurodegeneration induced by 2, 5-hexanedione. Biochimica et Biophysica Acta (BBA)-
Molecular Basis of Disease, 1866(1), 165581.
Fukuoka, K. (2016). Visualization of a hole and accident preventive measures based on the
Swiss cheese model developed by risk management and process approach. WMU Journal
of Maritime Affairs, 15(1), 127-142.
Fukuoka, K., & Furusho, M. (2016). Relationship between latent conditions and the
characteristics of holes in marine accidents based on the Swiss cheese model. WMU
Journal of Maritime Affairs, 15(2), 267-292.
Kamoun, F., & Nicho, M. (2018). A New Perspective on the Swiss Cheese Model Applied to
Understanding the Anatomy of Healthcare Data Breaches. In Handbook of Research on
Emerging Perspectives on Healthcare Information Systems and Informatics (pp. 58-81).
IGI Global.

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Patterson, S., Bailleux, F., Chen, J., & Zhu, M. (2019). Imbalanced Randomization in Vaccine
Clinical Safety Trials. Statistics in Biopharmaceutical Research, 1-5.
Sætrevik, B., Ghanonisaber, S., & Lunde, G. E. (2018). Power imbalance between supply vessels
and offshore installations may impede the communication of safety issues. Safety
science, 101, 268-281.