This week we saw the release of the report into the HMNZS Manawanui accident.
HMNZS Manawanui ran aground off the coast of Samoa shortly before 7pm on October 5 2024 and caught fire. The ship sank on 6 October but all lives were saved.
An inquiry was conducted a report was released on 4 April 2025. This blog is not about that report or all the causes that were discovered in the inquiry but what sits under the surface in most accidents, hidden safety ideologies/methodologies.
The full report can be viewed here: https://www.nzdf.mil.nz/assets/Uploads/DocumentLibrary/MAN-COI-ROP-FINAL-31-Mar-25_Redacted-v2.pdf
The list of causes is extensive namely:
Training and experience
- Risk intelligence
- Military hydrographic planning
- Orders
- Instructions and procedures
- Operational risk
- Force generation
- Operational release
- Supervision
- Violations
- Haste
- Leadership
- Distraction/interruption and
- Hollowness
- Cultural ignorance
The findings are extensive but like all findings in accident investigations – are common, unseen and under the surface. Particularly when organisations trust in traditional safety management systems like those advocated by Reason, Heinrich and Dekker. Most methodologies adored by Safety create a special form of blindness. We see this blindness demonstrated in the findings of the HMNZS Manawanui Report.
What is fascinating in this list of findings is, how so much is packaged under the banner of ‘human error’ and how everyone accepts and thinks they know what ‘human error’ is. Indeed, the safety community accept this meaningless language readily, so well prepared by the discourse of the likes of James Reason, Heinrich and Dekker.
However, when we dig into the discourse on ‘human error’, all we find is a naive attempt to give such discourse a facade of technical meaning. What you really get are semiotic models of file trees, tunnels, dominoes, swiss-cheese and language about: ‘violations’, ‘acts’, ‘lapses’, ‘intentions’, ‘slips’, ‘rules’, ‘mistakes’ and ‘types’. However, none of this language explains much for example, no-one can tell you what a ‘lapse’ is. No-one can explain what an ‘unintended violation’ is. Furthermore, there is no discussion in any of this about the nature of the human unconscious or collective unconscious.
In the discourse on ‘human error’, the foundational language of fallibility, mortality and imperfection is never discussed.
Of course, the semiotics and discourse of Reason and Dekker do not explain human error but simply give the safety sector a language to accept it. All of Reason’s discourse based on the semiotic of swiss-cheese explains very little. Indeed, the swiss-cheese serves as a distraction from the realities of incident causation.
If we use the HMNZS Manawanui as an example, there is no linear cause. There is no resemblance to any of Reason’s reasons (https://safetyrisk.net/no-good-reason-to-follow-reason/) as to why and how the HMNZS Manawanui sank. Indeed, when you engage with the reality of risk as a ‘wicked problem’ (https://safetyrisk.net/safety-wicked-problem/) you begin to give substance to the aspects of this accident that are beyond complexity, unconscious and messy.
Indeed, the way in which Reason and Dekker have prepared the safety world to tackle risk is in itself a distant cause of this accident too. The whole safety industry has been ‘set up’ by accepting ‘human error discourse’ to imagine prevention as a linear process to eliminate violations, acts, intentions, lapses, mistakes, slips, mistakes and failures.
And, the semiotic of the swiss-cheese, Heinrich’s dominoes or Dekker’s tunnel hide the myths they create. These semiotics are just a convincing myth, not reality. All myth is substantiated by semiotics.
The methodology of Reason and an uncritical culture that ‘deifies’ Reason as some guru of safety, is also part of the problem. When you are seduced by a weak methodology it creates a weak method.
It also creates a form of cultural blindness that makes the safety industry content with what it has been fed. Without sufficient critical thinking, the semiotics of Reason has been made the gospel of belief for an industry that still doesn’t realise that the model of Swiss-cheese is an unsubstantiated semiotic. Whilst the linear models of Reason, Dekker and Heinrich infuse safety texts, the reality is much different. The HMNZS Manawanui demonstrates that.
All semiotics create a belief that helps make a myth seem true. Myth, when substantiated by semiotics is quickly made truth. This is how the safety industry through its favourite (semiotic, visual and symbolic) texts, give status to concocted symbols that it likes. It is from this status and accompanying mythology that the sector accepts that it knows what ‘human error’ is. Once the myth of ‘human error’ is accepted as reality and made truth, then the mythological truth is politicised and can no longer be questioned. Therefore, in safety, all cause is linear and all prevention is plugging holes in swiss-cheese.
The safety industry then teaches the myths of Reason as truth in its texts, substantiated by a fictional concocted semiotic. Any criticism of orthodoxy is then deemed ‘heresy’.
Indeed, the safety industry shows little interest in the nature of myth or semiotics nor, the way in which myth is substantiated. Here are a few questions for consideration:
- Is an intentional violation a death wish? A suicide wish?
- Why is the power of allostasis and homeostasis so easily dismissed?
- Could an ‘unintentional violation’ be an unconscious misplaced heuristic?
- Is a lapse, an unconscious distraction?
- How can so many chaotic causes such as happened in the HMNZS Manawanui all be hidden and happening at the same time?
- What were none of these 14 failures seen or perceived?
- If a lapse is a memory failure, what is a memory failure?
- Why does Safety love the linear swiss-cheese, dominoes and Dekker’s tunnel?
- What does this choice of semiotics confirm?
- Could it be that causation is messy not linear?
- Could the assumption of linearity cause blindness to non-linearity?
In SPoR, there are alternatives to linear thinking and linear semiotics that are just as valid as what Safety has concocted.
In SPoR, we study the nature of semiotics and myth to understand how they are created and confirmed.
In SPoR, the semiotics created better manage the realities of risk as a ‘wicked problem’.
In SPoR, we have developed methods that help surface the unconscious and better tackle risk. These methods are based on a methodology that doesn’t expect linear or root cause.
If you are interested in a different approach to risk that accommodates non-linear thinking and methodology you can find out more through a simple email: admin@spor.com.au
The alternative to Reason, Heinrich and Dekker’s semiotics are positive, constructive, practical and real.
Dr Rob Long
Latest posts by Dr Rob Long (see all)
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- How to Make Safety Culture Myths True - April 26, 2025
- Building Belief and Networks of Belief in Safety - April 23, 2025
- The Harm You Cannot See - April 19, 2025
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