Maritime safety and environmental protection depend on the effective implementation of the International Safety Management (ISM) Code. Although the Code provides a structured framework for managing safety, accident investigations, audits, and inspections continue to identify recurring deficiencies, raising questions about how Safety Management Systems operate in practice and how effectively organisations learn from failure.The objective of this study is to examine ISM implementation using accident investigation material in combination with audit and inspection evidence, with a focus on distinguishing organisational control failures from operational mistakes and assessing their implications for safety performance.The analysis draws on multiple empirical sources, including audit data from IACS member organisations, Port State Control inspection records, accident and incident investigation reports, stakeholder surveys, focus group discussions, and relevant literature. Approximately 200 accident investigation reports were reviewed, with a subset analysed in greater detail. Comparative review and thematic grouping were applied to identify recurring non-conformities, causal attributions, and patterns across datasets. Findings observed consistently across audits, inspections, and accident reports over multiple years were treated as indicative of persistent rather than isolated issues.The results indicate that ISM-related non-conformities frequently arise in areas such as internal audits, risk assessment, incident reporting, emergency preparedness, and management review. Accident investigation material suggests that many operational failures occur within pre-existing organisational conditions shaped by inadequate procedures, weak oversight, or ineffective corrective action. To support analytical clarity, the study distinguishes between company-related errors, understood as systemic weaknesses within Safety Management Systems, and crew-related mistakes occurring during operational execution. The analysis indicates that events commonly attributed to human error are often associated with upstream organisational contributors.The findings suggest that persistent ISM-related deficiencies are more closely linked to weaknesses in implementation, management competence, and organisational learning than to limitations of the ISM Code itself. Improving safety outcomes therefore depends on clearer causal analysis, improved quality of accident investigation reporting, and stronger accountability within Safety Management Systems, rather than additional regulatory requirements.
Ziariti et al. (Mon,) studied this question.