Today's approach must change

26 mai 2017
by: Dr. Torkel Soma

The Titanic disaster has, for more than a century, been a reminder of the catastrophic potential of accidents at sea. Since then, the scale of damages from ship accidents has multiplied in terms of lives, pollution, cargo and asset value. On a typical day in shipping three persons are killed, 30 persons are injured, half a ship is lost and $8 million is paid in claims. Therefore, it is crucial that we use the right approach to prevent ship accidents from occurring. But we don't. There is a huge blind spot in our current approach.

Today’s approach is not working

The general approach to being safe consists of three strategies;

Strategy 1: Do it right in the first place (to avoid failures from happening)
Strategy 2: Manage threats and failures when they occur (before they escalate)
Strategy 3: Be prepared to handle critical situations

Shipping is amongst the best industry when it comes to implementing Strategy 3; handling critical situations. But we do not want to experience critical situations. Therefore, we need to be more proactive by preventing critical situations from occurring.

Today´s approach to preventing ship accidents is geared towards the first of these strategies; Do it right in the first place. This can be exemplified by the implementation of the ISM code when the saying was: Write down the right way to do a task, do what you write and prove it. And we do a lot to “prove it”. In fact, every second minute a safety inspection or audit is completed in shipping. Thousands of auditors and inspectors across the world are engaged by classification societies, flag and port state authorities, vetting, insurance and HSEQ departments. They verify that ships do the right thing and comply with technical and procedural requirements. However, ticking boxes never made anyone safer.

Today’s approach has positive effects on observed compliance and injuries, but not on ship accidents

As a result, the housekeeping, cleanliness, number of findings, non-conformities and observations have improved. Even the frequency of lost time injuries (where individuals are injured and cannot work the next day) has been greatly reduced. So, at first glance this approach appears to be the right way to go. But, there is a large “but”: Statistics show that ships involved in accidents with a huge damage potential “do it right” just as well as the rest of the fleet. They have the same compliance certificates framed on the wall, they have equally good results in audits and inspections, and rarely experience lost-time injuries. As a conclusion, the current approach of doing it right has an impact on observed compliance and injuries, but does not make a big difference when it comes to actual ship accidents.

The reason is that this biased focus towards doing it right has several side effects:

There are too many procedures and checklists for seafarers to digest
Many seafarers tend to rely too heavily on checklists and procedures
People tend to stop thinking, and act for themselves (just comply)
Safety is perceived as something controlling, dull and not important
There are fewer discussions and less sharing of experience

We have created an industry of “cover-ups”

There are now so many procedures that, in some cases, it is impossible to comply with all of them. In a survey of 12,000 anonymous seafarers, 45% admit that they break procedures on a regular basis. At the same time, seafarers are afraid of being caught breaking the procedures and, intentionally or not, cover-up their non-compliance and mistakes. Furthermore, most shipping companies support such a practice by sending on board pre-inspection task forces to ensure that everything is in place prior to an inspection. PROPEL´s measurement of organizational maturity of handling failures shows that 50% of ships in the global fleet have developed a “cover-up” culture.

A culture of “Management of failures” would have prevented most of the major ship accidents

The blind spot for the industry is the second strategy; to manage failures when they occur. Failures will occur, it is just a matter of time. If failures are not managed they may, over time, develop into critical situations and accidents. This is a blind spot because the biased focus on doing it right makes people reluctant to be open about failures, concerns and mistakes. In (by far) most ship accidents, failures were already known by the crew prior to the accident, but were not addressed and corrected. Some grave examples:

Costa Concordia grounding: Many of the navigational failures were known to the bridge team, but not acted upon.
Exxon Valdez oil spill: The lookout reported several times that the ship was off course but no action was taken.
Torrey Canyon oil spill: The Chief Officer corrected the course, but the Captain decided not to listen, to save time.
Herald of Free Enterprise capsize: Near-miss reports had been shared in the fleet, but were not acted upon.
Titanic foundering: The ship had received 30 iceberg warnings, but still decided to go full speed.

The culture maturity of “Management of failures” explains most ship accidents

In some companies 50-70% of the seafarers respond that they are reluctant to talk about failures and concerns, while in other companies the corresponding share is below 10%. It should not come as a surprise that this share correlates (>90%) with the company´s frequency of ship accidents. Our research shows that, in most ship accidents, somebody already knew about the failures that resulted in the accident, prior to the event. This implies that most ship accidents can be prevented by building a work environment that is more open to discussing threats and failures (Strategy 2). A revised approach focusing on management of deviations will therefore have a significant positive impact on ship safety.

The new strategy is precise and proven in other industries

Ambiguous terms such as “the human element” or “human factors” are often used as labels of human related causes. However, improving safety or performance is not about improving individuals; it is about improving collaboration. In a mature organizational culture, everybody is collaborating to manage failures by understanding the importance of failures, speaking up, being open to others’ concerns and acting upon them. This is what Strategy 2 is all about. Research shows that organizations highly exposed to disasters (such as nuclear power plants and aircraft carriers), but achieve exceptionally good safety results (High Reliability Organizations), have common characteristics. In the aviation industry, the transformation towards a more collaborative and open culture started 20 years ago by implementing what is called “Threat and error management”.

Everybody can (and must) participate in the new approach

All strategies must be combined. It is impossible just to add Strategy 2 (manage threats and failures when they occur ) to Strategy 1 (do it right in the first place). The three strategies are interlinked and the whole industry needs to change its focus from Strategy 1 in order to reduce the shame of failures and give room for the development of Strategy 2. Hence, a transformation into a new approach in preventing ship accidents does not only involve seafarers and the top management of shipping companies; it also involves charterers, regulators, insurance, owners, operators, and training providers in facilitating genuine openness rather than just focusing on doing it right.