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Persistent Error: Inadequate Safety Culture
November 10, 2010, Nieuwe Waterweg, Netherlands: Towage vessel Fairplay 22 capsized due to over-speeding, inadequate vessel stability, and the crew failure to close watertight openings.
And this happened because the vessel had an incomplete hazard identification and analysis system that is a part of safety management and culture. Flimsy monitoring did the rest.
On March 1, 2010, Llanddwyn Island was assisting an 870ton backhoe dredger near Roscoff, France when the single hawser connecting the vessel parted under tension. The recoiling hawser killed a deckhand.
Investigations blamed the safety culture. The company had not provided any guidelines on towing and pushing arrangements. Furthermore, the crew was not reminded of the possible operational risks.
A tug named Western Tugger was towing the barge Arctic Lift 1 near Newfoundland on May 10, 2014. Arctic Lift 1 capsized and the resultant strain on the tow wire shattered an auxiliary brake drum, the pieces of which killed a crew member.
Enquiry revealed the lack of safety practices that would have otherwise identified a flawed emergency tow release, the unsecured cargo, the minimal freeboard, and the partially-watertight hatches.
Helm Operations, Canada highlights these mishaps to demonstrate the issue of safety culture in the report The Impact of Crew Engagement and Organizational Culture on Maritime Safety in the Workboats and OSV Sectors.
Most accidents result from flawed safety cultures. This is so even for mishaps due to equipment failure, for humans fail to detect the symptoms of the malfunction. Making more rules will not improve safety culture, making the crew look positively at existing safety rules will.
Like everywhere else, time and money are the strongest considerations in the maritime business. Commercial and deadline pressures often supersede safety.
Underreporting of deviations from safety standards is rampant here. Correct reporting makes things ‘official’ and can dent the company’s safety reputation. The management may not look favorably at honest reports and this can endanger the reporting personnel’s job security.
For the same reason, crew members are notoriously unwilling to take safety surveys. The response rate for the said report-survey was a meager 24.15%.
Often personnel are not aware of safety standards or the correct procedure for reporting deviations. Sometimes the reporting procedures are too complex. Or the management may not institute feedback channels at all.
Management may make safety decisions for offshore crews without understanding finer issues. And there is the issue of communication gaps for multilingual crews in the genuinely global maritime industry.
Most onboard accidents result from:
- Non-Existent or Inadequate Risk Identification Processes
- Negligible or Zero Communication of Safety Hazards
- Absence or Flawed Execution of Safety Procedures
- Improperly Trained Crews
As part of the report, researchers conducted an International Online Survey with 50 participants from major offshore companies. Findings include:
- Unfavorable Weather and its Impact of the Vessel’s Exterior Surface is the main safety challenge particularly in the North Sea. Deadline pressures escalate this hazard
- Lack of Clarity Regarding Minimum Safety Standards in Different Regions
- Language and Communication Barriers particularly when working with crew from the Baltic, Far East, and the Middle East. Even those with English as their second language have peculiar, incomprehensible pronunciations
Operating at high engine-noise levels aggravates the communication gap. This issue becomes deadly during emergencies when personnel revert to speaking in their mother tongue
- Excessive Fear of Authority dissuades the crew from questioning superiors. This is particularly true for personnel from the third world. Many onboard personnel are the sole breadwinners for their family and therefore dread reprisals
- Region Specific Challenges:
- High Fatigue on the Canada-Africa Route
- Poor Safety Culture in the Gulf of Mexico where crews often do not follow their own safety procedures
- Piracy and Kidnapping in West Africa, especially Nigeria
- Differences in Enforcement of Safety Standards
Authorities in the North Sea are the best enforcers. U.S. and Brazil are good enforcers. But Brazil mandates vast paperwork for reporting, something that deters reporting
Shell, B.P., STAT Oil, Foss Maritime Company, Svitzer, and American Commercial Lines (ACL) have excellent safety cultures
Southeast Asia and Africa generally exhibit low-level safety culture. When operating here, companies with high-level safety culture find it hard to convince the importance of safety practices to local crews
- Complex and Diverse Paperwork Required to Operate in Different Regions. To work in multiple regions, personnel must possess a confusingly high number of certificates and equivalent qualifications
- Many respondents felt the need for additional training particularly for reporting deficiencies to superiors during odd hours
- Although 84% respondents believed the management will back them if they reported deviations, 78% believed commercial pressure could impact workplace safety. This is because most feel commercial pressures are outside their control
- 64% believed some accidents go unreported because:
- Fear of Repercussions, the main reason
- Burden of Paperwork for Reporting Accidents
- Likelihood of Looking Incompetent
- Fear of Spoiling the Company’s Safety Record
- Apprehension of Missing Deadlines because completion of the reporting procedures takes time
Crew engagement in the maritime industry is similar to employee engagement in the non-maritime world. According to the International Safety Management (ISM) Code, a company’s safety management system must address the following aspects:
- policy and procedures for safe and environment-friendly operation of ships by adhering to the standards of the relevant flag state
- codified levels of authority and communication lines between and amongst onshore and offshore employees
- procedures to:
- report deviations and accidents
- prepare for and respond to emergencies
- conduct management reviews and internal audits
Half of the respondents of the International Online Survey felt that more can be done to improve safety. Suggestions include:
- No-Blame Culture wherein everyone is allowed to openly report accidents and missed accidents without placing blame on anyone
- Adequate Handover Procedures so that lessons learnt by employees are transferred to the next generation. Foss Maritime has institutionalized the learning of lessons from all lost-time incidents
- Rewarding Genuine Reporting Personnel
- Appointing Safety Officers who are Beyond the Control of Superintendents, Vessel Captains, and Management
American Bureau of Shipping (ABS) zeroes in on eight factors that improve onboard maritime safety. These facets are mutually linked. Addressing one often leads to compliance with another and vice versa:
- Employee Empowerment
- Feedback Mechanisms
- Mutual Trust
- Problem Identification
- Safety Promotion
- Safety Awareness
Communication is the vital link between all personnel at all levels. Only proper communication ensures that everyone receives and understands the information necessary to execute their duties safely.
Now, the maritime industry is a genuinely global enterprise with multi-lingual crews. Language and cultural differences create communication gaps. Training in a common language is therefore essential.
Then there is frankness in communication. North American, European, and Australian personnel communicate frankly with their bosses. Those from Asia, South America, and Africa usually do not.
- ensure a work culture wherein people speak frankly across and within different hierarchical levels
- communicate safety-related information on all established channels such as website, newsletter, helpline, or intranet
- provide safety-related information in native languages for multilingual crews
Employee Empowerment nips many safety issues in the bud. A trained employee who understands the objective behind these standards does not hesitate to make suggestions or even act independently to contain or eliminate a safety hazard.
And he does so without disrupting the onboard hierarchy that is so very essential for safety aboard ships. Empowerment ensures that employees do not follow orders blindly and are not afraid to speak out on safety concerns.
Feedback Mechanisms ensure that crews report a deviation immediately. Combined with remedial action from the management and superiors, this goes a long way in preventing disasters. Plus, it boosts morale and helps learn important lessons.
Although it appears simple, feedback is not so simple. Personnel often think providing honest and prompt feedback is unmanly, unprofessional, and slows down operations.
Such reporting, in the perception of the personnel, makes the deviation ‘official’ and degrades the safety record of the company. Why report a deviation when it can endanger his job?
This is why management must not shoot the messenger but encourage genuine reporting through dedicated channels. ACL and Foss Maritime for example run an anonymous reporting helpline. Foss Maritime also operates an anonymous online reporting tool.
Mutual Trust between offshore personnel and onshore management is must if the offshore personnel are to report problems openly. Management must build trust through a just and ethical work culture where good performance is rewarded.
But while promoting open reporting, management must ensure that they do not promote indiscipline. Towards this end, they must categorically define the situations wherein they will not initiate disciplinary action against the personnel.
Problem Identification is heavily related to feedback mechanisms. Employees at all levels must possess the training and competence to identify a genuine deviation. A simple way to promote problem detection is to use safety checklists that personnel must use before starting work.
Safety Promotion begins at the top and percolates downward. Top management must lead by example and repeatedly demonstrate their commitment to safety values through deeds and words.
This includes periodic verbal and written communication to emphasize safety, allocation of adequate financial and training resources for safety, and prioritizing safety over performance targets. Svitzer for example asks its employees to stop working if they detect deviations.
Responsiveness ensures that personnel act in time to report a deviation and prevent it from escalating. They will do so only if they are trained to identify a deviation, report it, and initiate emergency response when necessary. And this requires them to trust the management.
Safety Awareness creates a situation where every onboard personnel feels responsible for the safety of the crew, vessel, and other people on the ship. This can happen only if they feel that their work is valued.
Being alert is a critical requirement to detect issues. And to be alert, personnel must be well rested. For, fatigue is a major and silent onboard killer. With rising traffic, rapid turnarounds, shorter sea passages, and lower manning levels, fatigue is rising.
Then again, fatigue affects everyone irrespective of their knowledge, skill, and training. Management must ensure that the crew gets sufficient and quality rest between work shifts and that the working conditions are reasonable.
Workload, fear, boredom, stress, and interpersonal relationships affect the quality and quantity of sleep. Management must try and limit the intensity of such causatives as much as possible.
Culture is the sum total of lifestyle. Safety culture must be such that it makes safe practices the second nature of every onboard personnel. Then, reporting deviations and addressing them becomes a natural course of action.