Can training solve the issue of human error at sea?

Those who have been employed in the maritime industry for even few months will have heard the term that 80% of the accidents incidents at sea can be attribute to human error. The solution for this is often quality maritime training for the personnel involved. However, training is perhaps the most easily reversible corrective action. System experts will even go so far as to say that when something goes wrong do not blame the individual but blame the system. Can it always only be the system fault. Surely human error does play some part.

With the onset of STCW, new rules were ushered in to ensure quality maritime training for all personnel at sea. Similar rules have been extended to those in the inland water towboat industry with the onset of Subchapter M. STCW required maritime training centers to have quality standards systems in place and for flags to provide oversight of the training institutions to ensure quality maritime training was indeed being delivered. So, with such well trained personnel why then do errors still take place?

Safety management system are truly only successful when a just culture for safety exists aboard the vessels. This means there is no fear of repercussion or reprimand for stopping someone performing an unsafe act or to report an unsafe condition. When human error does creep in, it can often be attributed to the dirty dozen of unsafe acts and conditions. When a non-conformity occurs, or a potential non-conformity is identified the corrective action identified must address the root cause(s) of the problem. Poor root causes analysis will lead to quick fixes but no long-term improvement. Identifying the root cause leads to systemic corrective action with solutions perhaps being newly identified competence, mistake proofing of the system, revised procedures and in some case training. However, this time the training is made systemic and so repeated at periodic intervals.

Quality maritime training is only the first step towards ensuring qualified mariners as required by the ISM code but they competent, qualified mariners need to have the support of the system. When human error, operator error, user error and the such are identified over time as root causes it may be possible that it is indeed such, but it may also signify a deeper root cause. Perhaps a poorly managed hiring process, or induction process, or onboard training program. Training may have some role to play in the success of a safety management system and the reduction of human error as a cause of incidents/ accidents. Quality maritime training may be a leading preventive tool, however, only when the issues are treated systemically will long term improvements be gained and safer operations as a result.

Maritime Leadership – Beyond Designated Person Ashore (DPA)

It appears the maritime leadership is limited to the DPA/DP (Designated Person Ashore). The worst is when senior leadership of a company, washes its hands off, of the leadership role, by assuming a DP will do all that needs to be done! The ISM (International Safety Management) Code, in clause 4 defines the role of the DP (designated person).  It is to be remembered that the DP is indeed the link between the company and those on board, to the extent decided by the leadership/ ownership of the maritime company. The DP with clause 4 of the ISM Code has his/ her role defined as the link. However, there is much more to it. There is a kind of upstream and downstream relationship between the safe operations of a vessel, and the leadership exercised by the shipping company. The DP can represent and do his best in meeting objectives if he/she is resourced and supported by the leaders. Maritime leadership is strengthened by the contribution of the DP. This is particularly true when a tragedy occurs, and the crisis management team is called to minimize the aftermath of the tragedy and hands-on dealing with the tragedy. The DP as part of the crisis management team and must play a lead role in providing his/ her experience, expertise to ensure the situation does not worsen. DP should be competent, involved and participate in designing the safe operations of the vessel as also to predict the risks and trends from the available company and industry data and make timely recommendations, to ensure tragedies do not occur. But once they occur the same detailed knowledge has to be used to meticulously plan the response actions.

The leadership of the company, particularly when not from the marine background, should orient itself to matters maritime during good times. It is in normal good times that the relationship of confidence has to build with the DP. Regular access to the TM (top management) of the company by the Designated Person Ashore, makes teamwork smooth in a crisis situation. The leadership working together with DP and the team is able to ensure the company’s safety objectives, environmental policy implementation and functional requirements are met. Regular drills and exercises and analysis of situations ensure that the lessons learnt thereof, are used as input for further planning and resourcing.  Clause 4 of ISM Code is not just a job description basis for the DP, but also an input to the leadership to see where they fit in so that the support when required can be provided in a crisis without delays in a crisis. Building trust is a responsibility both the DP and the organization must build. There is much more to this dynamic leadership role. Meeting the safety, prevention of human injury or loss of life, and avoidance of damage to the environmental objectives of the company given in clause 1.2 of the ISM Code are the DP’s responsibilities. He/ she is the implementer of safety and environmental policy as given in clause 2 of the ISM Code. This however cannot be achieved without resources and support from the company top leadership.

Emergency preparedness is a requirement of the ISM Code. Clause 8 of the ISM Code requires implementation on board, with office support lead by the Designated Person Ashore and resourcing provided by the top management of the company. The DP with his/her team brings the considered opinion as input to the organizational decision-making body. Making preparations for being able to respond to emergency situations at sea needs forethought in appreciating the risks, and preparations in advance. It starts with recognizing the hazardous situations, creating the procedures, conducting drills and exercises, and learning lessons from exercises conducted, other industry inputs, similar occurrences anywhere. Data drives risk appreciation and trend recognition. Managements have to look ahead at possible crisis and be prepared with timely quick response.

Crisis if handling well, requires and brings out clearly that not just competence, but motivation and leadership are all of the utmost importance. As primary consultants in the field of maritime work,  QMII (www.qmii.com ) has worked on crisis management, handling media, and building teams for over 30 plus years now. Our experience shows clearly that a leadership team working with not just the Designated Person Ashore, but all departments in a participatory manner determines the success of addressing a crisis.

Safe operation of ships and prevention of pollution requires dynamic leadership at the company level with the involvement of the DP using the expertise in the ISM Code and SOLAS as also other relevant IMO conventions, as also Flag State advises to formulate robust, well thought out plans for crisis management.  A process-based management system approach is most important. “If an organization can do not describe what they do as a process, then they do not know what they are doing,” it is to be remembered that behind every casualty at sea are many detentions, and behind them indicators like Major NCs (non-conformities) and near misses. The maritime leadership with Designated Person Ashore included must lead to prevent a crisis.

Effectiveness of the ISM Code

The ISM (International Safety Management) Code, in itself, is not a magic wand, that will bring safety or prevent pollution. It depends on the organization on how it implements the Code. Safe operation of ships and the prevention of pollution should have been any organization’s objective. Yet all over the world owners to save money compromise these objectives. Did not the Titanic on April 15, 1912, sink, trying to create a record of crossing the Atlantic, by going North to cut distance, run into the iceberg?

The sinking of the Titanic, with a loss of nearly 1500 passengers and the crew was an eye-opener. It led to the SOLAS (Safety of Life at Sea) convention. Did the negligence and continued operation of ships compromising safety stop with SOLAS? Sadly not. The investigation by Justice Sheen into the sinking of the Herald of Free Enterprise, on March 6, 1987, looked at why SOLAS had not helped prevent the tragedy. It brought out the necessity for a process-based management system, and the SOLAS Chapter IX was updated to authorize the ISM Code. It provides the guidelines for the implementation of a system to ensure the safety of vessels at sea.

The Flag State Administrations whose flag the ships sail under, legitimize the use of the code making it mandatory for internationally trading vessels. If any company is bent upon not implementing it in the spirit of it, then of course the objectives of the code as also the functional requirements will not be met. Owners and Operators of the vessels often look to short term gains wherein they compromise the standards and bypass the rules. They have to understand that behind every casualty at sea are many detentions and behind them indicators like Major NCs (non-conformities) and near misses.

The Flag States who do not strictly inspect and audit vessels to the ISM Code and issue SMC (safety management certificates), are actually, to retain the business of ship owners, jeopardizing the same ships! Even some responsible Flag States, due to shortage of manpower outsource their duties to ROs (recognized organizations), often represented by class societies. This results in diluted control, as an outsourced process needs strict monitoring of the process to ensure the performance is not affected. Not managing an outsourced process is as good as not taking responsibility. Authority can be delegated, bot the responsibility.

NCs (non-conformities) drive correction and CA (corrective action), and as such should be welcome as inputs to ensure continual improvement of the system based on the ISM Code. Yet, there are every day common examples of Masters of ships negotiating to somehow get the auditors to not give NCs. This is because the management ashore is not mature to realize, that keeping the master’s pressurized and performance being judged by NCs reported is creating an environment of fear and hiding of NCs. A good SMS (safety management system) based on the ISM Code, if correctly implemented should welcome NCs. The DP (designated person) should know that the “only bad NC, is the one which the organization does not know about.”

For domestic vessels, and for that matter towing and small vessels, and perhaps in due course of time for domestic passenger vessels, one would think a new standard would be required? Sub Chapter M for the towing industry in the USA, is nothing else but the ISM Code domesticated. The ISM Code is a useful well thought of document which provides strong fundamentals based on hundreds of years of sea experience, loss of life, cargoes, ships, and fortunes. The process-based management system it propagates would systematize operations. However, for an effective management system, the implementers have to be motivated and committed. The Flag States have to be strict and vigilant in their issue of certificates. When they outsource the certification to Ros, they must not wash their hands of their responsibility. The strict monitoring of the ROs by ensuring good clear concise MOUs (memorandums of understanding) with clear provisions to audit the ROs must be put in place. The owners and operators through their organization should put in place a robust internal auditing program that gives the objective inputs on the implementation of the ISM Code.

– by Dr. IJ Arora

ISO 14001-Benefits for Maritime Companies

Environmental accidents in the maritime industry get quick media attention. ISO 14001 does not guarantee that maritime accidents will not happen. It does, however, get organizations to consider their operations from a life cycle perspective of minimizing the impact of their operations on the environment.

The maritime industry has for a while now been governed by the requirements of MARPOL. MARPOL has 6 annexes and as of date all six annexes are in force. The six annexes cover the requirements for prevention of pollution of the marine environment by oil, noxious liquid substances, harmful substances in packaged form, sewage, garbage and air. However, MARPOL does not address the lifecycle operations of the shipping business. From an ISO 14001 perspective this would need to encompass the need for recycling of ships once they are done with their life.

The French Aircraft carrier Clemenceau is a good example of a vessel that faced major issues with being scrapped. Having sailed all the way to Alang, India it was denied entry and had to transit back to French Waters. It was denied access to Alang owing the Asbestos used on the vessel and the potential harm it would have on the scrap workers at Alang. MARPOL also does not address the operations as managed from operations ashore and the environmental impact of the operations of supporting the ships.

ISO 14001 encompasses the entire operations of the company if within scope and encourages organizations to look at all their operations from a lifecycle perspective. This essentially means that when designing office spaces and building ships companies need to start thinking about how they will dispose of waste from the processes in a responsible manner to the environment. Environmental sustainability is a new buzzword and demonstrating commitment to the environment, to stakeholders, through implementation of an internationally recognized standard ISO 14001.

ISO 14001 need not run independent of the existing management system that most maritime companies have conforming to the ISM Code. The requirements of ISO 14001 as with the MARPOL requirements get incorporated into the one management system on which the company operates. ISO 14001 as with other ISO standards is a voluntary standard. As such companies must choose to implement an environmental management system conforming to ISO 14001. Many leading maritime companies have already done so. QMII’s ISO 14001 training is delivered in multiple formats such as executive overviews, internal auditor and lead auditor. The training is also provided in an instructor-led online format and QMII’s instructors, having a maritime background, bring a unique skill set to the class in connecting the requirements of the standard through real life experiences.

Stop the Firefighting: Use Effective Root Cause Analysis

Root Cause Analysis (RCA) or Causal Analysis when applied correctly should help to prevent the recurrence and occurrence of similar issues within the organization. Why then is such little time, money and or effort afforded to it?

Heroes save the day! Yet again! How often have we come across news articles that laud those who manage the crisis, stop the plane from crashing or save the patient. The reality in any casualty is that, a system failure has resulted in a non-conforming product/service, including failed inspection. Organizations should laud and appreciate those who prevent incidents/ accidents/non-conformities and those who perform effective root cause analysis. Those who recognize near misses and perform CA  should receive equivalent if not more praise.

The root cause of many diseases is lack of a healthy lifestyle. Presumably, annual medical check-ups would show the flaws and enable risk appreciation to prevent a disease or illness from manifesting itself. This data however may not be enough to provide an accurate diagnosis or prevent a serious medical condition. Perhaps some may see the regular check-ups as a waste of money and time! This may help to explain why companies are reluctant to do root cause analysis when non-conformities arise. Their instincts are to do the firefighting when something goes wrong. This basic firefighting often appears to be less expensive, quick and seemingly more convenient. However, as has been proved again and again in various fields (quality, safety, security, etc.) prevention is better and more cost effective than the cure.

Why Problems Persist?

There are many methodologies for root cause analysis (RCA). It is not the intent of this article to educate its readers on the various RCA methodologies. Before we delve into why problem persists let us considers why problems occur. Problems usually occur because of the lack of a functional well implemented management system. This includes the lack of management commitment, timely identification of risks and lack of controls/adequate resources for the processes. Despite repeated warnings from their doctor, patients choose to continue living their current lifestyle. During incident investigation interviews this comment is often heard ‘this is the way we always did it’. Humans are not always accepting of changes and ‘if it ain’t broke then why fix it?’ Management of change is never easy. The larger the organization the more difficult it is to enable the change. Often in management systems, problems are ‘fixed’. This makes the issue go away albeit temporarily. Everyone likes a good score card and ‘fixing’ the issue makes everything look good again. However, when the root cause(s) are not addressed this dragon will raise its ugly head again.

When root cause analysis points toward leadership or top management, the job security aspects may prevent the middle managers from completing the RCA process. This political limitation, to avoid exposing process issues within the ranks of leadership are counterproductive, and yet a reality. As preposterous as it may sound, in some cases leadership may opt for paying the fine when things go wrong and then proceeding as is. This is seen as the ‘less expensive’ option than resourcing actions to prevent the recurrence/occurrence of problems. Conflicts of interest in the workplace, can often be a reason for a lack of effective root cause analysis.

Stopping the Firefighting.

With all due respect to firefighters and other emergency personnel, organizations want to solve the problem, so they do not have to call them back! This means getting to the root cause(s) of the incident. Very often when identifying the root cause(s), the work group or practitioners often stop short of finding the actual “root cause.” These may be the immediate direct or indirect causes. The root case may lie in another part of the organization and often gets missed. Root Cause Analysis when done correctly drives systemic changes to prevent similar issues from cropping up again. As with everything else the RCA team needs the backing of the leadership including the needed resources to be effective.

In conducting effective root cause analysis, the inputs of customers and other stakeholders may be needed. For effective root cause analysis is of interest to all organizations that are integral to the successful implementation of a management system. The element of social responsibility in the defined duties of leadership need to be audited and have consequences when customer focus is lost. The new root cause analysis model should have an element of responsibility attributable to the top management. The intent, not to encourage a blame culture, but a responsibility culture. As a part of QMII’s management system implementation we train selected candidates as a problem-solving team to enable and empower continued success of the system. To sit in the fire house and focus on other initiatives such as innovation, social responsibility etc. an organization has to proactive rather than be responsive.

Conclusion

Leadership often questions why money spent on management systems, particularly when based on ISO Standards do not work? Why a conforming product or service is not constantly delivered by an organization? Mature organizations recognize that the only bad nonconformity (NC) is the one that they do not know about. Once the NC is identified, the system must drive Correction and CA (corrective action, based on RCA). Closed NCs added to the database, along with the proper analysis of the information, will allow system users to appreciate risks and trends to identify the opportunities for improvement (OFI). However, all this will fail if the MS (management system) users do not understand the value of RCA.

For the success of a Management System, its outputs based on inputs must deliver conforming products and services.  When the Management System does not achieve this, all stakeholders should be interested in the root cause analysis and corrective action.

Re-thinking the ISM Code

The ISM code, when implemented in 1998, was meant to encourage organizations to take ownership for the safe operations of their ship and the safety of the environment they operate within. Many years hence and the benefit of the ISM code is still being debated. Has it been a boon or a burden to the maritime industry?

Given the number or maritime accidents and loss of lives, most would opine that safety would be second nature to those at sea. Something like wearing a seatbelt when driving a car where the person does it for their own safety and for those travelling with them. It is not done out of fear of the enforcement authorities. So then why has the ISM code not driven a similar safety culture within the maritime industry?

Boon or Burden?

In many companies, the ISM code implementation has become a paperwork drill; where it is seen as a means of demonstrating to regulators that the requirements have been met. The reasons for this culture are many, including but not limited to:

  • Lack of effective communication between ship and shore staff (one of the key issues the ISM code aimed to address)
  • Fear of reporting of non-conformities / near misses (lack of job security)
  • Hierarchical structure of companies
  • Authoritarian leadership (my way or the highway)
  • Systems not customized to the vessel (generic to the fleet)
  • Poor system implementation

The ISM code provides a system approach to continual improvement but only when the code is implemented in the right spirit. Personnel often do not understand the ‘WHY’ for implementing an SMS and their need to do the right thing. Often conformity/compliance is stressed even when the actions may not be the right thing to do. Measures such as Bridge Resource Management are add-ons to ensure effective communication of risks and challenging of group thinking. However, often the training is not sufficient to enable challenging a senior officer unless they are encouraged to do so. Most mariners today view the SMS on board as a burden. Over-documentation is slowly killing the system and once incorporated into the system, requirements rarely get removed. SMS reviews done by the Master do not truly evaluate how the SMS is adding value to the effectiveness of the system.

The Case for Risk-Based Thinking

ISO 9001 in its revision in 2015 introduced the concept of risk-based thinking, wherein organizations shall assess the risks to their system given the changing environment they operate within and then plan to take actions to address these risks. This concept of risk-based thinking is driven down to awareness of the entire staff of the need to contribute to the effectiveness of the system. While the ISM code in its objectives requires companies to identify and safeguard against all risks this has in many cases become a paperwork exercise of completing a risk assessment form and filing it. The ISM code in essence has encouraged companies to identify potential emergencies, prepare contingency plans for them and the drill in these. Often these are limited to the same 10 or 12 scenarios such as grounding, oil spill, man overboard etc. Many maritime companies are ISO 9001 certified but often the scope of this certification only extends to the shore-based offices. While the certification scope may be limited, there is nothing stopping companies from extending the system to vessels or at the least the concept of risk-based thinking.

The safety culture must start with the commitment of the leadership and then be reinforced throughout the organization. The fear of reporting non-conformities must be eradicated. This can only be achieved when personnel are confident that there will be no repercussions. Regardless of the safety culture of organizations however, given the contractual nature of employment at sea, it is often difficult to inculcate a sense of commitment to the SMS. Mariners in general tend to work safely and watch out for safety of their shipmates. At times though, the culture of “follow the procedure” leads to actions being taken even when they may not be the best, given external influences and circumstances.

Consultation and Participation

ISO 45001, a standard for occupational health and safety management systems, introduces the need for ‘organizations to maintain a process for consultation and participation of workers at all applicable levels and functions, and, where they exist, workers’ representatives, in the development, planning, implementation, performance evaluation and actions for improvement of the OH&S management system’. Getting inputs from the entire workforce enables quicker and easier buy-in to the system. The SMS while capturing the various requirements should be designed for easy use by the users of the system. Often SMS manuals on board are bulky and rarely referenced. Personnel choose to follow the practices they have learned over the years from other ship mates and mentors rather than reference the SMS.

When asked for feedback on how to improve the system, many mariners have ideas but the system at times does not provide an avenue for this feedback to be captured and formally implemented within the SMS. Best practices often remain limited to a vessel as a result. Following the concept of risk-based thinking, organizations need to consider the risk of barriers to participation and take measures to reduce these. Many accidents/incidents and near misses could be addressed if mariners could have asserted themselves in the situation and alerted someone to the problem/potential non-conformity.

Conclusion

Some in the industry are calling for increased regulation to improve the maritime industry in ensuring ships are operated safely. However, regulators can only do spot checks. They are not on board 365 days of the year. Operational pressures play a major role in how risks are assessed. The grounding of the Torrey Canyon is a prime example of this as is perhaps the Titanic.

As the use of technology increases and reliance on electronic systems, consequently new risks will be introduced to the maritime industry. This new era will benefit from a re-think of the ISM code to encourage the inclusion of risk-based thinking (beyond just a documentation exercise) and the participation of mariners to actively improve the SMS and embrace safety. In conclusion, maritime companies (with or without a change to the ISM code), in the interest of their mariners and the maritime industry at large need to rethink their approach to implementation and maintenance of the SMS.