Domestic Passenger Vessel Accidents Are Preventable Using a Management System (Part Two)

Dr. IJ Arora:

In the first part of this two-part article, we began to consider the key commonality of accidents involving domestic vessels such as the Conception and the Spirit of Boston, namely, the absence of a fully functional management system. Here in part two, we will examine this in more depth from the perspective of the Plan-Do-Check-Act (PDCA) cycle.

Emphasizing a proactive safety culture and systematically addressing risks can greatly enhance safety in the domestic passenger vessel industry. By being vigilant and forward-thinking, companies can significantly reduce the likelihood of accidents and ensure the well-being of both crew and passengers. A comprehensive systems approach that prioritizes safety at all levels is essential for fostering a resilient maritime environment.

As a consultant with almost four decades of experience, I feel that my emphasis on fostering a proactive safety culture within the domestic passenger vessel industry is both timely and essential. The sector has historically witnessed incidents that stem not just from operational failures but from lapses in systematic risk management. The simple PDCA cycle makes risk appreciation essential and helps create a proactive management system. A proactive safety culture is not reactionary, but anticipatory. It is focused on identifying and mitigating risks before they evolve into incidents.

In domestic passenger operations, where crew and passengers coexist in dynamic and sometimes unpredictable environments, the safety culture must be leadership-driven, with management exemplifying and enforcing safety values. It must also be behavior-based, encouraging crew to speak up about near-misses or unsafe practices. An environment for quality, health, safety, and security must be built and maintained. The overall management system must be systems-supported, with procedures that make it easy to report, track, and correct hazards. A genuine safety culture is evident when every level of the organization—from executives to deckhands—considers safety an integral part of their responsibilities, not an afterthought.

Right at the start of the PDCA cycle, at the Plan stage, organizations must commit to identifying, evaluating, and mitigating risks. This is not just a best practice, but a requirement under clause 6.1 of ISO 9001:2015, which requires “… actions to address risks and opportunities.” It emphasizes understanding internal and external issues and planning actions accordingly to mitigate risk. In a similar vein, clause 8 of the ISM Code requires organizations to evaluate all identified risks to their ships, personnel, and the environment and establish appropriate safeguards. Failure to account for risks at this stage can cascade into the Do stage, with flawed procedures or untrained personnel resulting in increased chances of accidents.

In a systems approach it should be completely unacceptable to transfer uncertainty to the crew. Uncertainty in procedures, poorly defined emergency roles, or ambiguous hazard controls lead to hesitation and confusion during critical moments. The vessel crew should never be the first line of discovery for unanticipated risks. The shore-based organization must do the heavy lifting in identifying, documenting, and training for these risks. This principle aligns with clause 5 of the ISM Code, which mandates the establishment of safe practices in ship operations and a safe working environment.

Systemic safety as a shield against repetition must be created from lessons learnt. Clause 7.6 of ISO 9001 on knowledge is relevant and a requirement. As can be seen from various NTSB investigation reports, many vessel accidents share common causal factors: complacency, procedural lapses, miscommunication, or design flaws. These can be mitigated when a systems approach is employed linking technical systems, human factors, procedures, and training into one cohesive safety net. Lessons learned from past accidents are institutionalized not just in the safety management system (SMS) but in organizational memory and training routines.

Most importantly, risk appreciation must be the foundation of resilience. The ability to appreciate (not just assess) risk is what distinguishes a compliant company from a truly resilient one. Appreciating risk means embedding foresight into the organizational DNA, training teams to ask, “What if?” before a situation turns critical. This should holistically lead to and support the creation of maritime systems that do more than tick boxes—they save lives.

Applying the PDCA Cycle

Connecting these insights to the 2019 Conception tragedy not only reinforces the urgency of implementing a proactive safety culture but also illustrates precisely how systemic failures in risk appreciation, planning, and organizational accountability can lead to devastating outcomes.

As you will recall, the dive boat Conception caught fire while anchored off Santa Cruz Island, California. This resulted in the deaths of 34 people, which was the deadliest domestic maritime disaster in modern California history. The victims were asleep in a bunkroom below deck, and none of them survived. Only five crew members escaped. This tragedy was a catastrophic failure of planning, risk management, and safety culture.

The Conception disaster links clearly to a breakdown in the PDCA cycle, as follows:

  • Plan. Inadequate risk appreciation was a vital failure. There was no comprehensive risk assessment identifying the dangers of leaving charging lithium-ion batteries unattended overnight in a confined space. The lack of clearly marked and accessible escape routes was a known risk that was neither mitigated nor escalated. There was no SMS, nor was one legally required for that vessel. Still, a proactive operator would have voluntarily implemented one. As has been said, “Failing to plan is planning to fail,” and in this case, a lack of foresight into fire hazards, emergency egress, and nighttime watchkeeping was fatal.
  • Do. Lapses in implementation are apparent and have been pointed out in the NTSB report. A night watchman was required by regulation and the vessel’s certificate of inspection but was not on duty. The crew had no fire detection system below deck that could alert sleeping occupants of danger. Emergency drills and preparedness procedures were either nonexistent or insufficiently enforced.
  • Check. The investigators saw no monitoring or audit mechanisms. The vessel operator, Truth Aquatics, had no self-checking mechanism for compliance with watchkeeping requirements. There was no internal audit or reporting structure that caught repeated violations, such as skipping the night watch.
  • Act. This final stage of the PDCA cycle is intrinsically connected to leadership both ashore and at sea. However, there was almost a complete absence of any corrective action, despite past observations and near-miss warnings about battery charging risks and poor escape routes. The organization normalized deviation, operating under the illusion of safety through habit.

Failure to appreciate risk is a violation of ISO 9001 and ISM principles. The Conception incident demonstrates how not appreciating risk in the Plan stage—especially related to emerging threats like battery fires—can result in fatal vulnerabilities. Had a formal risk-based approach been followed, battery charging, watchkeeping, and egress issues would have been flagged and corrected.

Mitigating risks with an SMS

Although not mandated for this class of vessel, the absence of an SMS and risk-based approach violated the spirit of the ISM Code. Clause 8 calls for evaluating all risks and preparing for emergencies. The lack of a nighttime watch, poor escape design, and no contingency procedures represent failures in both design and culture.

The failure to appreciate hazards and risks by the organization on shore was passed to the crew and passengers, who paid for it with their lives. Passengers had no idea there was no overnight watch, a basic safety expectation. The crew was not empowered with procedures or tools to manage an emergency, placing them in an impossible position once the fire began. I therefore emphasize “companies cannot pass uncertainty to those on board.” The burden of risk must be identified, mitigated, and managed ashore, before the ship even leaves port. All that was required was a proper management system, resourced and implemented effectively and efficiently.

By not having an SMS, organizations are ensuring that there is no safety net in case the worst occurs! A comprehensive, systems-based approach could have identified the risk of charging batteries and flammable materials in confined quarters and ensured continuous watchkeeping practices were in place. The SMS would have required mandated drills, escape route evaluations, and fire detection systems. Simple internal audits would have perhaps given the management the inputs to ensure continual improvement and planned a system to ensure compliance. This would have embodied the PDCA cycle, where each stage feeds the next with learning, foresight, and action.

Conclusion

My final thought on lessons written in loss and tragedy are that having a system is the least those charged with entertaining people can do to guarantee that lives are not lost. The Conception tragedy in particular is a grim testament to what happens when safety is assumed rather than engineered. The call for a systems approach rooted in proactive risk appreciation is exactly the kind of thinking needed to prevent another such disaster.

My argument for the mandated or voluntary adoption of an SMS in the domestic passenger vessel sector draws on evidence from NTSB investigations and international best practices. Domestic passenger vessels, though subject to U.S. Coast Guard inspection regimes, are often not required to implement a formal SMS. This omission has led to repeated safety lapses where identifiable risks were not systematically mitigated. As we have seen, the consequences of such lapses can often be fatal.

It is time for the overall national policy to encourage the U.S. Coast Guard to extend SMS requirements to large domestic passenger vessels and establish tiered SMS models scalable by vessel type and operation. To the industry czars my recommendations are to encourage industry bodies to provide incentives and recognition for SMS adopters and promote voluntary adoption through education and resource support. To the organizations and companies operating in the domestic U.S. waters, I suggest these company-level actions:

  • Begin voluntary SMS implementation aligned with ISO or ISM principles.
  • Train personnel in the PDCA methodology.
  • Perform internal audits and hazard reviews regularly.

The tragedy of the Conception and the other incidents we have discussed reveal that compliance alone does not ensure safety. Only a structured, systems-based approach can prevent recurrence. It is time for the domestic passenger vessel industry to adopt SMS—not only as a regulatory checkbox but as a foundational safety ethos.

Note – The above article (Part 2) was recently published in an Exemplar Global publication – ‘The Auditor’

Click here to read the article.

Click here to read part 1 of the article

Domestic Passenger Vessel Accidents Are Preventable Using a Management System (Part One)

Dr. IJ Arora:

Think of any accident, mishap, or tragedy involving a passenger vessel through history (or in recent times) and then look at the post-event investigation report. If you do this, you will find one shortcoming common to these tragedies: a poor appreciation of risk and the practical nonexistence of a management system. Occasionally, in slightly less disastrous events, you may see the existence of a system, but it is usually poorly implemented.

This two-part article considers the domestic passenger vessel industry in the United States, where there have been several tragedies. I hope (although hope is not a plan) that this work will inspire the industry to look at the proper implementation of management systems. In trying to narrow the discussion, we will analyze and learn lessons from the 2019 sinking of the Conception and to a limited extent the 2023 fire aboard the Spirit of Boston cruise ship. I will mention a few other incidents as well to make the connection and bring out the failure of the various systems that broke down.

A systems-based approach in analyzing accidents in the domestic U.S. passenger vessel industry involves looking at the various components and process interactions that could potentially lead to incidents. This can include factors such as crew training, vessel design, regulatory compliance, maintenance practices, and emergency preparedness. However, the major factor is usually the absence of a management system (or a badly designed and/or poorly implemented one). This is a tragedy in the making.

I am studying these accidents to demonstrate how a systems approach could have helped prevent many of these mishaps. The reluctance to implement an effective management system pains me, not to mention primary investigation agencies like the National Transportation Safety Board (NTSB), the United States Coast Guard (USCG), and other responsible bodies.

Note that I am not discussing technical processes here. Yes, those often fall short of the mark as well, but the bigger issue is the failure to apply simple systematic thinking based on existing management system standards. This reluctance to work systematically surprises me. I’ve recently expressed my views on the Baltimore Bridge collapse, the implosion of the Titan submersible, the collision between an American Airlines flight and a military helicopter over the Potomac, and the Boeing 737 Max inspection failures. In all cases, I cannot understand why a simple, cost-effective action such as properly implementing a management system should be such a critical weakness within so many different organizations. It is a leadership flaw, for (as W. Edwards Deming said) “A bad system will let down a good person every time!”

Titanic and Herald of Free Enterprise

When discussing this topic, many will think back to the Titanic tragedy which goes back more than 100 years. This is of course perhaps the most well-known sinking of all time, so I will not rehash the details, which are easily available online. However, I do want to mention that events like the sinking of the Titanic create the ultimate push—it caused a reaction and, ultimately, the creation of a workable system to help save lives and the vessels themselves. Depending on owners, operators, and masters, to use their judgment and do the right thing at the time of crisis was no longer enough. What the Titanic demonstrated was that the industry needed enforceable regulations and requirements. The result was the Safety of Life at Sea (SOLAS) Convention, which formalized a systematic approach to safety.

Before studying incidents occurring in U.S. domestic waters, I also want to mention the tragedy of the Herald of Free Enterprise, which occurred on March 6, 1987, at Zeebrugge, Belgium. The Herald of Free Enterprise was a roll-on/roll-off ferry owned by the Townsend Thoresen company. On that day, the ship capsized shortly after leaving port and 193 people lost their lives. It had departed with its bow doors open, allowing seawater to flood the car deck. Within minutes, the ship was lying on its side in shallow water.

The tragedy exposed severe deficiencies in the company’s safety culture and operational practices. Justice Barry Sheen was appointed to head the official inquiry into the disaster. His report, published in October 1987, was scathing and unprecedented in its criticism of the ferry operator, management, and the broader safety practices in the maritime industry. Justice Sheen’s report identified a “… disease of sloppiness and negligence at every level of the hierarchy.” This became one of the most quoted phrases from the report. Sheen emphasized that the disaster was not due to a single act of negligence but rather a “… catalogue of failures…” including the failure to ensure the bow doors were closed, poor communication between crew and bridge, inadequate safety procedures, and the absence of proper checks before sailing.

The report placed heavy blame on the senior management, asserting that safety was not a high priority for the company. It also noted that management failed to implement procedures that could have prevented such a tragedy.

It is indeed shocking and surprising that even today, decades later, investigations reports are still pointing out these same drawbacks. Lessons learned seem to be forgotten. I particularly wanted to focus on this incident because Justice Sheen’s report was a turning point in maritime safety regulation. It directly influenced the creation of the ISM Code under the International Maritime Organization (IMO), which mandated formal safety procedures and accountability in international shipping operations.

Conception

The Conception was a dive boat that caught fire off the coast of California, resulting in the deaths of 34 people in 2019.

Investigations into this disaster revealed several deficiencies, including inadequate fire safety procedures, lack of a proper emergency escape route, and insufficient crew training. There were also issues related to the vessel’s sleeping arrangements, where most of the passengers were asleep below deck at the time of the fire.

A systems approach would emphasize the need for comprehensive safety protocols, regular training for crew members, proper vessel design for evacuation, and effective regulatory oversight to ensure the robust implementation of safety measures.

Spirit of Boston

This incident involved a fire that broke out on the dining cruise ship Spirit of Boston while docked in 2022.

The fire was linked to a potential electrical malfunction, but it highlighted issues related to maintenance practices and emergency response protocols.

By applying a systems approach, stakeholders could focus on root cause analysis, looking into how maintenance schedules, crew training, and emergency responses are integrated and managed.

Overall recommendations for the systems approach

There are several important elements to consider in favor of the systems approach, as follows:

  • Interdisciplinary collaboration. Promoting collaboration among various stakeholders, including regulatory bodies, ship management companies, and safety experts, to share information and best practices
  • Root cause analysis. Encouraging investigations that go beyond the immediate causes of accidents to identify systemic failures that could contribute to unsafe conditions
  • Regular training and drills. Implementing continuous training and emergency drills for crew members to ensure readiness, competence and enhance situational awareness
  • Maintenance and safety protocols. Establishing stringent protocols for vessel maintenance and safety checks, with thorough documentation and compliance checks
  • Regulatory oversight. Advocating for robust regulatory frameworks that require adherence to safety standards and proactive risk management strategies
  • Cultural change. Fostering a safety-first culture within organizations that prioritize safety above operational pressures

We can see in these two recent incidents that, as with the case of the Herald of Free Enterprise, a systems approach enables a comprehensive understanding of the complexities involved in maritime operations, leading to better prevention measures and enhanced safety outcomes in the passenger vessel industry.

Other examples

Over the years, the NTSB has investigated numerous accidents involving passenger vessels. A few notable examples follow:

  • Estonia. Although this accident occurred in European waters, its implications affected international passenger shipping, including practices adopted in the United States. The Estonia sank in the Baltic Sea in 1994, resulting in the deaths of 852 people. The investigation revealed that the key issues were related to vessel design, including hull integrity and cargo securing. This incident led to enhanced safety regulations regarding passenger vessel construction and operational safety protocols.
  • Andrew J. McHugh. This collision involving the ferry Andrew J. McHugh and another vessel occurred in the narrow Houston Ship Channel, leading to the deaths of 17 passengers in 1980. The key factors included poor visibility, navigational errors, and inadequate communication between vessels. Subsequent recommendations from the NTSB aimed at improving navigational practices and vessel traffic control in critical areas.
  • Benson. The Benson, a tour boat in New York, capsized during a sudden storm. A total of 10 people died in this 2000 incident. The investigation pointed out questionable weather assessment practices and inadequate safety measures for handling sudden weather changes. The NTSB recommended better training for crew members regarding weather evaluation and emergency response.
  • Dawn Princess. A fire aboard this cruise ship in the South Pacific led to emergency evacuations in 2003. Although there were no fatalities, more than 150 passengers were affected. The fire was linked to flaws in electrical systems. The NTSB emphasized improved fire safety systems and crew training on firefighting and evacuation protocols.
  • Emotion. This fishing vessel capsized near Alaska in 2010, resulting in several fatalities. The investigation pointed out structural problems and issues with the vessel’s stability while loaded. Recommendations focused on vessel stability assessments and the importance of adherence to safety regulations during fishing operations.
  • Explorer. In 2007, the Explorer ran aground off the coast of the Antarctic Peninsula, leading to evacuations. All passengers were saved, but the incident raised alarms about navigational practices and inappropriate response to weather changes. The NTSB highlighted the need for enhanced navigational training and real-time communication.

For each of these incidents, a systems approach would involve comprehensive training programs for crew related to emergency preparedness, rigorous maintenance and operational checks, research and implementation of advanced technologies for navigation and safety, and collaboration among regulatory bodies to create uniform safety standards that encompass all aspects of vessel operation. These historical examples underscore the importance of a proactive stance on maritime safety, highlighting that every component of the system must work together to prevent accidents and improve safety outcomes in the passenger vessel industry.

A poor approach that fails to be proactive can significantly contribute to accidents such as these. When risks are not systematically identified and appreciated, several detrimental consequences can arise. Without a systematic approach to risk assessment, potential hazards may go unnoticed, increasing the likelihood of incidents. Vessels may not be adequately equipped to handle specific risks, such as extreme weather or equipment failures. There is a requirement for safety protocols, adequate training, and improvement of communications.

On the other hand, a reactive approach undermines effective communication within the organization and between vessels. Without established systems for reporting and discussing risks, lessons learned from previous incidents may be ignored.

The other factors are regulatory compliance lapses. In the absence of a proactive culture, vessels may not adhere to regulatory requirements consistently or may develop a compliance mindset that prioritizes minimum standards over comprehensive safety practices. Neglecting lessons learned from past incidents is another flaw. A failure to learn from past accidents can lead to repetitive mistakes. If organizations do not analyze historical incidents and implement changes based on those insights, they risk encountering similar situations again and again.

In the second part of this article, we will discuss the importance of using the Plan-Do-Check-Act cycle in embracing a safety management system.

To read Part 2 of the article – Click here

Note – The above article was recently published in an Exemplar Global publication – ‘The Auditor’

Click here to read the article.

How to Retain Auditor Training Knowledge When You Can’t Apply It Immediately 

Completing an auditor training course is an exciting milestone. You walk away with frameworks, methodologies to create checklists, audit question techniques, and—if you’re like most professionals—a head buzzing with new knowledge. Ideally, you’d jump right into an audit and apply your skills, reinforcing what you’ve learned while it’s still fresh. But what if that opportunity doesn’t come right away? 

At QMII, we recognize this common challenge among our alumni. Let’s explore effective strategies to bridge the gap between training and practice—so that knowledge doesn’t fade but instead becomes a solid foundation for your future audit work. 

1. Simulate Real-World Scenarios 

Action: Design mock audits for yourself or with peers. 

Even without access to an organization’s system, you can simulate an audit process by reviewing publicly available quality manuals, environmental reports, or sample procedures including your own. Pretend you’re preparing for an audit: write an audit plan, create checklists, additional documentation you would request and practice conducting document reviews. 

Tip: Use scenarios from your training or past experience and ask yourself: 

  • What would I ask as an auditor? 
  • What evidence would I seek? 
  • What risks could be present? 

2. Start a Learning Journal 

Action: Reflect on key concepts, standards clauses, and audit techniques by writing them down in your own words. 

Journaling isn’t just for reflection, it’s a brain-anchoring technique. When you write out what you remember and how you would apply it, you’re reinforcing neural pathways tied to that knowledge. 

Include: 

  • Summaries of ISO clause requirements. 
  • How you would handle nonconformities. 
  • Sample non-conformities within your organization and write down your assessment of them as also the effectiveness of corrective actions. 

3. Teach Others What You Learned 

Action: Participate in knowledge-sharing sessions. 

There’s no better way to solidify your understanding than teaching others. Reach out to other auditors in your organization and discuss applicability and interpretation of a clause. Participate and contribute to discussions on LinkedIn forums. Search the web for interpretation of clauses and see the differences as opined by various different personnel. 

Bonus: You’re also building your credibility and visibility as an auditor. 

4. Stay Active in the QMII Alumni Network 

Action: Engage with blog articles, LinkedIn posts, ask questions, and share insights. 

QMII’s alumni network offers a treasure trove of experience. Staying engaged keeps you in the loop on best practices and might even lead to mentoring or shadowing opportunities. React to blogs written by QMII, contribute articles for QMII blog, comment on QMII posts and connect to QMII alumni. 

Don’t hesitate to: 

  • Ask others how they’re maintaining their skills. 
  • Request mock audit partnerships. 
  • Share resources and templates you’ve created. 

5. Continue the Learning Loop 

Action: Sign up for webinars, read audit case studies, and revisit your course materials regularly. 

Audit skills are built not just on knowledge, but on judgment, observation, and communication. You can sharpen these even while waiting for your first official audit assignment. 

Suggested activities: 

  • Attend QMII webinars or ISO updates. 
  • Subscribe to quality-focused newsletters. 
  • Read ISO audit case studies and identify what went wrong—and why. 

6. Request to Observe Internal Audits 

Action: If you’re part of an organization, ask to shadow an experienced auditor. 

Even if you’re not leading, observing an audit helps you internalize the structure, flow, and behavioral nuances of auditing. Jot down observations on auditor behavior, techniques, and interaction styles. Create your own checklists and then compare it to that prepared by the lead auditor. Discuss the differences after the audit. 

If your organization doesn’t have an active program, this is a great opportunity to propose starting one—a value-added initiative from a proactive auditor-in-training. 

Final Thoughts: Don’t Let the Gap Become a Gully 

Skills fade when left idle, but they flourish with even light engagement. Whether it’s through simulation, teaching, journaling, or community interaction, there are numerous ways to keep your audit knowledge sharp and ready. 

At QMII, we believe that continual improvement isn’t just for organizations, it’s a personal practice. Stay connected, stay curious, and keep that audit mindset active until your next assignment arrives. 

Have your own tips for retaining training knowledge? 
Join the conversation by commenting on this blog or drop us a line—we’d love to feature your story! 

10 Steps to Safeguard Maritime Property from Cybersecurity Threats

IJ Arora, Ph.D

Cybersecurity threats have become a pressing concern in the modern era due to our lives becoming increasingly dependent on computerization. However, with the convenience of technology comes vulnerability to malicious attacks. The maritime industry, with a growing reliance on technology, faces significant cybersecurity threats. Dr. Jekyll and Mr. Hyde (i.e., good and bad) exist and have always existed. Protecting against cyberattacks is crucial to ensuring the industry’s stability and security.

Understanding cybersecurity in the maritime industry

Cybersecurity in the maritime sector involves safeguarding systems, information, and assets from unauthorized access, disruptions, or manipulations. The industry’s growing reliance on technology, including networks controlling essential functions like navigation and communication, makes it an attractive target for cybercriminals. To maintain business continuity, it is crucial that companies assess their current cybersecurity posture and act to proactively improve it. The maritime industry supports trade and the economy at large, so a cyberattack can have broader consequences beyond just affecting a single vessel or company. For this reason, the intent of the attackers might be broader than simply affecting a specific entity for ransom.

Current challenges in maritime cybersecurity

Before delving into the 10 essential steps to fortify against cyberthreats, it’s crucial to acknowledge the prevalent challenges faced by the maritime industry, which include:

  • Business continuity disruption due to breaches
  • Lack of comprehensive response plans
  • Growing reliance on automation
  • Insufficient awareness
  • Vulnerabilities in cloud computing
  • Rise in phishing and social engineering attacks
  • Internal threats and attacks

Controlling both information technology and operational technology systems is critical to fortifying cybersecurity. Various systems within the small passenger-vessel sector are susceptible to cyberthreats, including bridge systems, access control systems, passenger servicing and management systems, and communication systems.

The 10 steps

When addressing cybersecurity, organizations must consider protecting information itself as well as the asset on which that information is stored. Control of both information technology (IT) and operational technology (OT) systems is critical to fortifying cybersecurity. Additionally, management must consider the confidentiality, integrity, and availability of information and how these three aspects may potentially be compromised.

Step 1: Leadership commitment

Leaders must drive the need for cybersecurity and ensure that it is baked in (not buttoned on) to processes. They need to engage the workforce to contribute to the system. To do this, they can:

  • Appoint a cybersecurity manager to ensure accountability and garner buy-in.
  • Make cybersecurity integral to business processes and consider risks vs. rewards.

Step 2: Use a system framework

Employ the plan, do, check, act (PDCA) cycle as the foundation for a robust cybersecurity approach. This is also the approach prescribed by the Passenger Vessel Association (PVA) safety management system (SMS) framework.

  • Develop and regularly update cybersecurity policies aligning with organizational needs and threat landscape changes.
  • Identify clear roles and responsibilities for all concerned with cybersecurity aspects of the SMS.

Step 3: Contextualize risk

  • Consider the broader context of operations, trade patterns, technology, and legislative factors.
  • Identify stakeholders, online networks, assets, critical components, and business-sensitive information.

Step 4: Risk assessment (3D framework)

Leaving hazards in uncertain states is a drawback for proper risk assessment. It is the responsibility of leadership to convert uncertainty into clearly defined risks within the context of the organization and then prioritize those risks.

  • Organizations must assess hazards in terms of probability, severity, and the likelihood of detection.
  • Risks should be prioritized with consideration given toward confidentiality, integrity, and the availability of information.

Step 5: Build controls into processes

Controls can be split into various categories, including administrative, physical, human, and technological. In some cases one control may suffice, but for the most part a combination of controls must be applied. Identified controls should be implemented based on the feasibility rule, meaning that although they may look good in a vacuum, ease of implementation must be considered. Information security should be a part of everything the organization does—not an add-on. This includes:

  • Implementing technical security controls like firewalls and intrusion-detection systems.
  • Adopting a layered security approach (i.e., “defense in depth”) to effectively mitigate against various threats. This entails creating multiple barriers to prevent access to information—physical, passwords, firewalls, VPNs etc.

Step 6: Maintain basic measures

Basic safety measures are easy to implement and, for the most part, they are cost-effective. This can include cybersecurity awareness training for personnel, physical security, and password security. Below are a few more, although this is not an exhaustive list:

  • Keep hardware and software updated.
  • Enable automated antivirus and anti-malware updates.
  • Limit administrator privileges and control removable media.
  • Avoid public network connections without a VPN.
  • Regularly backup and test information-restoration capabilities.

Step 7: Employee awareness

It is important to make employees aware of the need for good cybersecurity protocols. Employees are often the weakest link in the security chain. Statistics show that almost 36 percent of data breaches are caused by employee negligence. Immediate actions organization can take include:

  • Educate employees on cybersecurity best practices to minimize human error.
  • Train personnel to identify phishing attacks and report incidents promptly.

Step 8: Emergency preparedness

No organization is immune to cyberattacks. It is important to have a plan in place for responding to attacks quickly and effectively. The plan should include steps for mitigating the damage, containing the attack, and investigating the incident. You can use ISO 22301: 2019, “Business continuity,” to develop this plan.

  • Your plan should include comprehensive processes for responding to cyberattacks swiftly and efficiently, including reporting mechanisms.
  • Test and improve your business continuity plan regularly.

Step 9: Assess effectiveness

The check stage of the PDCA cycle is vital to instill confidence in the effectiveness of the organization’s cybersecurity measures.

  • Conduct regular cybersecurity assessments, including third-party evaluations for objectivity.
  • Evaluate assets, vulnerabilities, IT/OT risks, physical access, and breach potentials.

Step 10: Continual improvement

  • Embrace continual improvement through the PDCA cycle to maintain vigilance.
  • Invest in training personnel on cybersecurity standards like ISO 27001.

Conclusion

Taking cybersecurity seriously and implementing these 10 steps can significantly mitigate the risk of cyberattacks. Begin the process by conducting a gap assessment using a qualified person to assess where your system currently stands and what actions need to be taken.

Your action plan should identify risks, gaps, and the controls needed. These controls can easily be integrated into the existing safety management system. Investing in cybersecurity today will better prepare your organization to manage future risks. Leadership involvement is crucial, and these steps serve as a solid foundation to effectively fortify cybersecurity measures.

About the author

Inderjit (IJ) Arora, Ph.D., is the President and CEO of QMII. He serves as a team leader for consulting, advising, auditing, and training regarding management systems. He has conducted many courses for the United States Coast Guard and is a popular speaker at several universities and forums on management systems. Arora is a Master Mariner who holds a Ph.D., a master’s degree, an MBA, and has a 33-year record of achievement in the military, mercantile marine, and civilian industry.

Above article is featured in the following:-

Foghorn Magazine

Exemplar Global Publication “The Auditor”

Looking Ahead at ISO 9001

ISO 9001 has proactively kept up with various industry expectations, over the years, to allow

application by a broad spectrum of industry including the defense forces. The 2015 revision was

a thoughtfully planned giant step. It defined risk (ISO 9001 Clause 6.1) in the context of the

organization (ISO 9001 Clause 4.1 & 4.2) and removed exclusions provision from certification by

redefining what an organization does not do or outsources in the scope (ISO 9001 Clause 4.3). It

also removed preventive action, a reactive concept, and introduced proactive risk appreciation

(Clause 6.1 of ISO 9001 & Clause 8.1 in industry specific standards as AS9100).

This took preventive action from the delayed “Act” stage of the PDCA (Plan-Do-Check-Act) stage

to the more logical sensible “Plan” stage. After all, “look before you leap”, as the historical

fundamental, could not be left as a preventive action decision. It had to be at the look – plan

stage! Risk also needed not just mitigation, but also acted as an input, to be used to bring in

innovation in terms of OFI (opportunity for improvement).

These were all positive steps in keeping with technical advancements and computerization and

AI (artificial intelligence) tools. The HLS (high level structure), later updated to HS (harmonized

structure), recognized the need to enable ease of implementation of integrated management

systems. This in turn leading to efficiency, ROI (return on investment) and where applicable

environmental protection, security of the global supply chain, business continuity, cyber

security and health and safety.

The differentiating of knowledge (ISO 9001 Clause 7.6) from competence (ISO 9001 Clause 7.2)

was also a clever needed change. Organizations needed to define their corporate knowledge

aspects and differentiate it from the individual knowledge of personnel. Knowledge and

competence needed merging and a healthy marriage but needed recognition that they were

different. Removal of the reference to Quality Manager (QM) and Quality Manual from the

standard, took away the narrowness of thinking in quality, and brought the clarity to leadership

to remain accountable and to differentiate authority delegation from retaining the

accountability.

I am a member of the TAG-176 group, and yet have not really contributed much to the next

expected changes to ISO 9001. I am sure the TC-176 is working on this. Nevertheless, it is time

to debate and consider updating the standard.

Since the 2015 version was a major fundamental change, I doubt there would be a significant

departure from this 2015 version in the next major update. Unlikely that the next version may

have revolutionary updates. The emphasis, I think would be to clarify and strengthen the

present thoughts in the 2015 version. I would consider the following:

1. Two Standard Concept: I have over the years thought about the two prongs:

manufacturing and service, approach. Both the service and the manufacturing industry

have been using the standard. Some may consider the need for a separate

manufacturing and a service standard as the next step. However, over the years I have

feared too much bureaucracy which the two standards approach brings. I think the two

standard approaches may actually cause more issues than to resolve them. Might I

opine that Clauses under 8.3 for D&D can, if needed, be strengthened, clarified or more

useful notes as applicable to service version incorporated to assist implementers,

consultants and auditors?

2. Risk be better defined and OFI be clarified, to avoid auditors using it as a tool to sneak in

recommendations. OFI is the outcome of considering risk as an input for innovation. It is

not a recommendation.

3. The knowledge clause needs meat to strengthen it, and to better make it inclusive to

systematizing the requirements for organizations to systematize lessons learnt.

4. An annex added to bring clarity and ease to designing and implementing a combined

management system for an organization.

5. Clause 4.3 Scope, in defining scope requires consideration of the context of the

organization, which is based on Clauses 4.1 and 4.2. However, while the scope has to be

available as documented, 4.1 and 4.2 do not require documentation. I would suggest

both clauses 4.1 & 4.2 to have context as a documented requirement.

In conclusion, I think, updating the standard ground up is not a wise idea at this stage. Perhaps

slight tweaking to include some minor changes would give stability in implementation of an

already robust standard.

How to Alleviate Common Management System Pain Points

Implementing ISO standards is not mandatory, however a management system conforming to a standard can have numerous benefits. Some benefits include increased efficiencies, proactive risk management, better interaction among departments and alignment with the needs of interested parties. However, once you are actually in the process of implementation, you may experience the following pain points: 

  1. Lack of top management commitment 
  1. Limited resources to effectively implement the program 
  1. Lack of buy-in from the workforce  
  1. Over documented systems  
  1. Lack of measurable objectives driving improvement  
  1. Teams lack adequate interaction and alignment  
  1. Company is focused on keeping certification at all costs  

Quality Management International, Inc (QMII), having over 37 years of providing sustainable solutions for our clients, recognized how these hurdles can impact an effective management system. QMII has developed and provided solutions to address and alleviate these pain points that continue to benefit our clientele. 

A management system consulting project cannot start without top management present to map the process of what they do (core process) and to identify the core objectives for the system. Policies, objectives, and motivation must be demonstrated from the top-down and evidenced by all the team players. To further reinforce commitment, we get top managers to develop a presentation to launch the system and that will then be used for awareness training as the system progresses. This is done using our Awareness Leaders Workshop. Without authority, responsibility, and resources, middle management and individual contributors cannot improve the business management system.  

We understand that companies have financial restrictions. With a mission to get organizations to appreciate the benefits of a process-based management system, we provide multiple options to work around this challenge. 

(1) We provide free information on our website so you can carry out ISO implementation at your organization.  

(2) Attending a lead auditor training course is a relatively minimal cost. You and your team will gain a comprehensive understanding of the desired ISO standard and gain the skills necessary to implement requirements and conduct audits to determine conformity.  

(3) If you need a little more guidance, we provide scalable consulting services. Our consultants are here to assist you with exactly what you need. You will not have to pay for the full package.  

(4) Our alumni have free email and phone support, for life, to get over average hurdles.  

As far as reluctance among employees, it’s human nature to be reluctant towards change. Keeping this in mind, QMII consultants get key process owners to evidence top management’s commitment and ensure that they are involved in QMS (Quality Management System) development. We analyze with them to capture the system AS-IS and what-should-be. It is essential to get the team buy-in during this process and get their input on the process’s actualities. Teams must also interact and be aligned. We provide team-building workshops where we align objectives to the vision and processes to meet objectives. 

ISO implementation is not an overnight process, it may even seem daunting. QMII’s Action Plan Checklist is readily available, and it focuses on the big picture to simplify the process. If you need more assistance, our consultants would be happy to work with you through the checklist. We appreciate the system you already have; we are simply helping you enhance it to meet requirements and set objectives. Documentation is a significant part of ISO implementation. To remove complexities, we incorporate existing documentation and use a format that works best for you. 

At the end of the day, ISO certification is primarily a marketing decision. QMII strives to help you develop a resilient, integrated management system so that you receive actual benefits. Once set up, your system will work independently and continue to improve while managing risk proactively.  

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.

Obtaining Top Management Commitment

Who cares about the system? 

Management systems need top management commitment to work well, and yet many systems lack the necessary commitment. You may recognize some symptoms.  Policy – ignored.  Objectives  are barely alive. Corrective actions remain open. Managers seem not to appreciate the value of the requirements.  Employees are unsure about the system’s requirements. Proactive identification and addressing of risks/opportunities is rare. Root causes of failure remain in the system. Consequently, the system is not improved. Employees are unaware of what the system should do for them. Management reviews are embarrassing. Leaders either do not show or do not contribute. Top Management Commitment is lacking. Audits may temporarily energize the players. Management representatives ask, “Am I the only person who really cares?” 

Who trained the leaders? 

Many leaders do not explain their management systems. They may know the importance of certification, but they rarely explain why their system is vital for survival and growth. Why is this? Examine your internal audit program; is it driven by top management’s objectives?  Audit your training records. Do they show that leaders are competent and confident to show their top management commitment? Who trained the leaders in their organizational management system?  Competent leaders take responsibility for their system. They explain how their system works and why its requirements are so important to them. Unaware leaders blame employees for mistakes caused by their system. 

Your system, is it perceived as worthy? 

Even if your system is certified, do not expect leaders to support it.  Every organization is a system. Does the documented part of this system describe how it converts stakeholder needs into cash (or continued funding)?  Is this the management system that was certified or was it some new ISO system built on templates?  

Is your system irresistible to the leaders?  If not, show how your system converts needs into cash so top managers would not want to lead without it. Try our methodology to appreciate how others have developed systems and gained top management commitment beyond certification. Everyone should fulfill their objectives and earn their bonuses by using and improving  the system.  

Awareness Leaders Workshop™ 

Engage us to design and facilitate your one-day Awareness Leaders Workshop™. Select attendees who are leaders by job title and those who are leaders by personality. Include the skeptics! 

We listen to your objectives and design your workshop to fulfill your required outcomes. This may need  system analysis to result in a diagram that explains how the system converts needs into cash. This  workshop is facilitated by our senior management system consultant and auditor, who for over 20 years  has helped many willing and reluctant managers to understand and commit to their systems. 

Prepare for action 

Remove the root causes of what ails many management systems. You want your top management commitment  to the requirements of their management system. Clear the backlog of stale CARs  and pending actions on identified risks to prepare for the surge of improvements flowing from the renewed leadership of your system.  

When you are ready, please email IJ Arora or call 888.357.9001 with your requirements.

Management review: A Necessity or Improvement driver

The management review is a critical step to ensure sustained success of the management system, yet this is often left to the relevant manager to document to meet the system standard requirements. A myriad of reasons is given for a management review not being done within the timeframe as defined by the organization. These include unavailability of senior management due calendar conflicts, waiting on inputs from department heads and sometimes just a lack of commitment by leadership.

Even when conducted ‘timely’ the review is often done purely out of necessity of meeting the requirements of the standard. The review, however, is a critical step for the success of the system and enables the continual improvement of the system. Leadership may, at times question, why money invested in a Quality Management System; that certification to ISO is not delivering the intended ROI. The answer often lies in their lack of commitment to the system as perceived by the users of the system.

Why are my reviews not driving improvement?

Management reviews when done out of necessity become a documentation exercise. The responsible manager collects all the data and analyzes/evaluates it for presentation to management. They proudly share these presentations with whomsoever asks about the management review. The ISO standards (e.g. ISO 9001, ISO 14001 and others) in clause 9.3 give the requirements for what shall be included in a management review. However, the review need not be limited to just these topics.

In consulting, QMII has often heard, “But we do daily reviews with our team and weekly updates with the managers”. Why not record these as a part of your management review? Do keep in mind that ISO standards ask organizations to conduct management reviews at planned intervals. It does not say it has to be a meeting or be held in a boardroom or the planned intervals need to be equally spaced. When the system is incorrectly implemented, or the standard incorrectly interpreted it often leads to a weak foundation of the system. Soon users of the system are complying and doing what has been documented rather than asking “is this really correct for us?”

With the passage of time, the lack of commitment percolates through the system to where the person tasked with championing the system, such as a quality or environmental manager, is fighting a lone battle. This lack of commitment may be apparent from the lack of decisions by management to issues presented in the review.  At times the concerned departments are trying to drive their own agendas, and this creates conflict and disconnect. Also, in recording the outputs of the review, the decision and actions from management must be recorded. QMII, often finds these missing.

How do I improve my management reviews?

To do so the organization must first understand the intent of this clause in the ISO standards. Clause 9.3 (under the high-level structure) asks management to review their systems to ‘ensure its continuing suitability, adequacy, effectiveness and alignment with the strategic direction of the system.’ This, in essence, must be the guiding principle for the management reviews.

This is the reason why these reviews must be done holistically. It is this guiding principle that will determine the intervals for the review. Clause 5.1 of the ISO standards (those aligned per the HLS) asks leadership to take accountability for the effectiveness of their systems. The management review is the platform via which they can assess if the system is effective in meeting their policy as set. The management review is also where management reviews the system and determines the required changes in the context of the organization, the needs of the interested parties to determine new risks,  if any changes to the policy / strategic direction needs to be made and resourcing needs.

Engaging Leadership and the rest of the team

There is no mantra that will deliver sure-shot success. I wish there was one, for I know many an organization that would willingly invest in it! However, educating management on the WHY of the management review has often helped. If need be consider external consultants to deliver the message. Additionally, you can consider these three steps to get more engagement:

  1. Gather review inputs from management team: This is a good method to get everyone involved. Pass around a draft meeting agenda so all system users can prepare for the review (should you be having a meeting) and can provide their inputs /items that they need management’s decision on. It is also an opportunity for them to gather opportunities for improvement from users of the system.
  2. Use a review format that works for leadership: Document how your reviews are done exactly the way they are done within your organization. Perhaps some agenda items are discussed on a quarterly basis and others on a weekly basis. The intent is not to please an auditor but to use this tool to drive improvements through the system, as needed. Remember, the guiding principle discussed above.
  3. Communicate the outputs of the review …. including leadership’s decisions. While the standard does not require this, it is implicit in ensuring continual improvement. Communication is important but the outputs of the review need not to be communicated to the entire organization. Perhaps relevant parts to the concerned managers and their teams. It demonstrates to the users of the system that management is involved, is aware of the problems and has provided decisions on various matters presented.

Management Reviews ….  Improvement Driver

When done correctly management reviews become the springboard for improvement throughout the system. It comes at the end of the ‘Check’ stage of the PDCA cycles leading into the ‘Act’ stage for continual improvement. It enables leadership to assess how well their system is doing. It delivers, in the long run, the engagement needed from users of the system and the ROI that leadership are seeking in their quality management system.

Defining Measurable Objectives/ Metrics to Drive Continual Improvement

Measurable objectives are an essential input for all levels of the management and come from the top management (TM). These objectives guide personnel at the work level to help ensure the success of a management system. The need for a set of value-based metrics is met by looking carefully at the company policy (based on the strategic direction) and then drawing the measurable objectives from it.

My thought is for any organization giving more than the desired value is a challenge! Values in today’s business world are often related solely to the ROI (Return on Investment). Providing value to the customer is a goal. The question is at what cost? Due to budgetary concerns, no organization wants to do more than what is required. Availability of funds is input to the design of the final product and or service. Consequentially, the values that an organization sets for itself must be based on trying to meet the objectives and expectations of the customers, or the statutory bodies (if relevant) within the constraints of the resources. Where a statutory body is involved, it is the vital responsibility of that body to precisely define expectations and what metrics they will accept.

My opinion is that the statutory bodies such as the FAA, FDA, EPA, and USCG, would have concerns about continual improvement by the external service providers. It is therefore critical to conduct an analysis and conduct management reviews internally to achieve the intended purpose of Clause 10.3 of ISO 9001:2015. However, it all starts with defining, providing and monitoring these clear expectations. This means that the statutory body should provide guidelines for stated requirements, as the IMO does in the ISM Code, within Resolution A.1118(30) & MSC-MEPC.7/Cir8. In a similar manner, the USCG could provide clear guidelines for TPO (Third Party Organization) and for the towing companies for the Subchapter M.

Statutory bodies, understandably, may struggle with defining their policy in the initial stages and clearly converting it to a set of measurable objectives (Value based metrics) for external providers. The need for the Leadership (TM) is to spend time and resources well at the plan stage of the PDCA cycle (Plan-Do-Check-Act) by understanding the context of the organization (Clauses 4.1 and 4.2 of the ISO 9001) and appreciate the various risks (Clause 6.1 of ISO 9001) keeping the customer focus in mind. The Standard here provides useful clauses to make the decision. An objective audit of the internal procedures of the statutory body (Clause 9.2 of ISO 9001) would provide the inputs for the Management Review (Clause 9.3) and ensure a robust decision-making process. This then should be followed by regular audits of the organization to which the processes have been outsourced (meeting the requirements of Clause 8.4.1 and 8.4.2 of ISO 9001). The organization which provides the outsourced service or product needs the information in terms of clause 8.4.3 to perform to the total satisfaction of the statutory body. As such providing clear requirements is a vital role of the statutory body.

Once requirements are clear, then the organization providing a product or service will use these inputs to design their Policy (Clause 5.2 of ISO 9001) 5.2.1d. This policy would then ensure that the feedback loop will help to drive continuous improvement efforts of the QMS. This policy would then provide the framework for the “value-based metrics” which in Quality terms would be the measurable objectives in terms of clause 6.2. Both 6.2.1 and 6.2.2 would put the organization on the correct path to success. The statutory body would vigorously and regularly audit the correct implementation itself or by using an independent professional service provider.

In effect, what this means is that just being certified to e.g. ISO 9001:2015 is not enough for any organization. What is required is a functioning PBMS (process-based management system) based on the chosen standard and other criteria implemented by committed leadership and motivated manpower.

(The author Dr. IJ Arora, is the President and CEO of QMII)