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Gard News 200, November 2010/January 2011

In 1912 the sinking of the TITANIC shook the world and led to the development of the SOLAS Convention, which sets out minimum requirements for the construction, equipment and operation of ships. However, it is fair to ask whether SOLAS addresses the underlying causes of the TITANIC accident.


The TITANIC had been launched into a highly competitive transatlantic passenger market and the owner wished to surprise the world by having her arrive in New York on her maiden voyage two days ahead of schedule. As a result, despite the observation of icebergs, the vessel maintained record-breaking speeds, which obviously made it much more difficult to avoid the collision. But why did an experienced master allow such high speeds despite the risk? The answer probably depends on whether in practice the master was in a position to say no.

Still today, many masters admit to having experienced commercial pressure, either explicit or implicit, to undertake operations which may compromise the safety of the ship. In a competitive market, goods must be delivered efficiently and timely, and there will be situations where complying with requests for delivery will risk the safety of the vessel. Research has shown, however, that the understanding and management of these conflicts are more dependent upon the culture of the particular organisation than on any rules or regulations developed to ensure safety.

Conflicts may develop at senior management level because of the perception that resources must be allocated on an "either/or" basis, to what are believed to be conflicting goals: production goals, i.e., delivery of services, and protection goals, i.e., considerations of safe operation (the two P's dilemma).

This article considers some aspects of the management of these conflicts and outlines the importance of addressing an organisation's culture to prevent commercial pressure having a negative effect on shipping operations.

Rules and systems may fail to influence safe behaviour
Domestic and international regulations have certainly increased the safety of shipping in general, but failsafe technology and compliance with manuals can not alone guarantee that mistakes will not be made. Human error is an element in nearly all accidents. An examination of 100 accidents at sea1 showed that in nearly 96 per cent of cases the accident should and could have been avoided had the humans involved acted correctly. Only four per cent of the incidents had causes beyond human control. These findings are supported by several other studies with similar results.

Traditionally, the focus on preventing human error has been on developing regulations and systems. However, in recent years it has become clear that such an approach has limited effect. Investigations following several major accidents have ascertained that the incidents were triggered by a weak safety culture. This expression is used to describe how, over time, organisations have placed a decreasing amount of emphasis on safety measures and thus developed dangerous practices. In other words, the problem is not errors made by individuals, but rather a number of errors made over time, that become part of general work practices. The culture of the organisation ignored the risk of such practices.

The importance of a proper safety culture is generally acknowledged, but it is often not properly addressed in day to day management. A typical example may illustrate this: a vessel collides with a quay and investigations indicate that proper procedures were not followed. A usual step to remedy such situation is to either introduce amended or additional procedures, or to send the officers involved on a course. In some instances, this may change the prevailing practice, but it is frequently an indication of a weak safety culture. Had the shipowners investigated more thoroughly, they might have found that procedures were not followed because there was insufficient time to do so whilst maintaining the voyage schedule. Where this is the case, the introduction of new procedures or sending senior officers on a course is unlikely to eradicate unsafe practices, but rather strengthen the belief that shortcuts must be taken in order to get the job done. The consequence is the tendency to cure the symptoms rather than the underlying cause, and the end result is that work practices remain unchanged.

Culture influences working practices
It is often said that procedures are not followed because of negative attitudes among crew members. However, usually these attitudes are a direct result of the culture of the organisation. Safety culture could be described as how an organisation prioritises safety and the behavioural norms which have evolved relating to safety.

How the members understand and relate to conflicting goals is a good example of how culture influences working practices. Conflicting goals are often seen as a perceived pressure or expectation which exists more or less implicitly within the organisation. This can lead to practices such as loading more cargo than permitted, operating at a higher speed than that seen as safe or skipping procedures. These can not be described as a poor attitude by an individual, but rather as a sign of a weak safety culture of the entire organisation. The safety culture governs how the whole organisation acts in safety-related issues. In some situations this may mean that although the organisation has an expressed policy of "safety first", this is not necessarily reflected in the culture and work practices.2 Figure 1 illustrates this by dividing safety culture into two different levels.3

Figure 1.

On the surface one will find many of the visible elements of the culture, i.e., "safety first" painted on the hull of the ship or the safety manager as an independent individual, all of which say very little about the organisation's actual approach to safety. On the other hand, it is the less visible elements, such as attitudes and values, which are of importance for working practices, as illustrated by the level below the surface in Figure 1. The difference between the middle and lower levels is that the middle level is the expressed stance, whilst the lower level is the unexpressed assumption. As illustrated in Figure 1, there can be considerable differences between these. The expressed attitudes often reflect the message of the official guidelines. In other words, how things ought to be. The unexpressed assumption has developed over time to form a common understanding across the organisation and has therefore become the norm when action is taken. These views have developed as a result of common experiences in the organisation. For example, if somebody is rewarded for keeping the operation going in spite of breaking formal guidelines, this will probably become the blueprint for future similar situations. Another example is where a master feels that he is being constantly challenged when he stops or questions an operation. This may influence his decision process in the future, and the option of stopping the operation may not be seen as a viable alternative. This illustrates that what the organisation does  is what guides day to day behaviour.

How you do it determines safe practices
Why is there a gap between what ought to be done and what is actually being done? The reason can be lack of focus on how the organisation as a whole handles situations where a balance is sought between earning money and conducting the operation in a safe manner. To ensure that safety considerations are not compromised when commercial decisions are made, the entire organisation must work actively to manage these conflicts. However, in shipping such decisions are frequently left to the master on board.

A typical shipping company is divided into ship management and commercial management. Ship management is responsible for the safe operation of the ship whilst commercial management is responsible for arranging commercial contracts. This organisational split can be a reason why conflicting goals are not properly addressed by some shipowners. Furthermore, the ISM Code requires the safety manager to be an independent entity to ensure that safety is prioritised. In reality, the safety manager is usually overburdened with administrative tasks and concentrates on ensuring that all formal requirements are fulfilled, rather than ensuring that safety is prioritised in practice. On the other hand, the commercial managers are in daily contact with the vessel to give instructions regarding future voyages and route planning. The potential conflict between the commercial side and safety must therefore be resolved by the master on board. Traditionally the master has overall responsibility for safety on board his ship and has formal authority to review all decisions should they, in his view, endanger the safety of the vessel. Many masters concede, however, that some commercial managers place considerable commercial pressure on them and that in certain situations it is difficult to say no.

Commercial managers do not usually consider themselves responsible for the safe operation of the ship, and will continue to put pressure on the master, as they expect him to say no when the risk is too high. However, everybody gives in to pressure occasionally, especially from their managers. Problems arise when these conflicts are not properly addressed and open space for a dangerous practice to develop. This shows that it is the way things are done, i.e., the safety culture, which influences safe working practices.

The starting point for improvement
Addressing safety culture and considering how an organisation prioritises safety may be a good starting point for improvement. The fact that conflicting goals will always be present must be acknowledged. In other words, it is impossible to totally eliminate conflicting goals so one should concentrate on methods to manage them. Organisations with a well-developed safety culture are fully aware of these issues. Safety is acknowledged as one of the core elements of the overall business goals.

In order to manage conflicting goals, the issue must be addressed through "open discussion". Managers have a vital role to play: without real commitment from management it is difficult, perhaps even impossible, to influence culture and working practices. Managers must be aware of their influence and be conscious of which practices to reward or sanction. A dangerous practice can not be rewarded the day everything goes well and money is earned, and sanctioned when things do not go so well. Managers must show that safety comes first, and set a good example.

Shipowners that have addressed the issue of conflicting goals emphasise that to be successful one has to acknowledge that these conflicts must be resolved ashore and not by the master on board. When communicating with the ship there must be a common understanding.  It is also important that the master's decisions are supported and not challenged.

These measures will create a more positive safety culture, which encourages everybody within the organisation to take responsibility for overall safety and warn of any possible risks to it. Work with safety culture is a never-ending story and it can take some time before results are evident. It is also important to be aware that, even in the best organisations, human error will occur. The difference between the good and the not-so-good organisations is that those with a good safety culture acknowledge that human error can occur and therefore try to improve working conditions. To quote from the influential safety researcher James Reason, "we cannot change the human condition, but we can change the conditions under which people work".

1 Willem A. Wagenaar, Jop Groeneweg, Accidents at Sea: Multiple Causes and Impossible Consequences. International Journal of Man-Machine Studies 27(5-6): 587-598 (1987).
2 Mostad, Linn Therese (2009), Management of conflicting goals.
3 Schein (1997) in Organizational culture and leadership, modified by Torkel Soma.