Preventing Major Ship Incidents
How the company's organizational culture works to prevent,
or contributes to incidents and disasters
By Tim Close, Captain U.S. Coast Guard (retired)
Senior Consultant, Independent Maritime Consulting LLC
This article is about preventing major ship incidents involving human factors by focusing at the company level regarding the organizational culture. Fatigue, training, or competence at the individual level can certainly cause or contribute to major ship incidents. However, the priorities, expectations, and mixed signals sent by different parts of the company contribute to the company’s organizational culture and can strongly influence decisions made and actions taken by shipboard personnel.
No one sitting in the company office ever ran a ship aground from their desk. No one in customer service ever caused a ship to lose power. So, can they really contribute to the causal factors for major shipboard incidents?
Your mariners are trained and licensed. They are professional and competent often with years of experience. Your ships undergo numerous inspections, surveys and audits by your classification society, by port state control inspectors, possibly also by flag state inspectors, by internal and external auditors, by vetting teams, etc. The company makes great effort to comply with all the national and international requirements for training, for equipment, for shipboard systems, for safety management, for pollution prevention, for emergency preparedness, etc. What more could possibly be done?!
Well, consider how many times you have heard a senior officer on a ship say …
· We just didn’t have time to do that; or,
· But we needed to get underway; or,
· But we needed to stay on schedule; or,
· The [someone] asked us to do [fill in the blank] to keep a customer happy; or,
· We are just trying to get the job done and do what the company needs us to do.
Do the mates routinely complete non-watch paperwork or answer company email while on watch? Do your ships ever get underway without completing stability calculations because the cargo weights and locations aren’t provided to the ship before they get underway? Do your engineers ever make temporary repairs that are more akin to “duct tape and baling wire” fixes? Do your Masters ever get underway when the ship isn’t really ready for sea? Do your ships ever get underway with a major machinery component not functional? Do your engineers have overdue preventive maintenance items that they just haven’t been able to get to?
If the answer to any of those questions is “yes” or “sometimes,” maybe your company is about average. But that doesn’t mean it’s okay. That’s a strong indication that other factors beyond mariner training, qualification and professionalism are driving decisions and actions that are less than ideal. If you think that every company and ship does those things, just remember something we all heard many times during our childhoods … “Just because someone else is doing it, that doesn’t mean it is okay for you to do it.” Keep in mind that almost every major initiative at IMO and large parts of the U.S. Coast Guard regulations have been the direct result of ship disasters resulting in losses of life, major environmental disasters, and/or the losses of ships.
The answer to the question “What more could be done?” lies in the culture at the company more than in the specifics of the safety management policies and procedures. It starts with a recognition that the culture across the company strongly influences ship operations.
I’ll briefly discuss three areas to demonstrate how the company culture impacts shipboard decision making. These include company priorities, company expectations, and the impact of mixed signals that can be sent from different departments, locations or groups within the company.
What are the company priorities? What are the stated priorities and what are the actual or perceived priorities?
I use the term “priorities” to include formal goals, mission statements, vision statements and value statements. They can filter down and be positive influencers. Or, those formal words can be distant noise to company employees and the mariners on the ships. They might look good on paper but not actually influence decisions and actions throughout the company. They can become the blah, blah, blah that’s perceived as being the same for every company.
“Priorities” also include what is measured and tracked at the company. You measure what is important. And the converse is equally true – those things that you measure become important simply because they are measured, compared across time periods, and graphed in charts, tables and diagrams. Therefore, decisions about the metrics must be made carefully with eyes wide open for any unintended influence.
For example, if a company measures arrival and departure times from port compared to the advertised times, those metrics can create huge pressures for the ship to get underway or maintain a certain speed. If those measurements are exact to the minute and “late arrival” is defined as one or more minutes beyond the advertised arrival time, there will be a lot of internally generated pressure to be on time. If that is one of the few metrics tracked, it will be a dominating influence.
This can be a problem at several levels. The Master will respond to that pressure whether the vessel operations manager says anything or not. Vessel operations may not care whether the ship is exactly on time, but others will. Sales and marketing employees will want good numbers to attract or retain customers. Customer service employees will always want to have good news to relay to the customers, and will always dislike telling a customer the ship will be arriving later than planned. And next week at the senior management meeting, those arrival and departure numbers will be shared as statistics or graphs for everyone to see.
So how does that play out in the real world? Does weather avoidance take on less importance than on time arrival? Is the safe speed for the weather conditions pushed just a little to help ensure on time arrival? Would a Master really jeopardize the ship just to arrive on time? That seems like a question with an obvious “no” answer, but reality is not that simple. Masters will surely slow down if they feel the ship is at risk of breaking apart. But what if the Master does not see that risk as likely? And how much will they slow down, or alter course? Only enough to not jeopardize on time arrival?
Consider also the Master’s decision to get underway. In the face of pressure to meet the advertised time of departure, will the Master depart even though supplies just brought onboard are still scattered throughout engineering and accommodation spaces and not yet secured? Has experience shown that calculating the ship’s stability prior to getting underway is not really that important? Is that especially the case when the Chief Mate is busy ensuring that cargo is secured properly and signing on new crew? Is calculating stability impossible because actual cargo weights and locations are not provided to the ship prior to getting underway? Does pressure to get underway result in an increased sense of urgency during potentially risky mooring or unmooring operations?
Expectations can be both stated and implied. The implied expectations can come from the stats and data that are measured and from senior shipboard officers’ beliefs about what is in the company’s best interest. Stated expectations can be formally or informally expressed by senior people at the company level. For example, a synopsis of quarterly earnings and the urging of the COO to cut costs and increase revenue creates a clear expectation. If the COO is convincing, he/she empowers everyone to look for ways to cut costs and increase revenue. Without communicating further clarifying guidance, does that influence the Master or Chief Mate or Chief Engineer to delay repairs or make only temporary repairs to reduce costs? Without any further clarifying guidance, does that influence the port engineers to delay maintenance or reduce the scope of shipyard projects?
The company expects the Master to be in charge and make traditional Master-like decisions without undue outside influence from others. In turn the Master expects the Chief Engineer to make sound decisions without undue influence from any one source. But is that realistic? At a time when ships are so well connected to shoreside personnel by email and voice and shared software programs, there is no way the senior shipboard officers will not be influenced by others throughout the company, i.e., expectations will be communicated to decision makers on the ship.
Clearly stated company goals can create positive expectations. Goals involving a reduction in injuries, a reduction in cargo damage, a reduction in fuel consumption, an increase in the completion of preventive maintenance, etc., can be very beneficial and positively influence decisions. If well understood in the broader context, they can be very valuable. If not well understood or if limited in scope, they can overly influence decisions. For example, consider a stated goal to reduce costs associated with engineering maintenance. If well understood and prioritized properly, the engineers and support staff will look for less expensive alternatives, less expensive sources of supply, and possibly consider shifting toward condition-based maintenance for certain equipment and systems. If not put into proper context, engineers and support staff might simply look for opportunities to postpone maintenance or solve issues less effectively. Consequently, the likelihood of major engineering problems increases. And those problems will occur at the least opportune time and location and weather based on Murphy’s Law.
Here is where good intentions and pressures from within the company collide.
Mixed signals may be when one part of the company tells the Master that ship safety is more important than on-time arrival while another part of the company is telling the Master that the customers are really focused on the company’s arrival time data. When one part of the company tells the Master to ensure all new crew members have completed the full orientation training before starting work and before getting underway, but another part of the company is not ensuring new crew members arrive early enough prior to getting underway, the Master and crew are put in a difficult situation where something must give. Similarly, broad mandates to reduce overtime costs for the crew may conflict with ensuring cargo is secured prior to getting underway, or ensuring required maintenance is getting done, or ensuring updates to navigation charts are getting done, etc.
These kinds of mixed signals tend to manifest themselves as dilemmas at the deck plate level. Consequently, they get solved on the deck plates but not necessarily in the best way. Tradeoffs may be made that are not be in the company’s best interest as well-intentioned mariners try to deconflict requirements or expectations that clash. And often, shoreside personnel remain unaware of the details of the dilemma and how the mariners are dealing with it “in the company’s best interest.” But how those get resolved becomes part of the company’s culture for better or worse.
The priorities and expectations of the company, and mixed signals from within the company contribute to the company’s organizational culture. These can strongly influence decisions made and actions taken by shipboard personnel either positively or negatively, and either intentionally or unintentionally.