A tale of two safeties

A superintendent visited two sister ships in the same port. He boarded the two vessels, over 3 days, along with the pilot. He stayed up on the bridge to observe the pilotage.  On both vessels, the Master, Second Officer (2O), Helmsman, and Pilot were on the bridge. On the first vessel, the 2O was engrossed in record-keeping, meticulously documenting in the running log; hardly looking up or looking out.

On the second vessel, the 2O was actively looking out and looking into the ECDIS and RADAR. He was actively seeking information and giving inputs; thus, contributing to decision-making processes, supporting the master and the pilot; and reducing the chance of making mistakes. He had filled just half a page of the running log.

Now, many months later, if these vessels were audited, the second vessel is quite likely to get some findings for missing entries while the first one possibly passes off with a gold star. But, which vessel was safer? Does exhaustive documentation enhance safety, or does it detract from effective operations?

The first 2O’s actions were dictated by perceived audit expectations. The master wanted him to record extensively because of his experience with audits. This highlights the potential tension between record-keeping for compliance purposes and the effective teamwork needed to reduce the chance of an error. This discrepancy creates a skewed reflection of operational reality.

Audit outcomes often reinforce this tension. Audit results are also assumed to be a reflection of the seafarers’ performance, their competence. So, seafarers often prepare for audits by modifying records or creating them. They are apprehensive and even scared of an audit. It will expose their competence and judge them normatively based on the procedures.

My master’s thesis was based on audits. During the research, I interviewed a senior Master who said: “Whatever we can, we either fix it or cover it. If we can’t cover it, we hide it somehow, so the auditor doesn’t see it.”  This undermines the flow of authentic information—a cornerstone of a healthy safety culture. Westrum’s typology of organizational culture underscores the importance of information flow; yet current auditing and inspection practices may inadvertently stifle this flow, killing transparency and fostering defensiveness.  

ISM code says that its objective is to ensure compliance with mandatory rules and regulations; it also expects the application of the code to support and encourage the development of Safety Culture.  It then appears that Safety Culture is something that can be developed through the application of the code. The code is applied through artefacts that the code gave rise to:  the SMS, checklists, procedures, policies, and audits.

Edgar Schein, a pioneer in Organisational Culture was cautious before he defined Organizational Culture. He said it is difficult to define what culture is because it is difficult to define what an organisation is.  The ISM code, here, is talking about the culture of an industry that not only spans the globe geographically but also culturally, economically, and linguistically – every which way. Culture, Schein says, manifests in a pattern of assumptions.

 If the Code by its application, hopes to change the culture of safety, then it is hoping to mould the pattern of assumptions of such a group of diverse people spread across the entire world. And to aggravate the condition, we have a workforce that changes every few months. This defeats another condition Schein considers necessary to develop culture: Shared history.

Another manifestation of common culture that Schein and Westrum draw our attention to is how a group of people identify and solve problems. Has our industry, as such a group of people, developed such a common assumption since 1998?  If you have been part of this industry, then you would have your answer to this based on your lived experience: how have incidents or audits you were part of played out for you? And so that would be a question for all of us to answer for ourselves. I have a theory on what this assumption might be.

For me, I think the assumption we have is that there is one standard way to do things. This is written down in our Safety Management Systems. All our problems are deviations from this standard. To solve these problems, we must find all deviations, and their extent and reset them to the normal so that we can “continuously improve”. 

Are finding deviations even the best way?

Every day people prevent incidents. Every day most things go right, but we rarely study them. Instead, convinced that identifying deviations and correcting them alone will lead to improvement, we focus on them. We are certain that the more we find, the more we correct, the better we get. 

We have always heard that “80% of incidents are caused by human error”. We continue to hear this. I doubt this figure has changed from when it was first coined. I doubt if it is even validated. It is a myth and yet it is difficult to get this out of our head. Can we change the paradigm if we say that people prevent incidents all the time, but some slip past them? Could we shift the paradigm? Think about it: how are we not having more incidents? Is that because of our procedures or because our seafarers are doing their best?

Resilience Engineering offers a useful perspective. Hollnagel, who is a proponent says that each day, thousands of things go right; by studying only failures we may miss critical insights.

If we studied from everyday work, we could accumulate insights that could improve procedures. Even regulations. These are rarely captured in a way that informs public knowledge. The seafarers’ lived experience contributes little to public knowledge and, thereby to SMS and even regulations.

As an industry, it appears that we are convinced that finding deviations and fixing them is the best way to continuous improvement. Is this not what the growing number of audits and inspections in our industry telling us? The ships and seafarers don’t seem to have any respite from inspections. They always appear to be preparing for one inspection or another. Even superintendents who go on board ships for their inspections have lengthy checklists to complete that help them pick deviations and non-compliances and therefore not enough time to talk to people and understand. They only have time to tell – follow procedures, be safe, safety is your responsibility….”, but not enough to ask.: “What makes things difficult for you?”

Why are we stuck here? Management systems based on Taylor’s Scientific Management theory built around the linear cause-effect paradigm found their way into the complex and uncertain world of maritime. This was codified in our ISM code. Standards were set, and there was an expectation of the one best way to do things. Adaptations become deviations. We were given a cookie cutter.

In the 1980s when we had many disasters across the world, sociologists and psychologists brought in their frameworks to understand what happened. They recognised that the complex systems people work in are not merely technical, they are Socio-Technical Systems. There was a recognition that context around the workplace matters. This shift brought by multi-disciplinary involvement in investigating the disasters of the 1980s may have missed the maritime bus. We also had the Herald of Free Enterprise in those times. We got the ISM code, but I am not sure we had a multi-disciplinary involvement in learning from this.

Was that an opportunity lost?

I invite all of us to reflect and see if we can recognise and accept that there are two types of safety that we do: one that improves conditions and another that provides business assurance. Through compliance.

Compliance is valuable. It serves a purpose. It provides customers comfort. It gives the organisation credibility.  What it doesn’t do is reveal the complexity at the sharp end. It doesn’t tell us what is really happening.

To make meaningful change, we need to understand the context that affects decision-making on the ground. Understanding what truly happens on the ground requires a system that allows a free flow of information. That needs trust.  There is research done in Australian mines and even in bp(a major oil company) that points to the importance of trust as an indicator of positive outcomes.

#1 Learn from Everyday Work, Not Just Incidents

We must adopt a grounded approach to understanding everyday work, focusing not just on accidents but also on everyday work.

We should understand what individuals do as part of their everyday work, not just when incidents happen, or we see non-compliance.  The insights we derive – into what works and what doesn’t- at the sharp end, are invaluable for evolving practices that work in real contexts and for informing public knowledge to influence regulations.

#2 From Compliance to Description

We must shift from auditing how we work, normatively to describing how we work. Non judgementally. We must find ways to understand what happens every day.  

We need to shift from fault-finding to genuine curiosity about how seafarers maintain safety despite operational pressures and complexities.  

Audit reports (if we call it that) must describe work instead of judging it. This is based on the fundamental assumption that people come to work to do a good job. They don’t have a malicious intent. If they have done something, it made sense to them. That is why they did it – not because it would lead to non-compliance or an incident. We have to understand that which made sense to them.

What we will spend on understanding how people work won’t be a cost. It will be an investment.

#3 Recognising and Respecting Expertise

Investigations and audits are done by former seafarers. Because we were seafarers once and we once did what seafarers are now doing, it becomes easy for us to judge their performance normatively. We are burdened by our experience. By respecting expertise, we will change the questions we ask – from why did you do it to what made it difficult for you?

Trusting and Respecting people is not an option. It is imperative.

#4 Engage more HF participation

And we need more HF expertise in maritime technology, everyday maritime operations and maritime research. We must also look at developing HF capacity in our industry by getting HF experts into ship design, investigation agencies, pre-sea education and the regulatory ecosystem. We must also foster interdisciplinary research and education in human factors beyond maritime-centric institutions. We must recognise that Human Factors is different from Human Element.

All of the above proposals are based on the fundamental assumption that people come to work to do a good job. They don’t have a malicious intent. (If our people have malicious intent, then we have a bigger problem!) 

Our industry’s current practices provide a limited picture of what is happening on board. This is because we are heavily driven by audits and compliance, believing in the adequacy and completeness of the SMS. But without a complete picture, we cannot create meaningful changes. We will continue to tell people what to do instead of asking what they need.

The views presented are only those of the author and do not necessarily reflect those of SAFETY4SEA and are for information sharing and discussion purposes only.