During the 2024 SAFETY4SEA Singapore Forum, Dean Crossley, Head of Loss Prevention Asia, West of England, discussed the normalisation of deviance in workplace practices, highlighting a specific example where a ship’s crew used the bulwark as a makeshift walkway to access the hatch cover more easily.
A concept related to human factors, called the “normalisation of deviation” is a subtle but dangerous phenomenon, often driven by the desire for practical workarounds. While it may seem harmless at first, it can lead to serious consequences over time and eventually become accepted as the norm.
What is the normalisation of deviance?
It occurs when small deviations from established safety protocols, like using the bulwark as a walkway, become routine simply because nothing goes wrong immediately. Over time, these small shortcuts become accepted as normal behaviour, even though they are risky.
This behaviour becomes ingrained and can lead to complacency, which increases the likelihood of accidents or injuries.
The case: Using the bulwark as a walkway
Now, let’s look at a specific incident. The bulwark, a raised structure along the sides of the ship, is primarily designed to shield the crew and cargo from sea spray and enhance safety on deck. In this case, the bulwark in this section was substantial in construction, as it also formed part of the hull superstructure to provide additional strength. However, it was not intended or designed to serve as a walking surface. However, in this case, the crew adapted it into a walkway to gain easier access to the hatch cover.
At first glance, this may have seemed like a convenient workaround—a way to save time during operations. But using the bulwark in this manner violated its intended use and bypassed safety controls.
Why this happened and what are the consequences?
First, the crew likely saw using the bulwark as a time-saver—a convenient shortcut to access the hatch cover. Over time, the lack of immediate harm reinforced the belief that this practice was “safe enough,” even though it violated safety protocols.
Unfortunately, lack of proper oversight and complacency allowed this unsafe practice to continue unchecked.
Eventually, a crew member fell off while using the bulwark as a walkway and sustained a life changing injury. The bulwark wasn’t designed for this purpose—it lacked essential safety features, including anti-slip surfaces, a level walking surface, and handrails. What started as a minor deviation turned into a significant safety hazard, leading to an avoidable injury.
A notable aspect of this case is that when our investigation extended to the fleet’s sister ships, it revealed that all the vessels had adopted the same modification to the bulwark. This practice appeared so widespread that it had not prompted any concerns, even from those responsible for overseeing the fleet. At no stage had anyone questioned the safety of this configuration or whether it should even be classified as a walkway.
Key lessons learned:
- Small shortcuts can snowball into dangerous practices over time if left unchecked.
- Just because nothing bad happens right away, it doesn’t mean the behaviour is safe.
- Complacency—where unsafe practices become routine—is one of the greatest risks to workplace safety.
- Leadership and oversight are crucial in preventing the normalisation of deviance. Supervisors need to actively identify and address unsafe practices before they become entrenched.
The key takeaway here is that fostering a strong safety culture on board is essential. When deviations from safety protocols occur, they need to be recognized and flagged immediately.
Preventing the normalisation of deviance:
To prevent the normalisation of deviance, we need a multi-faceted approach:
- Foster a strong safety culture where any deviations from protocols are quickly identified and corrected.
- Conduct regular safety audits and inspections to catch unsafe practices before they become routine.
- Encourage open communication so that crew members feel comfortable reporting unsafe behaviours without fear of punishment.
- Provide ongoing safety training to reinforce the importance of following protocols and avoiding shortcuts.
What we try to encourage is the use of checklists and procedures, which are all available on board the ship. Technically, deviations like this shouldn’t happen, but the issue often arises because the people carrying out the tasks are the same ones who are responsible for following those procedures. One effective way to ensure that checks and procedures are being followed is to involve a different department.
For example, when the deck department is performing a task, you can ask the senior staff from the engineering department to review the checklist for tasks. You’d be surprised how often deviations from the procedures are spotted this way.
The same applies to your superintendent. It’s important to rotate superintendents within the fleet, because a fresh pair of eyes can help identify issues that might otherwise go unnoticed by someone who is too familiar with the vessel.
Deeper understanding is crucial
Most importantly, we need to understand the psychology behind incidents. Too often, incidents are chalked up to “human error,” but this simplistic view misses the root causes.
Instead of just assigning blame, we should examine why individuals felt it was acceptable to deviate from the safety procedures.
This deeper understanding helps us address the underlying factors and prevent future occurrences.
In conclusion, the normalisation of deviance can quietly erode safety standards over time. In this case, using the ship’s bulwark as a makeshift walkway eventually led to a serious injury, highlighting how dangerous shortcuts can be.
Staying vigilant and committed to safety procedures is essential in preventing these kinds of incidents. We must ensure that convenience never takes priority over safety.
The views presented are only those of the authors and do not necessarily reflect those of SAFETY4SEA and are for information sharing and discussion purposes only.
Above article has been edited from Dean Crossley’s presentation during the 2024 SAFETY4SEA Singapore Forum.
Explore more by watching his video presentation here below
