Complacency as a concept in Accident Investigations

Ensuring that root causes of accidents are correctly indentified

Is complacency to blame?

Identifying the root cause is essential to prevent regular recurrences

Discussion on the use of correct terminology in apportioning causes

Following the publication of my article on complacency in the January Telegraph, I was interested to read the latest MAIB publication, which contains a report entitled ‘Complacency Leads to Blackout and Grounding’. Once again I wish to point out that majoring in complacency, allegedly shown by any of these officers, even if present in some degree, is not useful when looking at ways to avoid this happening again. The second engineer did not make errors on purpose and he did not pay insufficient attention to the checklist because of a desire to cause a blackout and subsequent grounding. Therefore, accusing him of complacency, even if it figures as an element of the findings, masks the real root causes and distracts the reader from fully taking on board the reasonable lessons the MAIB itself points out.

The lessons outlined by the MAIB in the report are useful, but some of the recommendations are not specific enough and/or do not directly address real root cause solutions. So what measures will stop our current merry go round of repeat accidents and get to the roots of the problem? Well, for a start, IMO needs to make Crew Resource Management (human factors) training compulsory. Why? Because this is where officers and their managers will learn how to avoid root causes manifesting themselves in the first place. In this case the root causes appeared to be a lack of knowledge in, or a failure to manage:

1. The strained relationships between the C/E and his team. (This is a critical root cause and we find this is implicated in many incidents, both in the engine room and on the bridge, or between the departments. This is dealt with thoroughly on the CRM course where delegates are taught the theory about management styles, leadership, situational awareness, shared mental models, teamwork and communication and then failures in any or all of these are shown up during the simulator exercises for effective experiential and discovery learning. This is the only effective way to encourage officers to hold a mirror up to their own performance).

2. The vital nature of short, relevant, ship specific, bought into and end-user owned checklists, to counter the small size and fragility of short-term memory.

3. The importance of Standard Operating Procedures (SOP’s) that are owned by and bought into by all, especially the end-users. In this case, SOP’s would or should have covered cases such as when the C/E must attend in the engine room and when watch handovers may be conducted, i.e. not in the middle of a critical operation. This removes emotion and opinion from critical operations.

4. The importance of conducting a team briefing to ensure a shared mental model and situational awareness. This is vital, especially at times of high workload or when handling a crisis.
Competency assurance with stipulated minimum requirements for conducting critical technical training and induction periods on board. These should be set out in the company Safety Management System and internally and externally audited to ensure compliance.

5. The differences between national cultures and the critical importance of building mutual respect within a multi-cultural team.

6. Allied to 6, the fact that if any team cannot converse in one tongue then clearly there are serious safety implications. (This is regularly shied away from perhaps because of the cost implications. We find that although English is the international language, engine room teams in particular still tend to have a poor grasp of this language).

7. Failure in engine room design (valves, etc) and in bridge ergonomic layout (position of sound powered telephone). The MAIB needs to be pointing out that poor design is one of the fundamental root causes and tell the reader how often they encounter this.

In this case, CRM skills were understandably absent because this training is not required: The MAIB should highlight in this and many other reports, how often the wrong management style, both ashore and afloat, and failures in teamwork and communication feature, and point the industry towards methods of how this can be fixed. After all, it was for similar reasons, avoiding incidents in the first place, that the aviation industry made this training compulsory in 1989 and lets face it, gravity will grab your attention if you make mistakes up their!

Most important of all, to encourage the marine industry to tackle these fundamental root causes and raise safety standards, the MAIB should have pointed out for this and many other cases that it is the responsibility of the shipping company management team to:

• Build a single one-team approach to their business by fully engaging with their people and closing the very common, unsafe and highly inefficient, ‘chasm’ between the ships and their management teams.

• Introduce the correct CRM, leadership and management training – as they do in aviation. This is a critical core competence for all.

• Validate that training by carrying out non-jeopardy audits to ensure the lessons are being translated to the desired actions on board – as they do in aviation.

• Train their people on board to identify the hazards associated with all critical operations and then conduct and own risk assessments for themselves to reduce the associated risks to ALARP (As Low As Reasonably Practicable). The risk assessment process is the fundamental tool of safety management but this process needs the help, guidance and support of the shore based management team and end-user ownership if it is to avoid being three shelf metres of useless unloved decoration!

• Ensure the correct length and quality of induction and handover times are set out in company SOP’s for deck and engine room.

• Ensure that design flaws are learned from, so they are excluded from future new builds. Involve the end-users in bridge and engine room design layout and avoid ergonomic nightmares.

• Ensure that teams speak the same language proficiently.

For the MAIB to take aboard my observations, their inspectors need to be trained in CRM themselves, since they cannot report upon what they don’t know about. What I know for sure is that so long as the MAIB insist upon majoring in complacency, this accusatory and finger-pointing word will continue to mask the real opportunities that would take this industry to the next level of managing safety effectively.

Our experience is that, with one or two notable exceptions, the marine industry is about ten years behind others in this whole area of human factors training and workforce engagement – which are the areas our company specialise in. Our experience from working with clients in many other industries, backed by researched facts, shows us that when the penny drops as to the efficacy of this training and workforce engagement, the changes not only ensure that ‘more people go home with their bits’ but results in financial success as companies learn how to harness the huge amount of latent horsepower residing in their workforce. Simple really!

Faced with all the evidence of how it is perfectly possible to raise safety standards and efficiency to a whole new level, I wonder why these ideas are catching on so slowly. Perhaps if the MAIB becomes a driving force for change I would cease to be one of the few lonely voices in the marine wilderness. I certainly hope so.

John Wright
Managing Director
WrightWay Training Limited

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