Am I alone in noticing the regular use of the word ‘complacency’ when describing the cause of a marine accident or incident? What a strange word to use in the context of accident causation when people so rarely set out to deliberately cause an accident, and even when an action is deliberate, it is rarely done with malice. It is however a very ‘convenient’ word to use, as it can save any deeper examination of the causation mechanisms that very often lie within the management systems of our companies and within the industry’s governing bodies. The ‘inconvenient truth’ is that such an examination might expose industry weaknesses that few apparently wish to tackle, even though it would be cost effective so to do. So, what does this word mean? The dictionary says:

             

 com·pla·cen·cy n.
1. A feeling of contentment or self-satisfaction, especially when coupled with an unawareness of danger, trouble, or controversy.
2. An instance of contented self-satisfaction.
 
com·pla·cent adj. showing smug or uncritical satisfaction with oneself or one’s achievements.

Mmm! Now, there is no doubt this phenomenon exists but does it really help us when we are trying to get to the bottom of why we have accidents on ships?

 

As someone who has taught in the field of human factors and accident investigation for many years, I am perplexed. When we humans master a particular skill we tend to execute the skill while running in automatic or semi automatic pilot, which we do for about 80% of the time. It is efficient and desirable and frees up our mental capacity to cope with other things, including unexpected things, which is particularly helpful in the moving dynamic world of a ship. Most of the time we get the particular practiced skill right and we suffer the least number of errors – but we do suffer errors. So in many cases the word complacency is being used to describe these errors that we all occasionally make when we are executing something with which we are familiar and have done many times before. The Danish psychologist Rasmussen calls this ‘Skill Based Behaviour’ as described in his SRK model (Skill, Rule, Knowledge based behaviours).

 

An example might be the daily routine of driving to work and taking a particular exit on the motorway. This is a skill in which we are well practised, require very little mental processing to execute, get right happily day after day and which frees the mind to think about a myriad of other things while driving. The error is that on this particular day, while thinking about tonight’s dinner party, say, you miss the turn off. This is a typical infrequent routine Skill Based error, not complacency.

 

Lets look at a real marine example: An experienced ferry master was approaching a port on a fine sunny day with a current across the entrance. The master was very familiar with his ship and had made this port entry many times before. Suddenly he found himself very close to the harbour breakwater, having been set down by the current. He recognised his error very late but was able to recover the situation. This is a Skill Based routine error, not complacency.

 

What we know is these errors, although infrequent, will always occur and the only real protection is the power of a synergistic competent team who are lead by a Captain (or any team leader) practicing the correct team working management style and who actively encourages:

 

a)    Assertive error spotting;

b)    Contributions from the team in decision making and ensuring the decision is having the desired outcome;

c)    The following of Standard Operating Procedures (SOP’s) to ensure everyone executes things in the same agreed way. (This encourages the pointing out of errors to the leader);

d)    Conducting pre-arrival and pre-departure briefings to raise the level of attention in the team;

e)    The practicing of ‘closed - loop’ communications (this means message repetition to guarantee all members of the team have the identical mental model);

f)     Ensuring the team has a shared situational awareness. This means that everyone is on the same ‘song sheet’ and any member of the team will tell his leader, without hesitation, if he sees a discrepancy between the agreed plan and the current situation.

 

In my opinion words matter hugely when one is trying to explain accident causation and the word complacency, whether I, or anyone else wants it to be otherwise, is a ‘finger pointing, blame encouraging’ word and thus in investigation terms is entirely unhelpful. The following world authorities in the field provide considerable evidence to support my case: Firstly, the recently published book ‘The Human Contribution’ written by my mentor, Professor Jim Reason (one of the acknowledged world authorities on Human Factors) and secondly, the work done on accident investigation by the Danish psychologists Koester and Rabjerg.

 

The February 2009 edition of the Nautical Institute publication ‘Seaways’, carried a Lloyds Shipping Economist Ship Finance conference report, which appears to offer us a much richer seam to examine if we are looking for real business changing learning opportunities. The article quotes Mr. Douglas Lang of Anglo Eastern when speaking about crewing problems. Mr. Lang said:

 

“There is a shortage of experienced and competent crews, an overwhelming demand for good people by the offshore industry and an escalation in salaries. Virtually all OECD countries have the same problems with ageing crews and diluted competences, which is being compounded by language problems with ships now averaging four nationalities. The erosion of competence is leading to higher incidence of machinery damage and a higher risk of collision and grounding. Substituting technology for people is not an answer. The authorities should stop sending masters and seafarers to prison”.

Now, I would never argue against the importance of personal responsibility for safety but the actions of an individual are normally the ‘last stop on the bus route’ and blaming that individual is like swatting a mosquito, rather than draining the swamp to kill millions of mosquitoes! It is a natural human tendency to reach for blame, especially if personally affected: It is also reinforced by the legal system that likes to ‘find the guilty and punish’. However, this approach does not help us uncover the critical root causes of an event, most of which track back to corporate safety management weaknesses. We call these latent ‘pathogens’ or accident causing factors, which lie within a system, sometimes for years, until one day they conspire to bite you.

 

The latent pathogens that spring immediately to mind are: Lack of, or poor, training and/or competence (for example in basic watch keeping); Standard Operating Procedures (for example, the lack of a risk assessment covering tasks such as a lookout on the bridge, berth to berth passage planning, Master / pilot exchange & team briefings); setting incompatible and conflicting goals (for example, a master expected to sail with a fatigued crew. If the causes of the fatigue are things like lack of rest caused by a procession of inspectors coming on board, then this in turn opens up fresh root causes); poor design (for example, poor bridge or engine room ergonomic layout, which regularly invite and attract errors): the wrong equipment supplied / used for the task, poor maintenance management, communication failures & a poor safety culture (for example the blaming and gaoling of masters after an incident).

 

There is nothing to fear from this approach. As the deeper mechanisms and latent pathogens are uncovered, they present wonderful business and industry learning opportunities. This is cost effective, as owners and industry harvest the learning and make the changes that head off costly accident repetitions. This is a loss avoidance system and this is where the top corporations in the world are headed. The best companies at managing safety are the most successful companies in the world: This is not a coincidence.

 

Our company has majored for many years in assisting clients to harness the enormous unused horsepower that resides within their workforce. The British Health & Safety Executive has overwhelming evidence demonstrating that an involved workforce is a safe workforce and so achieving this is the central objective of its 2009 strategy. In addition, the huge improvements in trust, employee morale, motivation, enthusiasm and productivity that derive from an engaged workforce are pointed out in the McLeod report ‘Engaging for Success: Enhancing Performance through Employee Engagement’ which was published in July this year for the British Department of Business Innovation & Skills. Times they are a changing!

 

In some companies, the employees own both the problems and solutions and uncover the root causes and learning opportunities for themselves. They are of course trained to do this within their teams and they are helped and supported by their managers and front line supervisors. Elementary really!

 

Some of the marine cases I see reported demonstrate to me how far the marine safety culture (with some exceptions) has to go. This is the prize our industry leaders should be encouraging, rather than giving life to the myth that we just need to cure this army of complacent people and all will be well! Well it won’t! The Emperor is naked, not wearing a beautiful suit of white ermine and for the good of our industry someone has to tell this “inconvenient truth”.

 

John Wright

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.
5.  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.
6. The differences between national cultures and the critical importance of building mutual respect within a multi-cultural team.
7. 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).
8. 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