The human element: safety lessons from other domains

No one actively involved in the maritime industry would deny the continued relevance of Joseph Conrad’s observation in Mirror of the Sea that the “sea never has been friendly to man … Its fickleness is to be held true to man’s purposes only by an undaunted resolution and by a sleepless, armed, jealous vigilance.”

Despite this awareness and many technological advances, we continue to experience significant maritime casualties. Recent examples include the sinkings of the ferry al-Salaam Boccaccio 98 in the Red Sea with more than 900 fatalities and the cruise ship Sea Diamond off the Greek island of Santorini, the strandings of APL Panama on the Pacific Coast of Mexico and the British Columbia ferry Queen of the North, structural compromise of the containership MSC Napoli in the English Channel and the catastrophic fire on Hyundai Fortune in the Gulf of Aden, to name but a few.

Distressingly, a social scientist studying high-risk industries recently noted that maritime transport seems to be particularly prone to human error. He found that human error, organizational or individual, was a factor in approximately 85 percent of maritime casualties. The International Union of Marine Insurance released figures showing that serious partial losses increased more than 200 percent between 1998 and 2006, despite the implementation in 1998 of the first phase of the International Safety Management (ISM) Code. Of these partial losses, about 35 percent were machinery related, 25 percent grounding related and 20 percent were collision/allision related.

Significantly contributing to this dismal record were frequent shipboard violations of procedures and standards developed ashore — a situation I have come to refer to as the “ship-shore disconnect.”

This ship-shore disconnect represents a crucial challenge to management. To meet this challenge the maritime industry can learn from analogous violations in other high-risk fields. An understanding of these situations will help management develop solutions for the maritime industry, which has received less study relative to its importance and potential for causing harm.

Illustrating the challenge is the Dec. 9, 2005, grounding of the 15,145-grt Bermudian-registered containership CP Valour in a bay on the northwest coast of the Azorean island of Faial and subsequent official investigation. Though no lives were lost, the vessel later broke up with considerable pollution damage to the environment.

While en route to Spain from Canada, CP Valour sought refuge in the bay to effect engine repairs. The available chart was of 1:175,000 scale, unsuitable for close inshore navigation, and displaying only a single sounding (118 feet) within the bay. However, the investigating body, the United Kingdom’s Marine Accident Investigation Branch (MAIB), determined that given the information available to the master (but not utilized by him), his decision to anchor in the bay was “fully justified under the circumstances.” The casualty arose from mutually reinforcing deficiencies in the bridge resource management practiced by the master, who “liked to do things himself.”

He failed to communicate to his chief and second officers where he planned to anchor. As a result, the former entered one anchor position into the GPS while the latter entered a different position into the electric chart system. The master, however, intended to approach as close as two cables off the shore to anchor, though the Admiralty Sailing Directions described the anchorage as being about four cables north of the head of the bay in about 115 feet. Relying upon the single charted depth, the master assumed a uniform depth of about 118 feet, though the chart was silent as to when and by what means the survey was done. He failed to call out the third officer to monitor the fathometer, located on the chart table, behind and out of sight of anyone in the forward area of the wheelhouse.

Once in the bay, in 230 feet of water and about 12 cables from the head of the bay, the master put the engine telegraph to slow, then half ahead and altered course to proceed toward shallower water further into the bay and more suitable for anchoring. The vessel arrived at the chart-indicated position for anchoring, about four cables from the head of the bay, but unnoticed by anyone, the ship had picked up speed on the half ahead bell to about 7 knots.

A minute later the master moved the telegraph from half to dead slow ahead. Concerned about the vessel’s speed, he asked the second officer and heard in apparent reply “point six.” He assumed this was read from the GPS information on the radar but did not so confirm. Accepting a speed of “point six” knots, the master entered the chart room and read from the fathometer an under-keel depth of about 49 feet. Over the next two minutes, he telegraphed various astern orders, whereupon the vessel ran aground, still making 6 knots over the ground, a speed that had continued to go unnoticed by anyone.

Believing his vessel still underway, the master ordered the starboard anchor walked out and telegraphed for full astern to set the anchor. Expecting a strain to be taken upon the anchor chain, the master must have been surprised that the chain remained up and down and the vessel was not moving. Eight minutes later he realized his vessel was aground.

The MAIB determined that “the second officer and the master (were) fully qualified, and (had) received good quality bridge resource management training … (and) the ISM system appeared good and in order.” This together with poor performance by the bridge team led to the observation that there is “no benefit to be gained from good training and qualifications unless they are used as the basis for good practice when the crew return to their ships,” thus raising the question “how employers and others can be sure that bridge teams are actually following instructions and guidance” from their training and safety management procedures.

The MAIB concluded that there is “thus a need for shipowners and managers to ensure that their orders and training are being put into practice by those operating their ships.”

Passing reference was made to on-board auditing by company managers, which was acknowledged to be only partially effective because performance would improve while being monitored, i.e., crews would be on their best behavior. In any event, monitoring catches only a snapshot of performance in an environment, which, unlike aviation, lacks specific observable maneuvers and reactions, such as flying on less than all engines or checklist proficiency. Also referenced was voyage data recording, but here again a voyage cannot be as effectively dissected as a flight of several hours.

Unfortunately, the MAIB appears more articulate in posing the challenge than in answering it.

Despite the prevalence of non-adherence to procedures, this phenomenon has received relatively little study in the maritime field. However, guidance is available from research conducted in other realms in which personnel fail to follow prescribed procedures, with the cognitive ability of the personnel not being an issue.

The aviation domain has developed from various cognitive psychology theories a human information processing (HIP) model. Its objective is to describe and explain factors influencing pilots’ violation of procedures. The 23 categories of nonadherence have been grouped as:
• relevant information not perceived (3 categories)
• relevant information (1)
• assimilation (7)
• faulty training (1)
• cultural issues (3)
• personality (5)
• stress (1)
• decision making (1)
• competing activities (1).

Significantly, each category can be identified with one or more avoidance strategies or barriers, an analysis too lengthy for this article.

From procedural violations on North Sea oil rigs, a behavioral cause model has been developed. This model works backward from the decision to violate, with the decision influenced by the goal to be achieved, the intention and expectation that a particular procedure should be followed and situational factors. The greatest factor turns out to be a combination of time pressure, no alternative way to do the job and poorly drafted or considered procedures.

From a study inquiring into what caused airplane pilots either to violate a procedure or to decide not to violate a procedure, the three controlling violation elements were found to be: high reward for successful violation, low probability of detection/high probability of success, and no (or minimal) adverse peer reaction.

Another situation inviting procedural violation is the failure to provide appropriate operational training in the use of on-board equipment and systems.

In 1999 the large high-speed ferry Sleipner struck a rock off the Norwegian coast and sank with the loss of 16 lives. The investigating commission determined that the officers’ training in the use of new navigation instruments was inadequate because they only “received sporadic instruction from colleagues, but there were no formalized training procedures.” Closer to home, our courts are unanimous in holding that failure to train can cost the vessel owner the benefit of liability limitation.

And of course shipboard personnel must be provided with the means to adhere to procedures, without management creating hurdles that make compliance impossible, impractical or otherwise difficult. Such organizational obstructionism can be common, obviously apparent after the event but not credited before.

An example is the situation confronting USS Cole, the destroyer attacked by terrorists in 2000 in Aden, Yeman. That port had been deemed a high-threat zone and there was no need for Cole to be there except that she needed to top-off fuel as a result of high consumption during her 27-knot passage through the Red Sea. Cole was transitioning from one battle group to another, with each group wanting Cole to remain within its respective operational area as long as possible. Thus, she was compelled to steam at maximum speed to bridge as quickly as possible the gap between the two battle groups. Procedural compliance was sacrificed to achieve the groups’ respective goals, goals in conflict with Cole’s best interest — steaming at an economical speed so as to avoid any need to call at Aden.

An interrelated issue is that the procedures must be communicated to the shipboard personnel by means commensurate with their importance and in language easily understood by the crew that is supposed to abide by them. The City of New York’s failure in this duty was a major factor contributing to the 2003 accident in which the ferry Andrew J. Barberi smashed into a pier, resulting in 11 deaths and scores of injuries.

Introduction of these issues only scratches the surface of means to reduce procedural nonadherence and how lessons learned in other domains can be applied to analogous commercial maritime operations. Application would depend upon the nature of the operation. While certain conditions could be consistent, there may be significant differences among, say, bluewater big-ship operations, inland-waterway operations and small-passenger ship operations. Also, the content and presentation of specific procedures would be relevant, since off-the-shelf solutions will not fit all needs. Violation-avoidance strategies appropriate to specific operations could be communicated and discussed at seminars held by the company for its senior officers and reviewed with management.

By Professional Mariner Staff