Mind The Gap, reshaping safety culture

An endemic attitude to safety culture in shipping focused on aiming at perfection, which discouraged anyone who made a mistake from revealing that an error had occurred, according to Torkel Soma, Founding Partner at Oslo, Norway-based Propel.

Speaking in a presentation entitled “‘Mind The Gap’ to reshape safety culture” at the Loss Prevention Workshop at IUMI 2018 in Cape Town, South Africa, Dr Soma argued that the way we think about and describe safety, influences what we do to stay safe.

Major accidents were very complex events, involving multiple failures and many people making mistakes. Less serious accidents, attributable to a single error, happened more frequently, but had fewer consequences.

Soma said that we had to focus on the major accidents to reduce losses.

“Failure will happen, but we have to fight it, if we fail to do that it will escalate”, he said.

Shipping, claimed Soma, focused too hard on trying to get things absolutely right, believing somehow that if all the bad apples are rooted out, if all the procedures are followed to the letter, accidents will not occur. Soma said that this was the wrong way to look at things.

For a start, this attitude made it hard to admit failures and mistakes, because no-one wanted to be considered a “bad apple”.

“When we look at most major accidents, the crew were aware of the failures before the accidents happened, but either they did nothing about it, or if they raised concerns, they were ignored.

How, asked Soma, could this line of thinking be altered? What could we do to install a safety culture that made it easier to be open about failures and so to prevent major accidents happening?

Soma noted that, on a typical day in shipping there were 700 safety inspections, three deaths, 30 injuries, and a ship lost every other day. Each day and average of $50m was paid in claims.

He said that shipowners needed to do more and in a different way. H&M saw 1% of most expensive claims making up between 30% and 60% of total claims in a year, and the few major accidents were causing much of the volatility.

The first mindset when it came to safety was to attempt to make everything safe, so that a failure cannot happen. Unfortunately, that results in blame when a failure does happen, and discourages people from reporting their own mistakes. The second mindset was to manage failures.

If we are of the first mindset, it’s saying “hire the best, follow right procedures, we will be safe, to strive to be ideal. The second ideal is to manage failures. If you focus on management of failures you see things differently. We cannot be safe. We have to work every day to be safe. We have to embrace failures.”

Soma accepted that this was not an easy path to achieve. Sometimes people are competent, but they do not use their competence because of the environment. “We see that a lot in major accidents.”

he noted that if an employee had a failure under the first mindset, the understandable self-interested reaction was to avoid being seen as a weak link (and possibly fired), and therefore either not tell anyone about the mistake, or if that is impossible, shift the responsibility of the mistake elsewhere. The result was that nobody learned from it.

Under the second mindset, it was not any easier to share a mistake, but once that reluctance was overcome, it was seen as a strength that a person shared a mistake, because now everyone knew that the potential mistake was there. Propel identified eight behaviours that explained why accidents happened.

  1. Care. Care for colleagues, for the vessel, during navigation
  2. Trust. If you are going to work well together then you have to trust each other. Full of mistrust – Ship to shore, crew to management, intra mistrust
  3. Teamwork. Ensure that everyone pulls in the same direction. Torrey Canyon saw difference of opinion to course that captain planned.
  4. Manage dilemmas. Safety will not always be the first priority. These dilemmas have to managed on a daily basis. Titanic had 30 iceberg warnings, but wanted to break the speed record.
  5. Speak Up – share your concerns. Two years before a captain said that he had left Zeebrugge with the Roro open. But he was ignored, so people stopped speaking up. Often people are aware, but they do not speak up
  6. Reward and sanctions. Give constructive feedback. Costa Concordia had four bridge members. Everyone knew that they were not doing what they should do
  7. Learning. Sharing experiences, being interested in the nature of risk. Roro capsized in Southampton. They knew cargo storage was different, know it would make a difference, but didn’t dig deeper.
  8. Be Open. EG Exxon Valdez reported twice to officer on watch and he was not open to the feedback. In El Faro people begged the captain to change course, but he was determined to stick to plan.

Soma said that, if we look at major accidents, we see that all eight behaviours, applied wrongly, were present in a large number of these disasters.

Soma observed that in a way the problem was systemic, a result of faulty mindsets all the way up the company authority chain. CEOs say “safety is paramount”, but the operations department feels it has to push for more and for others to say ‘no’. Then Superintendents feel that the winners among their peers seem to be those who take the risks, but stay lucky. Captains then feel that if they say ‘no’ to operations managers or superintendents, their job might be at risk, or their competence questioned, because other captains have said ‘yes”.

Finally at the lower levels they say “we hear safety first from the top, but we don’t see it.