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The main objective when working with safety is to reduce the number of injuries to or fatalities among the crew and passengers. Compared to the industry ‘best practice’ in OECD countries, the crew fatality rate is 10 times higher in the maritime industry. We have seen improvements in ship structure and system reliability and today’s ships systems are technologically advanced and highly reliable. However, the fatality rate is still high. What are the obstacles to overcome to reduce the number of accidents?
The ferry industry is responsible for a large number of passengers every year. There is instant public attention if an accident occurs and the consequences for the company involved can be dramatic. This article presents three different, but interlinked, goals for increased safety in the industry. The first goal is to use human error as a symptom of weakness in the system, rather than as an explanation for an accident. The second is to manage major accident risks, and the third is to assess and improve the safety culture.
The human error as a symptom of weakness in the system
Human error has been one of the most used explanations for accidents in both the maritime industry and other industries. While many other industries have managed to move on and search for more underlying causes, the maritime industry appears to be lagging behind and still blame the individual operator in too many occasions. People are making mistakes, but it is very seldom that the mistakes are deliberate. The reason for people making mistakes could be discovered by understanding what affects a person’s performance. The causal network below shows that the deliberate violation link is almost non-existing and that the wrong action or judgement is the main contributor to accidents. Further, the reason for this could be discovered by looking at a set of performance-shaping factors. The eight factors are presented in the rectangle in the network and represent both the areas that could negatively affect the operator and what could increase the likelihood of good performance.
View graphic in higher resolution - a network of causes of grounding and collision accidents: the thicker the arrows, the more evidence was found for the causal chain of events in accident investigation reports. The nodes in the rectangular box represent the performance-shaping factors.
To move from an old-fashioned view of blaming the operator to a modern perspective on safety, it is important that the company asks itself ‘why’ when people are making mistakes. The answers can in most cases be found in one or more of the performance-shaping factors. A typical example of human error is a combination of the operator experiencing a situation he/she has not been trained for, the work load growing too high because of a lack of cooperation in the team, the procedure being too extensive and detailed, and the complexity becoming too great. When the operator then makes a mistake, we often see that the blame is laid on the individual rather than identifying all the contributing factors.
If the ferry industry wants to improve in this area, it needs to establish an understanding of the company’s responsibility to facilitate good human performance. If human error occurs, it needs to be treated as a symptom of weakness in the system, and not as a standalone human error. If companies are able to make this shift, it will have a long-lasting effect on their organisation, preventing human error across vessels and fleets.
Manage major accident risks
Managing major accident risk may seem difficult when looking at the variety of causes presented in the network. However, there is evidence that this is necessary and that a structured methodology would work. Major accident risk is often associated with the risk of ship accidents. In the maritime industry, about 900 lives are lost due to ship accidents every year. Nevertheless, in many shipping companies the everyday safety focus is on preventing occupational accidents, often called the slips, trips and falls. In such accidents, we often see a linear chain of events; hence it is easier to identify the reason(s) and to implement risk-reduction measures. The occupational safety measures help and great improvements can be observed. One example is the Norwegian Maritime Authority’s increased focus on occupational accidents, which has led to a documented 50% reduction in Lost Time Injuries (LTI) over the last 10 years. However, in the same period, the number of vessels involved in serious accidents has increased. This indicates that we cannot keep chasing LTI statistics based on occupational accidents alone when the safety improvement potential is much higher in other areas.
The industry needs to take a broader view on safety and the next step is to include the major accident risk in the everyday safety focus. One challenge with major accident risks is that they are more difficult to measure than occupational accidents. The reason for this is that the chain of events leading up to a major accident is much more complex. Managing major accident risk can thus often be seen as being about managing complexity. Good systems that capture this complexity and reduce uncertainty are needed to manage major accident risk. Barrier management is one approach to manage the complexity, and covers both technology and operations accidents. The purpose of barrier management is to reduce the major accident risk by establishing and maintaining barriers to prevent hazards from being realised or to mitigate the effects of a hazardous event. James Reason’s “Swiss Cheese Model” is one of the most used models to explain barrier management. It is based on illustrating the barriers as cheese slices and the weaknesses in the barriers are illustrated as holes in the cheese slice. The model builds on the principles of ‘defences in depth’. If there is a hole in one barrier, a new barrier should be able to prevent the hazard from leading to an accident.
For the ferry industry, it could be of interest to implement a barrier management process to a larger extent. The process of identifying barriers would highlight safety-critical equipment and the operational actions taken by humans to ensure safety. The concept also covers the methods of monitoring the barrier performance. This allows for adjustments if weakness is experienced in one of the barriers. By monitoring the barrier performance, the company will be able to identify leading indicators of major accident risk.
Assess and improve the safety culture
Safety culture is on the far left of the causal network and influences a large variety of the other nodes. Safety culture has been denied in many different ways in literature, however the saying ‘it’s what we do when no one is watching’ sums up the definitions quite well. Safety culture is about the awareness of safety amongst the employees. Evidence from safety-critical industries suggests that a good safety culture can help make organizations less vulnerable to incidents and accidents.
Safety culture is not something that is in place or not in place. Some kind of safety culture always exists in a company, but it could be more or less mature. Organisations with a mature safety culture are often recognised by their open and sharing culture in which safety is prioritised and also seen as a profit not a cost. They are constantly searching for new ideas to improve safety and will never settle for the view that they are safe enough. At the other end of the safety culture scale, we find organisations that blame accidents on the people, and also explain accidents by the nature of the risky business they are doing. The majority of organisations are somewhere in the middle, and recognised by chasing statistics, focusing on audits and wondering why people are not doing as they are supposed to.
For the ferry industry, it could be beneficial to assess the culture to identify the current status and then implement improvement measures. The safety-culture assessment would identify how mature the safety culture is in the company. Some assessments could highlight pockets of less mature safety culture in parts of the organisations, and also benchmark the company against other companies within the same segment and/or other segments. The reason for conducting safety-culture assessments is to be able to put the safety focus on the right place, and also to maintain and learn from the good initiatives which can be found in most organisations.
When improvement areas are identified, it is important that the changes aim to alter the culture, not only the symptoms. To change the culture, all parts of the organisation, including top-management, mid-managers and employees, need to be involved. If not, the initiatives will not lead to a lasting cultural change. The initiative needs to be anchored and communicated, prioritised and lived by the top-management. Mid-managers have key roles to play in following up the initiatives and must be role-models and prioritise the same areas as the upper management. The employees need to feel they are involved and responsible for maintaining and improving safety in the organisation. If the company manages to identify the right improvement areas and make cultural changes based on these, the risk of incidents and accidents will decrease.
The ferry industry, like the rest of the maritime industry, is under constant pressure to improve. Safety will be one of the most important areas in which to show continuous improvement. This article has suggested three goals to achieve in order to climb up the safety ladder. Awareness of the contributing factors of human error, managing major accident risk in everyday safety work and improving the safety culture could be focus areas that the ferry industry could consider when choosing its future safety work.