1. Introduction
“Things will go wrong in any given situation, if you give them a chance” (Murphy’s law).
On November 13, 2002, the heavy fuel oil tanker Prestige sprang a leak in its hull on the Galician coast. When the first difficulties were realised, the vessel’s master refused the support of a tugboat due to cost factors. Later on, four tugboats attempted to rescue the leaking oil tanker. The Spanish government refused to give permission for the vessel to take refuge in one of their ports, deciding instead to place it out at sea. Finally, on November 19, 2002, the tanker broke into two parts and sank (Guardian 2002).
The Prestige disaster raises the question of whether it could have been avoided and if all precautions had been taken. Other serious accidents at sea, such as the grounding of the container ship Rena on a reef in New Zealand in 2011 or the capsizing of the Costa Concordia in 2012, all similarly identified the human factor as one of the most significant causes (Porter 2012; Anon 2012).
Whether accidents cause oil pollution, loss of life or any other damage, the main issue that arises in these situations is the question of maritime safety and in connection with this, a well-implemented and robust safety culture. Safety cultures can easily fail due to a variety of reasons. One could be the style of management, as this can vary to a large extent (Roughton and Mercurio 2002).
Safety is of the utmost importance in the maritime industry, as incidents and accidents can have a devastating effect on humans, vessel, cargo and the environment (Cooper 2001).
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The Accident Database Review of Human-Element Concerns Report 2004 by the American Bureau of Shipping states that “human error continues to be a dominant factor in approximately 80 to 85 % of maritime accidents” (Baker 2004, p. 1); hence, the prevention of this contributes greatly to a strong safety culture in maritime organisations.
Within the last 12 months three of our vessels have been involved in serious incidents. In order to prevent such incidents from developing into accidents and to prevent further incidents the purpose of this report is to critically analyse and evaluate the importance of a more robust safety culture for our company with the intention of developing and implementing it on board our vessels.
2. Literature Survey and critical evaluation and analysis of safety culture
2.1 Critical evaluation of safety culture constituents
The term “safety culture” was initially used after the Chernobyl disaster in 1986, in order to investigate that the main contributor for such disasters and accidents is not necessarily engineering design or equipment failure, but people, “poor human performance” (Taylor 2010, p. 1).
However, since then, a wide range of different industries has defined safety culture, implying various forms of interpretation.
The International Atomic Energy Authority (IAEA) defines safety culture in their context as “that assembly of characteristics and attitudes in organisations and individuals which established that, as an overriding priority, nuclear plant safety issues receive the attention warranted by their significance” (Clarke, 2000, p. 66).
The Confederation of British Industry (CBI) however, focuses more on the common perceptions toward safety culture of all parties involved, defining it as “ideas and beliefs that all members of the organisation share about risk, accidents and ill health” (Hurst 1998, p. 21).
The Health and Safety Commission (HSC) defines safety culture as the outcome of the combined interactions of “individual and group values, attitudes, perceptions, competencies, and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation’s health and safety management” (Antonsen 2009, p. 16).
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These definitions share a common thread, the idea that culture is socially constructed. In other words, members of the culture in question create, define, protect and teach it to new members. Humans cannot operate without cultures. These systems provide roadIN BRIEF maps for their members to know how •This case study discusses to make sense of what is happening in how new training videos were ...
Although all these components contribute to safety as a whole, as they take into account a whole range of psychological factors, other elements contributed by the organisation, such as a safety management system, have to be taken into consideration as well.
Cooper (2001, p. 15) defines safety culture as “the product of multiple goal directed interactions between people (psychological), jobs (behavioural) and the organisation (situational)”.
(Figure 2: Cooper`s Reciprocal Safety Culture Model, source: Cooper 2001)
Cooper (2001, p. 15) argues that safety culture depends on a “dynamic inter-relationship” in an organisation, driven by the components of perception and the attitudes the personnel has towards it, as well as the organisation`s safety aims, combined with the daily goal-oriented safety behaviour of each individual. In addition, he emphasises that the availability and quality of the company’s safety management systems play a significant role in contributing to a goal-oriented behaviour. This concept can be seen as well-defined, comprising the main areas which affect safety culture. However, the concept has a deficiency, as it does not consider that some of the specific components might contribute more to a desired level of safety culture than others. The person-psychological factor is definitely the most difficult one, as it is the people themselves who have to operate safely. Rules and prescriptions can easily be changed. However, people’s perception and commitment as well as personal goal-setting in correspondence to the organisation’s safety culture present some difficulties. Hence, Rothblum (2005) argues that focus has to be on the human component, as it is people who will make changes in safety culture.
Furthermore, Weick (1987, p. 113) identifies that a well-established safety culture requires a “clear understanding of the system and its safety features, positive attitudes towards safety measures, and an incentive system that encourages safety in operations”. Moreover, Thai and Grewal (2006) argue that safety culture has to be viewed as the basis of all factors that contribute to safety management.
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Thai and Grewal (2006, p. 290) identify “management commitment” and “employee involvement” as the two most important components contributing to safety culture. They argue that the quality of safety performance in an organisation is mainly dependent on the quality of management attitude, instead of simply relying on safety procedures and regulations, and define safety culture as an “attitude of mind”. Thus, safety culture must place critical emphasis on its communication flow in the organisation going from the highest level of the organisation’s hierarchy to the lowest. Moreover, it is crucial that both senior management and employees pay their utmost attention to safety and encourage other members of the organisation to do likewise. Thus, personal commitment, responsibility, communication and learning are some of the key elements which contribute to a safety culture but these have to be implemented by higher-level management (Havold 2005).
Historically, maritime focus on safety was mainly based on technical improvements. Nowadays, emphasis is increasingly placed on the contribution of the human factor in respect of accident occurrences. Rothblum (2005, p. 1) argues that although ship structure and the reliability of ship systems have been greatly improved in the past, the risk of accidents has only been slightly reduced, as the human factor is still largely responsible for accidents in the maritime system.
The following table identifies the contribution of human error to marine accidents:
|Type of accident |Percentage | |tanker accidents |84-88 % | |towing vessel groundings |79 % | |collisions |89-96 % | |fires and explosions |75 % |
(Figure 3: Contribution of human errors to marine accidents, source: Rothblum 2005)
Hence, this is where the difficulty arises. A system and rules can be measured and changed, but the human component is far too complex to be measured and controlled. The safety of shipping relies to a large extent on seafarers. Errors occur if a crew has insufficient knowledge of safety and has not internalised it. Reasons can be inappropriate working management, working atmosphere or culture, and the crew’s perception of working (Hetherington et al. 2005).
Thus, Rothblum (2005, p. 2) argues that in order to reduce marine casualties, “we must begin to focus on the types of human errors that cause casualties”.
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The International Maritime Organisation (IMO) defines a company with a well-implemented safety culture as one that gives “appropriate priority to safety and realises that safety has to be managed like other areas of the business” (IMO 2011).
In respect of shipboard operations the organisation outlines that a safety culture implies doing the “right thing at the right time in response to normal and emergency situations” (IMO 2011), and seafarers have to give the highest priority to safety culture. The IMO (IMO 2011) argues that a high quality safety culture can be achieved if there is a conscious recognition by each individual that accidents can be avoided if procedures are followed with the utmost diligence in accordance with regulations. Additionally, there must be permanent, internalised safety thinking and a constant striving towards improvement.
According to the HSC a strong integrated safety culture in an organisation is achieved by “communications founded on mutual trust, by shared perceptions of the importance of safety and by confidence in the efficacy of preventive measures” (Clarke, 2000, p. 67).
2.2 Analysis of recommendations for the development of a more robust safety culture
Thai and Grewal (2006) identify that the development and implementation of a strong safety culture is of the utmost importance for a shipping company. In the maritime world, taking into consideration the various possible hazards, a robust safety culture will prevent injuries and save lives as well as protect the marine environment (Hansen et al. 2002).
Borodzicz (2005, p. 41) argues that by improving the safety culture of an organisation, economic efficiencies will also accrue and the organisation will benefit from profit both in the long- and the short-term. It contributes positively to an increased profitability, lowering costs, increasing the efficiency of staff, maintaining or improving the public reputation and improving quality, reliability, and competitiveness (Taylor 2010).
Moreover, Esbensen et al. (1985) argue that an obviously well-implemented safety culture in an organisation is also very important from an economic point of view as charterers make their decisions between vessels according to the availability and quality of safety on board.
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However, there are various challenges when developing and implementing a strong safety culture in an organisation. Challenges can be seen from a financial point of view. Moreover, due to its development over many centuries, the marine industry has traditionally been very conservative. New ideas and concepts have often been avoided until an obvious success has become visible. Safety is perceived as being very cost intensive and it appears to be difficult to demonstrate that safety and profitability go hand in hand (Vaughn 2011).
2.2.1 Safety culture review
Taylor (2010) argues that before developing a safety culture in an organisation, a safety culture review has to be conducted in order to examine possible safety culture characteristics and supporting attributes. This can be achieved by quantitative (i.e. questionnaires, interviews, observed human performance) and qualitative assessments (i.e. by a review psychologist).
However, in order to achieve a representative result, a combination of both is required.
2.2.2 Development of a safety management system
According to Roughton and Mercurio (2002), the implementation of a safety management system (SMS) will support a successful safety culture. The safety management system of a company outlines how safety is treated in the workplace and in which way particular policies and procedures are implemented. However, it is supposed to be treated as an active component of an organisation’s management system, and not only as a “written set of policies and procedures” (Kuo 1998, p. 168).
The IMO states that all employees have to be actively integrated and feel responsible for contributing to safety (IMO 2011) and reflect this in “The International Management Code for the Safe Operation of Ships and for Pollution Prevention” (ISM Code) (SOLAS 2009).
However, even if safety culture is closely linked to the ISM Code, it represents only the minimum standard in order to achieve maritime safety, meaning that further measures should be integrated for a more robust safety culture (Thai and Grewal 2006).
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2.2.3 Three level strategy for the development of a more robust safety culture
For the development of a robust safety culture, Cooper (2001, p. 34) argues that a three level strategy has to be adopted, comprising an “immediate, intermediate and ultimate” level of effort.
To achieve an immediate level of effort, strategic plans first have to be developed and implemented in order to completely integrate safety into the organisation, taking into consideration all divisions of the organisation. There should be an emphasis on the quality of the safety leadership, meaning the senior management team in the company (The Nautical Institute 1997).
Hence, Cooper (2001, p. 18) suggests a “Management Control System” consisting of precisely formulated and “measurable objectives, monitoring procedures and regular feedback”. In order to create a robust safety culture, it is imperative that the enforcement of strategic plans is monitored and reviewed on a regular basis. Moreover, the results have to be regularly communicated to all employees, thus, a communication system and an organisational structure have to be guaranteed. Additionally, a safety practitioner is of great importance in an organisation seeking a positive safety culture.
This person must have “direct, independent and unimpeded access” to all entities of the organisation, including the senior management team (Cooper 2001, p. 5).
According to the ISM Code, “one or more designated persons ashore shall have direct access to the highest level of management” (Kuo 1998, p. 156).
Furthermore, the organisation’s risk control system presents a further significant feature. Kristiansen (2005) argues that the combination of risk analysis and risk assessment processes will contribute to a robust safety culture where risk analysis is a risk calculating process for the identification of hazards. Subsequently, risk assessment is the process using the results obtained in risk analysis to improve safety through risk reduction by introducing safety measures. The process is illustrated in the following figure:
(Figure 4: The process of risk analysis and risk assessment, source: Kristiansen 2005)
Furthermore, there are various techniques recommended for the identification of hazards. Kuo (1998) identifies the Fault Tree Analysis (FTA) and the Event Tree Analysis (ETA) as the main instruments for the measurement of occurrence and gravity of the consequences regarding hazards with respect to risk analysis. Whereas the FTA model provides an instrument for the identification of critical, unwanted occurrences (for instance, the estimation of probability regarding the loss of the propulsion function on a tanker), the ETA model goes beyond this and estimates and analyses the possible consequences of an event or incident (Kristiansen 2005).
In addition, section 11 of the ISM Code states that a safety management manual has to be drawn up and used to describe what the organisation`s specific safety management system contains (SOLAS 2009).
According to Roughton and Mercurio (2002), such an organisation’s instruction booklet provides a further indicator of a positive safety culture, but it must be actively used.
The second part of the threefold strategy is the intermediate level of effort. This is concerned with the development of a management information system, which, inter alia, is supposed to evaluate current safety activities and to measure their effectiveness (Cooper 2001).
Florczak (2002) argues that the development of a monitoring system plays a further significant role by reviewing the whole safety management system on a regular and planned basis.
The third part of Cooper’s strategy, the ultimate level of effort, is concerned with convincing people and actively engaging them in the organisation’s safety cause. He argues that this should be achieved by developing “high quality safety training programmes”, including encouraging and empowering employees to incorporate safety into their day-to-day working routine (Cooper 2001, p. 233).
2.2.4 Psychological factors
Nevertheless, the most challenging aspect is posed by the psychological factor. People’s values and perceptions can hardly be measured and moreover, due to their nature, they are very resistant to change. New implemented changes can generate a sense of insecurity and raise fears (Vaughn 2011).
In the maritime industry seafarers exhibit a wide variety of personal attributes regarding knowledge and competence. On board the vessels there is often a combination of seafarers with different nationalities and from different backgrounds and cultures. Even though the seafarers` knowledge and competence is regulated on an international basis controlled by the standards of the STCW Code (Standards of Training, Certification and Watchkeeping for Seafarers), their level varies to a great extent as they have been educated and trained at different places. Hence, group work will be the result of people with individual knowledge, experience and cultural background and this may pose some difficulties. These difficulties can be, for example, the result of dominance or a lack of communication skills (Hetherington et al. 2005).
A safety culture should ensure that the whole crew share the same values and has the same aims which should ultimately result in self-regulation. Values and behaviour should conform to all the safety standards and, ideally, these should be enthusiastically followed. (Esbensen et al. 1985).
Kuo (1998, p. 170) argues that in order to develop a positive culture for marine activities, a collaborative philosophy is required and needs to be adopted in the organisation and defines such a philosophy as follows: “the best solutions are usually derived via close collaboration between the prescribing authorities and the users”. The major values of such a philosophy are responsibilities shared by both parties to overcome the authoritarian nature of prescriptive regulations. Over time, such a philosophy is supposed to encourage the development of positive attitudes to safety matters (Kuo, 1998).
Vaughn (2011) argues further that common respect and dignity when dealing with each other, caring and looking out for one another are the keys to creating a successful safety culture. Hence, the management of an organisation with a well-implemented safety culture does not punish staff, but motivates and encourages them (Thai and Grewal 2006).
Safety has to be included as a way of life (Thai and Grewal 2006).
3. Critical evaluation of the implementation of the new safety culture on board the vessels
Finally, there will be a concept comprising supported recommendations for the implementation of a strong safety culture on board the vessels, leading to a time scale for the implementation process.
The analysis shows that the implementation of a robust safety culture will be highly beneficial and profitable for the company in that it will contribute positively not only in the context of general safety on board the ships, but moreover, it will lead to financial benefits.
It is imperative that the highest level of maritime safety is aimed for, meaning that safety always has to be the first priority in the crew’s daily operating business and has to be ingrained in every manager`s and employee`s mind. A change towards a more robust safety culture will be greatly focused on individual commitment.
The implementation concept will comprise a schedule that will consist of eight main steps:
(Figure 5: Schedule for implementation, source: own construction)
1. The strong safety culture has to be prioritised as a highly important part of the organisation’s culture
Therefore, a safety philosophy has to be implemented, to be prioritised by every member of the organisation, including the highest level of management. The philosophy will contain a safety vision, key policies, aims, procedures, and strategic and operational plans, to be committed by the senior management and to be communicated to all employees as well as to be evident in daily activities at all levels. This philosophy of safety is based on a concept of continual improvement, personal commitment and responsibility on the part of everyone in the company. Safety is considered as a continuous, never-ending process. The interconnected successful functioning of the organisations both on board and ashore is a basic requirement and both must have common goals. Hence, there must be short communication ways. Short decision-making processes by the management will simplify work on safety and bring strategic plans closer to realisation.
2. Clear safety policies
The SMS will be individually monitored and adopted on every single one of our vessels (as they are not of the same type).
Safety standards above the ISM Code prescriptions are highly sought after. All tasks that have critical safety implications have to be identified and standards and procedures have to be created in these areas. Our safety policies will be reviewed in our safety management manual, comprising structured policies also in respect of reward and punishment regarding safety matters. For easy access this manual will be available in electronic form. In particular, our policies outline that we operate in a “no-blame” culture, in order to support failure transparency. Thus, failure reports shall not contain names, only “crew-culture”.
This is of utmost importance, so that people tell the truth. The company`s mentality reflects the idea that safety is an intrinsic part of daily work practices and dangerous actions will not be tolerated. Furthermore, safety regulations have to be established and to be strictly followed, from the top to the bottom of the hierarchy, by the shipping company as well as by the crew and vice versa. Moreover, subordinated staff must be allowed to stop superior staff in cases where incorrect decisions are being made. Charterers and third parties have to accept that vessels can be delayed due to safety training.
3. Establishing and maintaining a safe workplace and working environment
A safe workplace will be guaranteed on each of the vessels due to the implementation of appropriate individual safety management systems. This will be adjusted to our safety culture and its requirements and principles. Additionally, the provision of resources and safety equipment will be assured. Furthermore, our safety culture philosophy will also be taken into consideration during the process of recruitment.
Additionally, there will be a guarantee that vessels are regularly improved by a strict maintenance philosophy (complete integrated preventive computerised maintenance system for each individual vessel).
4. Full commitment to safety by leadership and crew
Senior management commitment is indispensible. This means effective, regular communication about safety on a horizontal and vertical level between managers and crew. The crew`s awareness of a positive attitude toward safety has to be examined. Personnel on board and ashore have to act safely and responsibly at all times.
The DPA (Designated Person Ashore) must be competent and have a good understanding of the concept of safety culture. It is vital that the DPA is acknowledged by the whole personnel as a “trustworthy” person, in order to create confidence. His role is extremely important and he has to be loyal to everybody.
5. Changing personnel’s behaviour
A strong safety culture can only be achieved if both personnel ashore and seafarers start believing in safety, behave that way and constantly strive to make improvements. All employees have to be encouraged to examine and constructively discuss safety issues, and to be willing to take positive decisions in this regard without fear of repercussions from managers or colleagues. In addition, attention should be paid to the composition of the crew. The same crew should be placed on certain ships over a period of time, at least some years, in order to achieve commitment at the workplace. This is critically important as people have to have a feeling of trust and identification with the company in order to carry out safety measures on the basis of the safety philosophy of the company.
For the crew, the vessel as a workplace must also be attractive as a place to live. The whole environment has to be such that everybody feels comfortable and can carry out leisure activities. Additionally, there has to be regular internal training and incentives for career opportunities have to be provided. If the crew is enjoying their work, this will have a positive impact on maritime safety work.
People have to be motivated and given incentives, e.g. by means of praise or bonus systems.
If safety regulations are repeatedly disregarded, personnel must be expelled from the company with immediate effect.
6. Adequate provision of training
In order to achieve an appropriate, goal-related attitude and performance, the quality and effectiveness of the seafarers’ education and training plays an important role. Training sessions have to be conducted on a regular basis as well as emergency response training. Safety training has to be repeated on a regular basis for everybody (shore- and sea-personnel) in training centres ashore and should be conducted in an interesting and understandable way with enthusiastic qualified trainers, and not only carried out on board with boring computerised training systems.
7. Implementing risk management
Risk analyses and risk assessments have to be carried out and as a consequence, further measures implemented. If countermeasures have been applied, this has to be reported. Guidance for the process of risk assessment and control will be as follows:
(Figure 6: Schedule for risk assessment and control,
source: Germanischer Lloyd 2010)
8. Creating a good evaluation and control system of safety management
Finally, the implementation of a safety management control system will be essential. Therefore, the company’s current performance will be effectively monitored on a regular basis in order to improve continuous safety. Moreover, increased importance will be attached to a system comprising the reporting of near-misses, that is very important in the identification of hazards and the avoidance of accidents. Thus, incentives have to be given so that people will submit these reports. Hazards have to be recognised. Plans have to be devised in order to identify hazards on different ships. In order to avoid accidents, it is also very important to relieve people’s stress. In this context, good pre-planning in the team is important. Internal and external monitoring will be conducted on a regular basis on all vessels as well as in the office, including a management review.
In the following, there will be a timescale outlining the process of the safety culture implementation:
(Figure 7: Timescale for safety culture implementation, source: own construction)
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