Maritime Risk and Organizational Learning

Michael Ekow Manuel

• Publisher: CRC Press
• Year: 2017
• ISBN:
  9781317100539
• Edition: 1
• Topic: Tecnología e ingeniería
• Subtopic: Seguridad y salud industriales

Bridging an identified gap between research and practice in the domain of risk and organizational learning with respect to human/organizational factors and organizational behaviour, this book highlights the common and recurring threads in contributory factors to accident causation. Based on an extensive research project, it investigates how shipping companies as organizations learn from, filter and give credence/acceptability to differing risk perceptions and how this influences the work culture with special regard to group/team dynamics and individual motivation. The work is presented in the context of the literature regarding conceptual links between risk and the theoretical and operational themes of organizational learning, and in light of interviewees' comments. The themes include processes and structures of knowledge acquisition, information interpretation and distribution, organizational memory and change/adaptation and also levels of learning. The book concludes by discussing some practical implications of the research carried out in various maritime contexts and gives recommendations for the industry and other stakeholders.

Chapter 1
Introduction

It is unwise to be too sure of one’s own wisdom. It is healthy to be reminded that the strongest might weaken and the wisest might err.

Mahatma Gandhi¹

Purpose and Outline

This book focuses on how shipping companies learn from risk perceptions and how that learning influences the companies’ work culture, group dynamics and individual motivation. As an introduction to the questions and analyses that is the book’s focus, Chapter 1 presents a number of examples of accidents in high-risk industries taken from official accident report extracts and the safety literature and is intended to highlight a common and recurring thread in contributory factors to accident causation. It also gives a brief outline of the shipping industry and presents the book’s aims and potential value.

Social Dynamics in Accident Causation: Examples

One of the most significant current issues in high-risk industries is the role and influence of human factors in operational efficiency, safety and environmental protection. Recent developments in the supply–demand dynamics of manning in the maritime industry have resulted in increasing interest in and acknowledgement of the need to address human factor issues, not only at an individual level, but also at team and organizational levels. A number of accidents, incidents and near-misses over decades have increasingly highlighted the fact that the most competent of operators and systems are fallible and that the augmentation of knowledge by drawing on aggregate team knowledge and perceptions of risk makes risk management better. Following are narratives of some accidents that serve to illustrate some of these dynamics.

The Kegworth Accident

On the 8 January 1989, British Midland Flight 92 en route from Heathrow (London) to Belfast, while trying an emergency landing at the East Midland Airport, crashed at the edge of the M1 motorway near Kegworth, Leicestershire. One engine (of the two-engine plane) had caught fire during the flight and in an attempt to control the emergency situation the pilots shut down the wrong engine (the right engine instead of the left engine). Many factors were identified to have contributed to the accident (see the 152-page report by the Air Accidents Investigation Branch of the UK, 1990 for a detailed analysis). Despite all the technical, training and ergonomic issues that were identified as proximate or distant causal factors, this accident could have been avoided had the system and role-status perceptions being such that cabin crew would have informed the flight deck that they had seen fire in the left engine. In the words of the report:

It is extremely unfortunate that the information evident to many of the passengers of fire associated with the left engine did not find its way to the flight deck even though, when the commander made his cabin address broadcast, he stated that he had shut down the ‘right’ engine. The factor of the role commonly adopted by passengers probably influenced this lack of communication. Lay passengers generally accept that the pilot is provided with full information on the state of the aircraft and they will regard it as unlikely that they have much to contribute to his knowledge … The same information was available to the 3 cabin crew in the rear of the aircraft, but they, like the passengers, would have had no reason to suppose that the evidence of malfunction they saw on the left engine was not equally apparent to the flight crew from the engine instruments … In addition cabin crew are generally aware that any intrusion into the flight deck during busy phases of flight may be distracting … However it must be stated that had some initiative been taken by one or more of the cabin crew who had seen the distress of the left engine, this accident could have been prevented. (Air Accidents Investigation Branch of the UK, 1990, p. 106. Reproduced under the terms of the Click-Use Licence of the UK Office of Public Sector Information (OPSI)).

The report further noted (p. 109) that ‘it could be argued that the pilots of this aircraft did not make effective use of the cabin crew as an additional source of information’. While this may have been understandable in light of the whole accident report findings, it is nevertheless a sad omission, the avoidance of which could have saved many lives.

Herald of Free Enterprise

The Herald of Free Enterprise accident occurred, on the 6 March 1987, when this ferry sailed from the port of Zeebrugge with a bow door open leading to the significant ingress of water and subsequent capsizing of the ship; 150 passengers and 38 crew members lost their lives. The proximate cause of the accident – the non-closure of the bow door by the designated crew member – was attributed to ‘errors of omission on the part of the Master, Chief Officer and the assistant bosun’ (UK Department of Transport, 1987, p. 14). However, the investigation report also noted more fundamental but relatively latent issues, observing that, ‘from top to bottom the body corporate was infected with the disease of sloppiness’ (1987, p. 14). This accident shocked the world of shipping. It led to a rash of new legislation (Lavery, 1989) and an increased focus on the shipping company’s role in accident causation and prevention. It also highlighted how the reticence of masters/ship crew to challenge shore management when put under inappropriate commercial pressure, compromises or jeopardizes the safety of the ship and crew. This is indicative of the way risk information based on individual perceptions is attenuated by organizational systems, culture and economic priorities.

The report indicates (p. 23) that a few years earlier (in October, 1983), a sister ship of the Herald of Free Enterprise, the Pride of Free Enterprise, had sailed from Dover with all doors open because an assistant bosun had fallen asleep just as in the case of the Herald of Free Enterprise. The organizational structures of the company had been unable to achieve proactive learning from this earlier incident and indeed from many other communications of risk from ship to shore.

While the subsequent focus on organizational systems have been significant, the underlying social dynamics, onboard and between shore and ship, that lead to reticence concerning the communication of risk and the lack of fundamental proactive learning seem not to have been sufficiently addressed in the maritime industry.

Paediatric Death

Accidents and even fatalities that occur due to sub-optimal social dynamics in teams and the resulting attenuation of risk information and signals are not restricted to the aviation and maritime industries. One other high-risk domain where this is an issue is the medical field. According to Helmreich (2000, p. 784), an eight-year-old boy died unnecessarily, due to the actions (or inactions) of an anaesthetist during elective surgery on the eardrum. Among other arguably very unprofessional conduct, the attending anaesthetist was observed to be dozing during a critical time in the surgery. Some nurses observed this but did not speak up because they ‘were afraid of a confrontation.’ The young boy subsequently died, despite the efforts of an emergency team that had been summoned. The causes of death were attributed in no small way to the actions (and inactions) of the anaesthetist.

This is not an isolated case. Lingard et al. (2004, p. 330) cite the Chief Coroner of the Province of Ontario in Canada as reporting ‘communication difficulties at all levels [emphasis added] of the hospital, including doctors to doctors, doctors to nurses, nurses to nurses and nurses to doctors, as the primary cause of errors leading the death of a paediatric patient’.

Green Lily

In November, 1997, the reefer vessel Green Lily grounded off the Shetland Islands, after having sailed into severe weather. One life (of a rescue helicopter winchman) was lost with the ship being driven ashore resulting in a total loss. The accident report indicates that:

The master received no external pressure to sail. He was aware that the vessel would be heading into adverse weather and that progress would be slow. He was also aware that adverse weather was forecast for several days ahead, and that if he chose not to sail, the vessel would be significantly delayed. When sufficiently clear of the land, he intended to turn the vessel on to a more southerly heading to reduce the adverse effect of the wind on the vessel’s speed. In deciding to sail on 18 November, the master was optimistic that the prevailing and predicted weather conditions outside Lerwick would not unduly hinder the vessel’s progress. He should have considered the worst predicted conditions and their effect. Although at least one officer was concerned about the master’s decision to sail, no one openly questioned him. After clearing Bressay, the vessel was effectively hove to in south-east force 9 winds. The master recognised that the weather conditions were worse than he had expected and that progress would be much slower than he had hoped. He had the opportunity of returning to Lerwick but chose not to do so, in the hope that the weather would improve. Having decided to sail, his decision not to return to harbour was possibly influenced by his not wishing to be seen as having failed to consider the worst predicted conditions. The reluctance of anyone on board to question the master’s decision to sail from Lerwick, and his decision not to turn back after realising he had failed to consider the worst predicted weather conditions, suggests an autocratic style of management. A less authoritarian style might have encouraged greater discussion of the issues and would have enabled decision-making shortcomings to be identified at the outset. (Marine Accident Investigation Branch, 1999. Reproduced under the terms of the Click-Use Licence of the UK Office of Public Sector Information (OPSI)).

It is pertinent to ask why the master sailed in the absence of any external pressure to do so. One plausible reason could be that ‘pressure to sail’ results, not only from overt statements from the shore office, but also from the tacit prioritization of economics over safety or even the lack of significant and overt statements that create ‘pressure not to sail’ where there is doubt. This kind of latent organizational culture may also have influenced the crew in their unwillingness to state their perceptions of risk.

Bow Eagle

On the 26 August 2002 the fishing vessel Cistude collided with the Norwegian-registered chemical tanker Bow Eagle. The collision resulted in the loss of 4 lives (from Cistude) and the spilling of 200 tonnes of ethyl acetate (from Bow Eagle). After the collision, the Bow Eagle failed to stop to render assistance. The events in the immediate aftermath of the accident as indicated in the accident report are of particular interest in this book’s context. The following² is an extract from the original report:

After hearing the PAN PAN PAN message [from the damaged Cistude], at about 03H45, the lookout [of the Bow Eagle] asked the officer to inform the master. The officer did not follow this suggestion. Instead he demanded that the lookout keep the incident a secret – not to speak about it – which the lookout obeyed. This exchange took place in Tagalog (Philippines vernacular). The officer reiterated this the next day with the same results. At 04H00, the watch was handed over to the second officer without any special comments. (Bureau Enquêtes – Accidents/Mer [BEAmer], 2003, p. 51)

Despite the obvious potential presence of latent causative factors and a real opportunity to query contributory factors to risk situations (for example, social relations, attenuation of risk information), this only subsequently (at least at the level of investigating for lessons learned) led to the jailing of the officer on watch on the Bow Eagle (‘Officer of Norwegian tanker jailed over collision,’ 2003). This seems to be a typical reaction in the maritime industry.

Bow Mariner

The Bow Mariner accident is perhaps the one accident that most clearly shows the potential effects of failure in organizational learning in the maritime industry as well as the attenuation (or complete inhibition) of risk signals/perceptions in the risk cognition process.

On Saturday 28 February 2004 the chemical tanker Bow Mariner, while engaged in tank-cleaning, caught fire, exploded and sank about 45 nautical miles east of Virginia, USA. The accident resulted in the death of 3 crew members and 18 missing (presumed dead) along with a substantial release of a cargo of ethyl alcohol and fuel. According to the report ‘contributing to this casualty was the failure of the operator,³ and the senior officers of the Bow Mariner, to properly implement the company and vessel Safety’, Quality and Environmental Protection Management System (SQEMS) (United States Coast Guard [USCG], 2005, p. 1). On pages 42 and 43, the report notes that:

The master, chief officer and chief engineer of the Bow Mariner were Greek and the remaining officers and crew were Filipino. The authority and responsibility of the senior shipboard management is spelled out in 6.1.3 of the SQMM [Safety and Quality Management Manual], as well as Sections 2.2 (master), 2.3 (chief officer) and 2.4 (chief engineer) of the FOPM [Fleet Operating Procedures Manual]. Under the SQEMS [Safety, Quality and Environmental Management System], the master has ‘total responsibility’ for the operation, seaworthiness and safety of the vessel at all times. The chief officer is also designated as the safety officer, responsible for maintenance of equipment and training of personnel, in addition to his other duties. All three senior officers are charged with implementing the SQEMS.

Section 2.1.1 of the FOPM describes the master’s authority as follows:

The master has full authority over all persons (personnel and passengers) onboard his vessel. The Master’s authority is not questioned and must be supported and maintained by onboard personnel. Orders must be carried out and obeyed as said, in letter and in spirit. Refusal to do so is grounds for prompt disciplinary action, including possible termination of employment.

Such absolute authority is not unusual aboard seagoing vessels. Indeed, many would argue such absolute authority is essential to maintaining good order and discipline. But on the Bow Mariner the distinctions between the Greek senior officers and Filipino crew were remarkable. Filipino officers did not take their meals in the officer’s mess, were given almost no responsibility and were closely supervised in every task. The second assistant engineer, who was working aboard a vessel managed by this company for the first time, was upset when he was chastised on his first day aboard because he inquired about his management and administrative duties. The chief engineer sternly told him that he would be given verbal job orders daily, was to do only as he was told and would have no administrative duties beyond making log entries. In contrast, Section 2.4.2 of the FOPM spells out significant duties for the second engineer – duties the chief engineer on the Bow Mariner was not prepared to entrust to his subordinate officers. This contrast between the content of the SQEMS and actual practice aboard the Bow Mariner was pervasive. The lack of trust was apparent on deck as well. The surviving deck crew reported that the chief officer would not sleep, beyond short naps in a chair in the CCR [Cargo Control Room], during cargo operations. They stated this practice was common aboard vessels managed by this company. The chief officer performed all management and administrative duties himself, including the preparation of plans for cargo loading/unloading, ballast management, tank cleaning and gas freeing, training and drills. He did not delegate or attempt to train the junior officers to perform any of these tasks, either to reduce his own workload or provide for their professional growth. As a result the Filipino crew had little knowledge of the technical aspects of their job, so much so that they failed to question unsafe actions or procedures. When questioned about what they would do if instructed to do something unsafe by one of the senior officers, each crewman replied that they would do as they were ordered. (One crewman said that the orders of the Greeks were ‘like words from God’.)

This lack of technical knowledge and fear of the senior officers explains why the crew did not qu...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• List of Figures
• List of Tables
• Abbreviations
• Preface
• Acknowledgements
• Acknowledgements for Figures
• Acknowledgments for Tables
• 1 Introduction
• 2 Social Dynamics and the Construal of Risk
• 3 Organizational Culture and Learning
• 4 Research Questions, Methods and Measures
• 5 Research Findings
• 6 Discussion of Findings: Theoretical and Operational Themes
• 7 Discussion of Research Findings: Emergent Themes (I)
• 8 Discussion of Research Findings: Emergent Themes (II)
• 9 Research Conclusions, Implications and Recommendations
• Appendix 1 Glossary
• Appendix 2 Final Administered Survey
• Appendix 3 Demographic Variables for Survey Data Set
• Appendix 4 Survey Scales and Inter-Item Correlation Matrices
• Appendix 5 Statistical Data for Computed Construct Variables
• Appendix 6 Results of Statistical Tests
• Appendix 7 Semi-Structured Interviews: Guidance Questions
• Appendix 8 Qualitative Data Codes
• References
• Index