Unit 6: The Human Element: Cultivating a Culture of Safety

1. On accountability

Maintaining a safe living and working environment on a vessel is a shared responsibility of all on board and ashore. All personnel have a role to play and they can adversely affect others on board by their acts and/or omissions. For these reasons, it is important that:

• there are well-defined rules and guidelines, which are clearly understood;

• responsibilities are clearly defined for all on board and ashore;

• consequences of unacceptable (safety) behavior are made clear; and

• there is a fair, transparent and consistent response to unacceptable safety behavior, commonly referred to as a ‘just culture’.

On accountability, it is necessary to highlight the current separation of responsibility from authority.

The first two Points have been covered under ‘Clearly defined expectations’ and ‘Good communications’ above.

2. On just culture

A just culture policy is an important part of a positive health and safety culture. It clearly sets out the expectations for adherence to procedures in the workplace and provides a context for enforcing them. It recognizes behaviors that exceed Company expectations as well as those that fall below expectation, but are not always the fault of the seafarer.

A just culture places responsibilities on management to provide support, training and resources such that seafarers will have the necessary competence to undertake their tasks to the required standard.

The just culture policy provides a process (with appropriate support) for managing behaviors that fall below expectations in a transparent and fair manner. A just culture seeks to improve the organizational culture and the performance of the organization by modifying behavior, encouraging seafarers to take greater personal responsibility for their actions and rewarding behavior exceeding expectations. It also recognizes that firm action may be needed in circumstances where, despite management having carried out their responsibilities, inappropriate behaviors are still evident.

The just culture decision tree is a guide for ensuring consistent management for those who exceed or deviate from Company standards. The model presents a simple, yet robust, means of dealing with both exemplary and inappropriate behaviors, linked with a structure for an appropriate management response. It also recognizes that there are overlaps between the areas of any given established disciplinary response. It is essential that managers or supervisors fully understand the causal factors and root causes of an event before applying the decision tree. Where incorrect causes have been identified and applied to the model, there is a danger that inappropriate action is taken.

The decision tree operates on an increasing personal accountability baseline:

• On the proactive side, the baseline covers a range from expected behaviour to exemplary behavior.

• On the reactive side, the baseline covers a range from initiating actions that were malevolent, reckless, etc. (at the most extreme end) through to a no-blame error.

• The decision tree is linked to a Company action model:

• On the proactive side, Company actions range from actions for management to encourage behavior through to rewarding seafarers for their exemplary work.

• On the reactive side, Company actions range from dismissal (at the most extreme response end) to coaching/mentoring (at the least extreme response end).

This recognizes that both seafarer and Company have responsibilities for achieving improvements in behavior and increasing the Company’s safety culture.

3. Substitution test

The substitution test asks a reasonable person: ‘Given the circumstances that existed at the time of the event, could you be sure that you would not have committed the same, or similar, breach of procedures, standards, unsafe act, etc.?’ This should be conducted by several people independently and reviewed by all involved to gain agreement and consensus.

4. Management of supervisory interventions

Management or supervisory interventions following breaches of procedures/codes of practice/standards or any formalized Company/vessel rules can be an effective and powerful way of modifying individual behavior.

However, it is essential that the type of management response is appropriate. The just culture provides a framework to guide management in identifying an appropriate and common response. The decision tree should be used as a guide to ensure consistent handling of deviations from acceptable standards of behavior.

The National Maritime Occupational Health and Safety Committee has published guidance in Guidelines to Shipping Companies on Behavioral Safety Systems.

5. Effective knowledge management

From an occupational health and safety perspective, efficient management of knowledge can significantly improve learning and understanding and prevent accidents and incidents from being repeated. This is particularly useful in our industry where similar high-risk activities are being carried out on numerous autonomous units, such as a fleet of ships.

It has been said: ‘Man learns from his mistakes, but a wise man learns from the mistakes of others.’ By effectively collecting relevant information, organizing it so it can be understood and distributing it to those who can use it, we can share experiences and increase our knowledge. Applying this knowledge to our own working environment will allow us to reduce the likelihood of the same type of accident or incident reoccurring on our vessel.

Knowledge management is about:

• getting the right information - understand what information and knowledge has value, can improve safety, operations or services, or is necessary for fast and effective decision making;

• making it easy to understand - convert the information into a format that can be easily understood and acted upon at all levels in the Company - getting it to the people who need it, when they need it.

This information must be presented so that it can be understood and is clear, useful and available to the end user. There are many ways that this can be done: posters, memos, video, computer-based training, amendments to the safety management system and safety alerts are some examples. The choice of the best medium to transmit the information will vary in each Company. Often a Company newsletter can be a very effective means of getting the information out to the fleet in an easy-to-understand way.

No amount of shared knowledge will be useful unless those receiving it are empowered and feel comfortable using it. An open and honest safety culture that encourages all seafarers to share the same high values and beliefs in healthy and safe working is essential. All should be encouraged to use the knowledge and to gather useful information to share.

It creates the necessary technical and cultural ‘delivery systems’ and organize information and knowledge so it is useful and available; and encouraging them to use it; develop an organizational structure and culture that encourages seafarers to take what they know, apply it effectively for both continuous improvement and innovation, and share it with others.

Knowledge management does not have to be complicated or difficult. Most companies will have many of the elements in place already; it is often just a case of ensuring that they are all working together.

Information is gathered from data retrieved, both internally and externally. Accident and incident investigations, Accident Investigation Agency reports, safety alerts, audits and inspections, maintenance records, trip reports, safety meeting reports, masters’ reviews, vessel visits, safety observations and improvement suggestions are but a few of the sources. It is likely that some form of analysis of the data will be needed. This can be achieved in several ways including the use of spreadsheets to create statistics. It is important to ensure that all personnel at all levels are involved in gathering this information.

Different approaches may be needed for different levels of the organization. For example, statistics presented as a spreadsheet may be appropriate for senior management but safety alerts, amendments to procedures, bulletins and learning points memos may be more effective in introducing any lessons from the accidents and incidents depicted in the statistics. It is important that the data received are converted into useful information that makes sense to the end user. It is helpful to ask for feedback from the end user on the usefulness of the information.

Lastly, incident investigation can help reduce the risk. Effective incident investigation is a key component of a good knowledge management system. In the best systems, this would include all accidents, near misses, unsafe acts, unsafe conditions and non-conformities. The ISM Code requires that a safety management system includes procedures for reporting, investigating and analyzing every non-conformity, accident and hazardous situation, in order to improve safety and pollution prevention. This should then lead to the implementation of corrective actions. The safety officer will often undertake this work and guidance is provided in Safety officials. However, on ships with no safety officer, the Company must make other arrangements to ensure that this function is carried out. Any accident or incident should be recorded so that it can be investigated to find out what went wrong and to see if anything can be done to prevent it happening again.