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1 INTRODUCTION
Thestrengtheningofsafetycultureinanorganization
has become an increasingly important issue for all
high risk industries. A high level of safety
performance is essential for business success in
intensely competitive global environment. The most
important objective is to protect individuals, society
andtheenvironmentby
establishingandmaintaining
aneffectiveprotectionagainsttherespectivehazards.
This is achieved through the use of reliable
structures, systems and components as well as
adequate clear procedures, and acting people which
arecommittedtoastrongsafetyculture.
The term ‘safety cultureʹ first appeared in the
International Atomic Energy
Agencyʹs initial report
following the Chernobyl disaster. In the early
investigationofthisaccident,theinitialemphasiswas
focussedonplantdeficiencies.
However,morethoroughanalyses also identified
organizational, cultural, and managerial issues and
showedalackofanadequatesafetyculture.
In the nuclear industry, international
organizations such as
the International Atomic
EnergyAgency(IAEA)recognizedtheimportantrole
that all regulators should play in monitoring safety
performance in the nuclear industry. Following the
Chernobyl accident, the IAEA published two guides
onsafetyculture(IAEA1991and2002).
Morerecently,theIAEAdevelopedthefollowing
definition for safety culture
(IAEA 2006): “The
assembly of characteristics and attitudes in
organizationsandindividualswhichestablishesthat,
asanoverridingpriority,protectionandsafetyissues
receivetheattentionwarrantedbytheirsignificance.”
Human Factors and Safety Culture in Maritime Safety
(revised)
H.P.Berg
BundesamtfürStrahlenschutz,Salzgitter,Germany
ABSTRACT:Asineveryindustryatrisk,thehumanandorganizationalfactorsconstitutethemainstakesfor
maritimesafety.Furthermore,severaleventsatseahavebeenusedtodevelopappropriateriskmodels.The
investigation on maritime accidents is, nowadays, a veryimportant tool to identify
the problems related to
human factor and can support accident prevention and the improvement of maritime safety. Part of this
investigationshouldinfuturealsobenearmisses.Operationofshipsisfullofregulations,instructionsand
guidelinesalsoaddressinghumanfactorsandsafetyculturetoenhancesafety.However,eventhough
theroots
of a safety culture have been established, there are still serious barriers to the breakthrough of the safety
management. One of the most common deficiencies in the case of maritime transport is the respective
monitoringanddocumentationusuallylackingofadequacyandexcellence.Nonetheless,themaritimeareacan
beexemplifiedfromotherindustrieswhereactivitiesareongoingtofosterandenhancesafetyculture.
http://www.transnav.eu
the International Journal
on Marine Navigation
and Safety of Sea Transportation
Volume 7
Number 3
September 2013
DOI:10.12716/1001.07.03.04
344
Accordingto(IAEA2009),safetycultureshouldbe
basedonasetofsafety‘beliefs’(assumptions)andon
a code of conduct that reflects the right attitude to
safetywhichisheldincommonbyallindividualsin
the organization. Ultimately, the safety culture is
manifestedin individualand collective
behaviour in
theorganization.
In the meantime, inquiries into many major
accidents such as the Kingʹs Cross fire, Piper Alpha
andtheHeraldofFreeEnterpriseandmorerecently
the accidents in the Mexican Gulf (Deepwater
Horizon blow‐out) in 2010 have found faults in the
organisationalstructures,safety
managementsystems
andtheprevailingcultures,throwingtheimportance
ofsafetycultureintothespotlight.
Themostrecenteventinthenuclearindustrywas
inMarch2011whenamagnitude 9.0earthquakeoff
the coast of Japan and the resulting tsunami caused
extensive damage at the Fukushima Daiichi nuclear
powerplant.
Afullunderstandinghasyettoemerge
ofwhatJapaneseauthoritiesandthenuclearindustry
havelearnedaboutsafetycultureimplicationsatthe
Daiichiplant,asfacilityandequipmentdamagefrom
the earthquake and resulting tsunami has been the
initialfocusofeventstudies.Aswithallmajorevents,
getting
to the underlying safety culture issues
requiresmoretimeandfurtheranalysisbeforeallroot
causes can be identified, but a recent report by the
Japanese Government strongly points to safety
cultureissues(NAIIC2012).
Furthermore,an internationalexperts’ meeting in
May 2013 on human and organizational factors in
nuclearsafety
inthelightoftheFukushimaaccident
recommended to strengthen human including
organizational aspects and to improve the synergy
between technology and human factors (e.g., Ryser
2013).Moreover,asafetyculturetrainingcourse has
been described with the main goal to develop
awareness of the importance of each individual’s
personal
contribution to safety culture improvement
amongworkersandmanagers(Rusconi2013).
Althoughthereisawealthofinformation,articles
andreportsrelatingtosafetyculture,thereisstillno
universaldefinitionormodel.Safetyculturehasbeen
definedinavarietyofwaysincluding(Berg2011):
The ideas and beliefs
that all members of the
organisation share about risk, accidents, and ill‐
health,
Asetofattitudes,beliefsornorms,
A constructed system of meaning through which
thehazardsoftheworldareunderstood,
Asafetyethic.
The assessment of safety culture is key to
identifyinga
companiescurrentlevelofsafetyculture
(knownasitsmaturityordevelopmentlevel)inorder
to identify how to learn and improve. There are a
numberofdifferentassessmentmethodsincluding:
safety attitude surveys (using questionnaire to
elicitworkforceattitudes),
safetymanagementaudits(using anauditprocess
and trained
auditor to examine the presence and
effectivenessofsafetymanagementsystems)
safety culture workshops (involving a cross‐
sectionoftheworkforcetoconsiderperceptionsof
thesafetycultureandelicitimprovementideas)
safety performance indicators (analyzing data on
indicators such as the number of safety tours
performedor
nearmissdata).
Suchaquestionnairewhichisoftenusedasafirst
stephas tobe carefully developedforthe respective
needsandarea.Inthenuclearfield,aso‐calledIAEA
safety culture perceptions questionnaire has been
elaborated with 132 questions in this survey. The
purpose of this survey
is to refine the current pilot
version of the IAEA safety culture perceptions
questionnaire for future use in conducting safety
cultureassessmentsinthenuclearindustry.Thiswill
bethetopicofameetinginAugust2013withinvited
experts.
An explorative study of Swedish masters’
perceptionoftheconcept
ofmaritimesafetyincluding
safetycultureisprovidedin(Mauritzson2011).
InFinland,amaritimetransportstrategyisunder
preparation, where also the safeguarding and
developmentofthe expertise in maritimeindustries,
in particular from the viewpoint of maritime safety
culture (Ministry of Transport and Communications
2013).
Asafetycultureassessment
allowsanorganisation
to better understand how its people perceive safety
and the companyʹs approach to safety
management. It allows the organisation to identify
bothstrengthsandweaknesses thatthenenableitto
continuously monitor and improve its approach to
safety.
As in every industry at risk, the human
and
organizational factors constitute the main stakes for
maritime safety. Furthermore, several events at sea
have been used to develop appropriate risk models
(Chauvin 2011). Operation of ships is full of
regulations, instructions and guidelines also
addressing human factors and safety culture to
enhancesafety.However,managementashoreandon
board
need not only to ensure that the formalskills
areinplacebutalsoensure,encourageandinspirethe
necessaryattitudestoachievethesafetyobjectives.
2 HUMANFACTORSINMARITIMESAFETY
2.1 Roleofhumanfactors
Regulations and systems have not achieved the
desiredeffectsinavertingmarineaccidents
whichare
aresultofhumanerrorsandaccountfor80%ofthose
occurringworldwide.
Studieshaveshown(Rothblum2000)thathuman
errorcontributesto:
84‐88%oftankeraccidents,
79%oftowingvesselgroundings,
89‐96%ofcollisions,
75%offiresandexplosions.
These estimations are
still valid. Thus, the
maritimetransportsystemis25timesriskierthanthe
air transport system according to the accounts for
deaths for every 100 km. Intensification of sea trade
for last ten years causes the increasing of potential
risktotheshipsafety.
345
The implementation of the International Safety
Management Code (IMO 2008) has played a
significant role in addressing this issue through
trainingandeducationofcrewmembersbuttosome
extent casualties can be prevented by eliminating
other indirect causes including hardware, such as
equipmentsystems.
It must be noted that
if the possible cause of an
accidentishumanerror,findingandeliminatingthe
root cause of such errors is vital for preventing
recurrence‐whetheritis related to human element,
hardware factors, organizations and management
factors.
However investigation in human factors, main
cause of such accidents, is increased nowadays
and
themethodologiestocarryoutsuchaninvestigation
are being developed by several institutions. These
methodologies, adopted from the investigation on
riskanalysisarefrequentlybasedontheestimationof
risklevels,whosevalues,inthecaseofhumanfactor
investigationarenotalwaysclear.
In any case, a comprehensive
risk assessment
consistsof:
1 Identifyingthehazardinthesystem;
2 Evaluatingthefrequencyofeachtypeofaccident;
3 Estimatingaccidentconsequences;
4 Calculating various measures of risk, such as
deathorinjuriesinthesystemperyear,individual
risksorfrequencyofaccidentsofaparticularkind.
For improvements in operability and working
environment it is necessary to ensure that the
operability is not poor or inconvenient or is
encountering obstacles during operations. Since it
heightens the risk of an accident, it is important to
pay attention to the arrangement and layout of
equipment.Henceitisimportant
thatoperatorswork
incongenialandsafesurroundings.
Itisclearthattotalsafetyovershipsoperationcan
not be achieved, but it is possible to obtain a high
degree on it. Research on the influence of human
factorsovermaritimeaccidentsis,also,verydifficult.
Ontheonehand
wefindthatanaccidentinvolvesthe
interaction of individuals, equipment and
environment, as well as unforeseen factors (Caridis,
1999),andontheotherhand,humanfactorscomprise
operativehumanerrors–derivedfrompersonnelown
qualifications, or from their physical, mental and
personal conditions‐ and situational errors– derived
from work environment
design, management
problems, or human‐machine interface, amongst
others
Being aware that risk is an inherent factor of
maritime activity which can not be totally removed
and that errors are part of human experience, it is
expected that elements such as good management
policies, effective training and having suitable
qualifications
and experience, can reduce the
occurrenceofhumanerrors.
The practical application of this kind of analysis
seems clear: obtaining the cause parameters, both
direct and indirect parameters, from the studied
factor, one can better understand the root of the
presence of such a factor, and one can take specific
and
direct corrective actions to try to minimize the
accidentrisk.Themainweaknessofthismethodlies
inthelackorshortageofdatarelatedtoaccidentsand
incidentsonmaritimedomains.
Even though the roots of a safety culture have
beenestablished,therearestillseriousbarrierstothe
breakthroughofthesafetymanagement(Lappalainen
&Salmi2009).
The poor reporting practises cause further
problems. The information about the non‐
conformities, accidents and hazardous occurrences
does not cumulate at any level of the maritime
industry. The personnel of the other ships cannot
learnfromtheexperiencesoftheothervessels.
There
areno possibilities to interchange information about
incidents between the vessels. The company cannot
utilize the cumulative information when improving
its safety performance. Companies do not have the
opportunitytolearnfromothercompanies’mistakes
(Lappalainen & Salmi 2009). Under these
circumstances the national maritime administrations
arepowerlessin
theirattemptstofurtherdevelopthe
maritimesafety
The fundamental philosophy of the IMS Code
(IMO 2008) is the philosophy of continuous
improvement. The procedures for reporting the
incidents and performing the corrective actions are
theessentialfeaturesofthecontinuousimprovement.
Ifthisinformationisnotprovidedthesuccessfulcycle
of continuous improvement cannot function
(Lappalainen&Salmi2009).
Operation of ships is full of regulations,
instructions and guidelines which officers and crew
are expected to know and adhere to. A culture of
safety may perhaps be achieved through written
instructions, but in the end it is a question of
a
common mind‐set throughout the organisation.
Management ashore and on board need not only
ensure that the formal skills are in place but also
ensure,encourageandinspirethenecessaryattitudes
to achieve the safety objectives. Statistics prove
beyonddoubtthatinvestinginagoodsafetyculture
providesresultsand
paysoffinthelongterm.
The effort of allocating various forms of human
errorasverifiedaccidentcausesissurelynotatrivial
task. Moreover, this difficulty is augmented in the
case of maritime transport, since the respective
monitoring and documentation is usually lacking of
adequacy and excellence. Nonetheless,
marine
industry can be exemplified from other sectors of
industry (e.g. civil aviation, nuclear plants), where
considerable load of attention is already given in
pinpointingandrevealingvariousinvolvedaspectsof
human element extracted from comprehensive
databasesofsafetyrelevantevents.
Human behaviour and performance can be the
prevailingfactorsthat
prescribethelevelofsafetyfor
numerous maritime transport procedures and
practices of management (Martínez de Osés &
Ventikos 2006). This means that they can also
influence,inaconsiderabledegree, the protection of
marineandcoastalenvironment.Thus,a feasibleway
to reduce the frequency and severity of naval
accidentsis,byidentifyingthecontributingfactorsto
the so‐called human error, and by investigating for
346
methods,whichwilleithereliminateormitigatethese
mistakes.
Over the last 40 years the shipping industry has
focused on improving ship structure and the
reliability of ship systems in order to reduce
casualties and increase efficiency and productivity.
Improvements can be seen in hull design, stability
systems, propulsion systems,
and navigational
equipment.Today’sshipsystems are technologically
advancedandhighlyreliable(Rothblum2000).
Therefore,onefurtherimportantaspecttoreduce
marineaccidentsisthecollectionandinvestigationof
near miss data as it is practice in other transport
industrieslikeaviation.
Incident and near miss reporting is used as
a
proactive tool of safety management in many risk‐
prone industries. The ISM Code requires shipping
companies to establish a system for reporting
incidents and near misses. However, it has been
statedin several studies that incidentand near miss
reporting is deficient inthe shipping industry.Near
missreportinghas
beenseenasthefailingpartofISM
code’s implementation and received resistance from
theusers(Lappalainen,2011).
Theaimofarecentreportistopresentexperiences
and best practices of incident reporting in order to
offer information for improvement (Storgård et al.
2012). It is concluded in (Storgårdet
al. 2012) that‐
althoughsomeprogresshasbeenmadeinconnection
with shared incident reporting systems in the
shippingindustryintheBalticSeaarea‐thesharing
ofexperiencesandlessons learntatindustrylevelis
stillinitsinfancy.
The main objective of another report (Erdoğan
2011)wasto
identifysomebestpracticesaboutnear‐
missreportingfromthecompaniesthatareactivein
SwedishandFinnishshippingindustryandbelieved
tohavehighlevelofsafetywithintheirorganization
Themajorityoftheparticipantsbelievethatnear‐miss
reportinginprinciplehasasignificanteffectcreating
andenhancing
thesafetyculture. However,theactual
benefits of the near‐miss reporting are reported as
beinglimited.Further,itseemsthatthecompaniesare
not yet utilizing the reported data for establishing
trends to improve the follow‐up and the awareness
withintheorganization
Yet,the maritimecasualtyrate is still
high. Why,
with all these improvements, was it not possible to
significantlyreducetheriskofaccidents?Itisbecause
ship structure and system reliability are a relatively
small part of the safety equation. The maritime
systemis a people system, and human errors figure
prominentlyincasualtysituations(Rothblum
2000).
Arecentanalysis(Chauvinetal.2013)showsthat
most collisions are due to decision errors. At the
preconditionlevel,ithigh‐lightstheimportanceofthe
following factors: poor visibility and misuse of
instruments(environmentalfactors),lossofsituation
awareness or deficit of attention (conditions of
operators), deficits in
inter‐ship communications or
BridgeResourceManagement(personnelfactors).At
theleadershiplevel,theanalysisrevealsthefrequent
planningofinappropriateoperations.Inotherwords,
instructions given to the bridge team were
inappropriate,giventhesituationrequirements(poor
visibility or heavy traffic) and also constitute
supervisory viola tions. They may reveal
some
difficulty for leaders to adapt their instructions to a
changing situation may also reveal a poor safety
culture(Chauvinetal.2013).
Human reliability also influences the overall
systemreliabilityinautomaticsystems.Thisinfluence
can both be negative (e.g. human working error) or
positive (e.g. controlling system breakdowns or
system problems). Human performance could be
definedas the human beingʹs execution of anaction
withthepurposeofaccomplishingagiventask.
2.2 Exampleofanaccident
The example provided in the following (Gard 2012)
dealswiththeaccidentgrounding.Avesselisunder
way on an ocean
crossing with course set out from
start to end. The course is set out and the voyage
plannedonasmallscaleplanningchart.Thecourseis
set to pass some small groups of mid‐ocean islands
and the CPA (Closest Point of Approach) is
considered and thought to be well
on the safe side.
On a nice tropical night with calm seas and good
visibility, the vessel makes its approach to pass one
groupofislandswellontheportsidesometimeafter
midnight.
The chief officer observes during the last two
hoursofhis1600‐2000hrswatch
thataslightbreeze
and current are working together to set the vessel
slightlyoffcourseandtowardstheislandsahead.He
therefore makes a correction to the course to
compensateforthedriftandsettingtokeepthevessel
onitsintendedcourse.Whenhandingoverthewatch
at2000
hrs,thechiefofficermakesthesecondofficer
awareofthis.
Thesecondofficer continues toplotthe positions
throughouthiswatchandobserves thatthevesselis
still drifting somewhat off course to the effect of
making the CPA to the islands ahead less safe than
planned. He therefore
makes some minor course
adjustments to compensate for drift and setting. At
midnightthewatchishandedovertothefirstofficer,
who is also made aware of the drift and the course
adjustments. At 0040 hrs the vessel runs aground at
fullspeedonthebeachofasmalllow
atoll.Thebeach
ismainlysandandpebblesandslopesatalowangle
into the sea so the vessel suffers minor damage but
can not be re‐floated with its own power. A costly
salvageoperationfollows.
Thehumanaspectofthisaccidentisdiscussedin
thefollowing.The
positionswereplottedinthesame
small scale planning chart covering the entire ocean
wherethevoyagewasplannedandthecoursesetout.
In a small scale chart it is difficult to accurately
measuresmalldistances andobservesmalldeviations
fromthecoursebetweenhourlyplots.Thereasonfor
using
asmall scalechartwasprobablythatitwasnot
considered necessary to conductʺmillimetreʺ
navigation when crossing the ocean. The island on
whichthevesselgroundedwasmarkedonthechart
inuse,butonlyasasmalldotandthecoursewasset
topassatwhatseemed
tobeasafedistance.
The drift and current, however, worked together
tosetthevesseloffcoursetowardstheislandanditis
347
painfullyobviousthatthecorrective actionstakenby
thenavigationofficerswerenotadequate.
Itcanbeconcludedthatthegroundingwouldnot
havehappenedif:
a large scale chart had been used for position
plottingsinceitwouldthenhavebecomeapparent
thatthecoursewasheadinggradually
towardsthe
island,and/or
a much wider passing had been planned in the
firstplace,and/or
a considerable safety margin had been applied
whenthecorrectionsweremadetocompensatefor
driftandsetting.
Itisalsopossiblethatproperlook‐outanduseof
radar could have
been an issue. On the other hand,
theislandwasverylowanditisarguablethatitcould
not have been spotted visually in time in the dark
tropical night. It is unclear whether and why the
island was not seen on the radar, but it is a known
fact
thatradars are subject toa lot of interferencein
tropicalwatersanditcouldbethatboththerainand
sea clutter settings had been adjusted to deal with
that,thusatthesametimeremovingordiminishing
theradarimageoftheisland.
One further example is the
cruise ship Costa
Concordia’sgroundingattheItalianislandofGiglio
in January 2012 which will probably labelled as
humanerror(Porathe&Shaw2012).
3 MARITIMESAFETYCULTURE
3.1 Generalaspects
Safetyculturecanbeviewedfrommanyangles(Berg
2011). Typically, the environment close to safety
managers of the
organizations provides most of the
research material, and consequently the middle
management view dominates. Similarly, employee
perspective is strong in internal material of the
organizations,typically workinstructions and safety
management documentation. From the top
management viewpoint, lesser amount of practical
informationisavailable.
However, in shipping, and especially on
board
ships the organization is hierarchic, due to tradition
and the need for clarity in emergency operations.
Therefore, safety considerations depend strongly on
theactionsofthemastersandtheofficersoftheships,
and the interactions of the land‐based organization
(Räisänen2009).
One typical feature of shipping is that
ships are
mannedwithcrewsofmultiplenationalities,andthe
much of it is carried out in international setting,
outsidenationallegislations.Theseissuescomplicate
thecommunicationandinteractionswithintheships,
betweenthem,andwiththeland‐basedstakeholders.
Moreover one has to emphasize the effects of
national culture,
which is less prominent in related
safety discussions of other fields (Håvold 2005,
Håvold2007).
Theprevailinggoals,principlesandproceduresin
an organisation, which can safeguard against errors
andwhenerrorsareencounteredthroughwhichitis
possibletoreactwithsubsequentchangesinpractises
before serious incident or accident
occurs. Accident
investigationispartofthemaritimesafetyculture‐a
reactiveone‐butanexcellentobserverpoint.
In the Baltic Sea the maritime traffic is rapidly
growing which leads to a growing risk of maritime
accidents.ParticularlyintheGulfofFinland,thehigh
volume of traffic causes a
high risk of maritime
accidents.Thegrowingrisksgiveusgoodreasonsfor
implementing the research project concerning
maritime safety and the effectiveness of the safety
measures,suchasthesafetymanagementsystems.In
order to reduce maritime safety risks, it is
recommended in (Lappalainen et al. 2010) that the
safety
management systems should be further
developed.
ThepurposeoftheMETKUProject(Development
ofMaritimeSafetyCulture)whichstarted2008wasto
study how the ISM Code has influenced the safety
culture in the maritime industry, to evaluate the
development of safety culture in maritime industry
and to examine the
weaknesses found in the safety
management systems of shipping companies
(Lappalainen et al. 2010). The main results found
were that maritime safety culture has developed in
therightdirectionafterthelaunchoftheISMCodein
the1990´s(Heijari& Tapainen2010).Inthisstudyit
hasbeendiscoveredthat
safetyculture has emerged
and it is developing in the maritime industry. Even
though the roots of the safety culture have been
established there are still serious barriers to the
breakthroughofthesafetymanagement(Lappalainen
2008).
The ISM Code is seen as been effective over a
decade. However, the
old‐established behaviour
whichisbasedontheoldday’smaritimeculturestill
occurs, e.g., there are still serious barriers to the
breakthrough of the safety management. These
barriers could be envisaged as cultural factors
preventing the safety process. For more details see
(Lappalainenetal.2010).
However, experience has shown
that there are
perceived gaps between the desirable leadership
qualities,andwhatiscurrentlybeingdelivered.These
primarilyconcern:
Cleartwo‐waycommunication,
“Toughempathy”,
Opennesstocriticism,
Empathytowardsdifferentcultures,
Ability to create motivation and a sense of
community,
Knowingthecrew’s
limitations,
Beingateamplayer.
Moreover, there are other important explicit
barrierstoeffectivesafetyleadershipthatrelatetothe
currentstructureoftheindustry,standards,practices
and economic pressures. These barriers would need
tobeaddressedirrespectiveofthepersonalqualities
andskillsoftheMaster.
Therefore, workshops on
leadership and safety
culture for senior experts are regularly provided by
the IAEA in the nuclear field, the next one in
September 2013. This workshop will focus on the
topics such as international standards for leadership