125
Reason, J. 2001. Managing the risks of organizational accidents.Aldershot:Ashgate.
1 THEVOLUNTARYDOCUMENTOF
COMPLIANCE
For the purpose of this study, there are two large
passenger ferry operations worldwide that currently
maintainaVoluntaryDocumentofCompliance.One
operator, Canada’s BC ferries acquired their
VoluntaryDocumentofCompliance(VDOC)in1995
fromLloydsRegister.Thesecondoperator,NewYork
City’s Department of Tra
nsportation operates the
StatenIslandFerrywhichobtainedtheirVDOCfrom
the American Bureau of Shipping (ABS) in 2005.
These operations have experienced fundamental,
introspectivechangeassociatedwith majoraccidents
International Safety Management
–
Safety Management
Systems and the Challenges of Changing a Culture
G.A.Hanchrow
SUNYMaritimeCollege,NewYork,UnitedStates
ABSTRACT:Overthepastgeneration,theISMcodehasbroughtforthtremendousopportunitiestoinvestigate
andenhancethehumanfactorinshippingthroughtheimplementationofSafetyManagementSystems.Oneof
thecriticalfactorstothisimplementationhasbeenmandatorycomplianceandarequirementforobt
aininga
DocumentofCompliance(DOC)forvesselsoperatinggloballyoratleastinternationally.
Aprimary objectiveof thesesystems isto maintainthemas“living”or “dynamic” systemsthat are always
evolving. Asthe ISM code has evolved, there have been instances where large organizations have opted to
maintainavolunta
ryDOCfromtheir respectiveclasssociety.Thishasbeenaccomplishedwithalargehuman
factorelementastypicallyanorganizationalculturedoesnotalwaysacceptchangereadilyespeciallyifthereis
not a legal requirement to do so. In other words, when considering maritime training is it possible tha
t
organizationsmayrepresentculturalchallenges?
The intent of this paper will be to research large maritime operations that have opted for a document of
compliancevoluntarilyandcomparethemtosimilarorganizationsthathavebeenmandatedbyinternational
lawtodothesame.Theresultshouldbetogaininsightint
othehumanfactorsthatmustcontributetoaculture
changeintheorganizationforthepurposesofalegalrequirementversusthehumanfactorsthatcontributetoa
voluntaryestablishmentofasafetymanagementsystem.Thisanalysiswillincludeboththeexecutivedecision
makingthatdesignsasystemimplementationandtheoperationalsectortha
tmustexecuteitsimplementation.
Allsuccessandfailuresofeducationandtrainingcanbedeterminedbytheoutcome.Didthetrainingachieve
itsgoal?Orhastheeducationpreparedthestudentstoembraceanewideainconjunctionwithacompanygoal
or a new regulatory scheme? In qualifying the goal of a successful ISM int
egration by examining both
mandatory and voluntary ISM implementation in large maritime operations, specifically ferry systems,
hopefullywecanlearnfromthevariousfactorsthathavegoneintoeach.
http://www.transnav.eu
the International Journal
on Marine Navigation
and Safety of Sea Transportation
Volume 11
Number 1
March 2017
DOI:10.12716/1001.11.01.15
126
which resulted in the implementation of a Safety
Management System (SMS) as way to capture the
causal elements of each accident, mainly the human
element. Although the circumstances behind each
operation’s SMS are different, they share the fact of
“Voluntary”compliancewiththeISMcode.Asyou
can imagine when
dealing with the human psyche
there are challenges inherent when introducing and
attemptingto applyanythingvoluntary.Thiscanbe
primarily due to the observation that humans,
seafaring ones in particular, are not always open
mindedtochange.
When change is tangible, such as the advent of
containerization and the
shift away from traditional
breakbulkcargo, changewasacceptedonthebasisof
notbeingabletohideit.That,andthefacttherewas
simplyno stoppingthe forcescausing the changeto
beimplemented.
But when confronted with something like a
“Safety Management System” that has the notion
of
being voluntary attached to it, the challenge of
implementing it becomes more difficult.This said
the challenges of implementing an institutional
change,suchasISMtotheglobalindustryrepresents
aparadigmchangeinthewaycompaniesoperateand
areheldaccountablefortheiractionsandforthoseof
thepeopletheyemploy.
The curious nature of “change” as it applies to
maritimeoperationsvoluntarilyacceptingISMisnot
exclusivehowevertothevoluntaryaspect.Thenotion
of ISM being required and NOT optional does not
alterthedynamicchallengesofimplementation.This
canbefoundintheeventssurrounding
thetragicloss
of the Costa Concordia. Costa Cruises was in
possession of a DOC through international
requirementsanddidsomandatorily.Inaddition, the
vessel in question maintained a non‐voluntary Ship
Management Certificate (SMC), however the
company and the vessel crew will undoubtedly
become identified through this accident.
This
situationwassimilarintheeventinvolvingtheNYC
Ferry Andrew J. Barberi in 2003. Whereas the latter
ferryboatdidnotmaintainanSMCandNYCdidnot
possess a DOC, the Staten Island Ferry has become
identified to a larger audience through the events
surroundingthetragic
accidenttherethanbefore.
In the case of BC Ferries, the decision to
voluntarily adopt the ISM code into their operation
was done so after a tragic accident in 1992 and
another accident in 1995 involving ferry casualties
with human elements as the causal factor. The
purpose of exhibiting a subsequent
case to is draw
comparisons to three passenger vessel operations
worldwide and their different relationships to the
ISMcode
1 BCFerries–VoluntaryISM–QueenoftheNorth
accidentpostISMimplementation
2 StatenIslandFerries– VoluntaryISM–AndrewJ.
BarberiaccidentpreISMimplementation
3
CostaCruises–MandatoryISM–CostaConcordia
accidentpostISMimplementation
2 BCFERRIESANDTHEQUEENOFTHENORTH
The Queen of the North was a large passenger ro‐ro
ferry operated by the British Columbia (BC) Ferry
system.The vessel ran aground and subsequently
sankduringatransit
initsnormaloperatingareaon
22 March 2006. The report of the sinking concluded
thatthevesselfailedto makeneither arequired nor
any course change for four nautical miles and over
fourteenminutestopreventitfromgroundingat17.5
knots.Italsoconcludedthathumanfactors
werethe
primary cause of the sinking that ultimately led to
two passengers being not accounted for and
presumeddead.Althoughthispaperisnotareview
of accident causal factors, nor is it in any way
representative of an analysis of any company or
operation,itdoesrepresentanobservation
ofmarine
operations operating with a VDOC and some of the
factorsthatshouldprovokethoughtintohowISMis
implementedandmanagedworldwide.
The following is an excerpt from the report
conductedbyTransportCanadaintotheaccident.
“…In order to comply with the ISM Code, BC
Ferries established
procedures for identifying and
responding to emergency situations. The Emergency
Management and Response Manual outlined corporate
strategy for emergency management, as well as
policies for organizing and activating its response.
Vessel‐specificmanualscontainedtheproceduresfor
on‐site responses to vessel emergencies and
emergency procedures checklists were developed.
Furthermore,the
BCFerriesFleetRegulationsrequired
thatcontingencyplansbedevelopedforallidentified
potential emergency situations‐including
abandoning ship‐and that a schedule of drills and
exercisesbeestablishedforeachplan.Atthetimeof
the occurrence, the QueenoftheNorth had abandon‐
ship procedures in the vessel‐
specific manual, but
thesedidnotaddressthevarioussituationsthatmay
be associated with an evacuation. Such situations
includeidentifyingand locating missing passengers,
and directing passengers from assembly stations to
embarkationstations.
BC Ferries was in the process of developing
evacuationplansforitsvessels.Althoughithasbeen
aregulatory requirementsince 1996,itwas not until
TCinspected the QueenoftheNorth in early
March2006 that the requirement to have an
evacuationplan/procedurewassingledout.
The objectives of the International Safety
ManagementCode(ISMCode)aretopreventhuman
injury, loss of life, and
damage to the environment.
Although most vessel operators in Canada are not
requiredtocomply,severalhavedonesovoluntarily.
Thegoalofasafetymanagementsystem(SMS)is
to permit participants to detect and prevent unsafe
practices and conditions before an accident occurs
rather than having others identify safety
shortcomings
afterward.Itisthereforeimportantthat,
when any non‐conformity is reported, appropriate
correctiveactionbetakeninatimelymanner.
In this occurrence, internal and external audits
failed to identify a number of shortcomings. It was
also reported that external audits did not always
apply the same standards regarding
compliance.
127
Major non‐conformities, for example, which would
haveotherwisebeencited,maynothavebeenissued
becausetheISMCodehadbeenadoptedvoluntarily.
Therefore, less emphasis may have been placed on
taking corrective action‐ effectively defeating the
objectivesofboththeISMCodeandaneffectiveSMS.
In Canada,
TC has delegated five classification
societiestoperformISMCodeauditsonConvention
vessels.TCalsomonitors,viaaudits,theactivitiesof
these classification societies. However, TCʹs
monitoring,auditing,andoverviewisformandatory
systemsonly:TCdoesnotmonitortheapplicationof
theISMCodewhereithas
beenvoluntarilyadopted.
TheBoardisconcernedthatthislack ofconsistent
application compromises the objectives of the ISM
Code. Moreover, the Board believes that, with the
large numbers of passengers that may be carried at
anyonetimeonapassengervessel,qualityauditsare
essential in being able to
identify deficiencies
requiringcorrectiveaction.TheBoard,therefore,will
monitorthesituation…”[1]
ThisreportconcludestheTransportationSafetyBoardʹs
investigationintothisoccurrence.Consequently,theBoard
authorizedthereleaseofthisreporton30January2008.
Itisimportantto notethattheaboveconclusions
are observations on
the general state of ISM
performanceatBCferriesandwithsuchconclusions
inhindsight,howtheycontributedascausalfactorsin
theaccident.
However,thehumanfactorsthatarealsoincluded
inotherareasofthereportindicatesomethingmuch
moretangibletoavesseloperation.Includingbutnot
limited
tointerpersonalandintercrewrelationships,
intravesselandintracompanycommunicationsanda
generalquestionofhowISMprincipleswereadopted
into the everyday working life of the vessel. Was
therebuyin?Specifichumaninterfaceelementsnoted
inthereportarethefollowing.Firstasteeringstand
had
been recently retrofitted with a new steering
mode selector switch. There was much deliberation
and communication between the two crews that
sharedrotationsonboardastotheprocedureforthe
quartermastertofollowwithhandsteering,autopilot,
and conning position. Ultimately there were two
different procedures onboard specific to each crew.
Secondly, the use of raster charts instead of vector
ENC prevented certain ECDIS specific alarm
functions from being enabled and useful in alerting
thewatchstandersofthedevelopingsituation.Lastly,
therewasasignificantelementofintracrewpersonal
relationships that potentially caused the watch
standing crew to not
maintain focus on safety
management.
Again,thesecommentsarenotintendedtofurther
anyassignmentofblame buttohighlightconditions
that areunfortunately typically found when there is
notaveryfirmguidancefrompractitionersofISMas
to WHY the ISM needs to be embraced, instead of
WHATneeds
tobedoneinordertocomplywithit.
The three conditions referenced above might have
met better resolution if a poignant level of
communication was focused on ensuring there was
honestunderstandingofintrinsicvalueoftheSMSas
opposedtotheinstrumentalvalueofsimplyseeking
to comply
with requirements. As it stood, they did
contributemateriallytotheendresultinthistragedy
andwereconditionsthatthedevelopmentofISMwas
intendedtocaptureandresolve.
3 STATENISLANDFERRYANDTHEANDREWJ.
BARBERI
TheAndrew J.Barberi isapassengerferry operated
bytheNew
YorkCityDepartmentofTransportation.
Atragicaccidentoccurredwhentheferryallidedwith
a pier in close proximity to its terminal destination.
The text below is taken from the U.S. National
TransportationBoard(NTSB)report.
National Transportation Safety Board‐2005.
Allision of Staten Island Ferry Andrew J. Barberi, St.
George, Staten Island, New York, October 15, 2003.
Marine Accident Report NTSB/MAR‐05/01.
Washington,DC.
Abstract: This report discusses the allision of the
passenger ferry Andrew J. Barberi with maintenance
pierB‐1attheStatenIslandferryterminalonOctober
15, 2003. The ferry carried an estimated 1,500
passengers and
15 crewmembers. Ten passengers
diedintheaccidentand70wereinjured.Aneleventh
seriously injured passenger died 2 months later.
Damages totaled more than $8 million, with repair
costsof$6.9millionfortheAndrewJ.Barberiand$1.4
million for the pier. From its investigation of the
accident,
the Safety Board identified the following
safety issues: actions of the assistant captain and
captain, oversight of ferry operations by the New
York City Department of Transportation, medical
oversight of mariners, safety management systems,
and the potential contribution of navigation
technologytothesafetyofferryoperations.
Onthebasisof
itsfindings,theSafetyBoardmade
recommendationstotheNewYorkCityDepartment
of Transportation, the U.S. Coast Gua r d, the States
thatoperatepublic ferries, andthePassenger Vessel
Association.[2]
TheStatenIslandFerryoperatesafleetofvessels
on a single route between Staten Island, and
Manhattan Island
and since September 2001 carries
only passengers. Vehicle carriage is limited to
emergency response, or NYC government vehicles.
All vessels are of the “double ended” bow loading
type with two identical ends, and two identical
pilothouses.Uponcompletionofatripthevesseldoes
notturnabout,buttheoperatingpilothouse
transfers
itscontrolpowertotheoffshorepilothouse,andthe
next trip commences after passenger loading is
complete, as if the vessel simply was returning in
reverse. In this manner, the Captain of the vessel
would traditionally transfer power to the Assistant
Captain who would be stationed in the opposite
pilothouseorviceversa.
During the ensuing investigation after the
accident, it was determined that there was an
unofficial policy, a practice more specifically, where
the Captain and Assistant Captain assigned to each
vessel did not both occupy the operating pilothouse
while underway. Once the operating officer
transferredthepowerto
theother,theywouldremain
intheir respective pilothouse until theconclusionof
128
that voyagelegand await the power to be returned
andassumecommandagainforthenexttrip.Asa
resultofthispractice,whentheAssistantCaptainon
theBarberibecameincapacitated,theCaptainwasnot
in the operating pilothouse, but in the offshore
pilothouseasdescribedabove.In
addition,duetothe
absence of appropriate procedures developed in
accordance with accepted risk management
principles,thebridgeteamconsistedoftheAssistant
Captain,andalookout.Thelookoutdidnothaveany
traininginhowtomaneuverthevessel.Thischainof
circumstances contributed materially to why the
vessel
allidedwiththepier.Attheconclusionofthe
investigation, the NTSB made numerous
recommendationstotheCityofNewYork.
One of the central themes brought out of the
aftermath of this accident was the familiar style of
managing the operation. This means there was no
formalSafetyManagementSystem
presenttoperform
the function of capturing safe operating practices as
has been recognized worldwide with the advent of
theISM.Althoughthiswasthecase,theStatenIsland
Ferry is a very mature operation that has been in
servicefor over100 years. Duringthattimethesafe
performance
of the system has been very good
relativetoincidents pervessel movement.However,
aftertheaccidenttheoperationneededtotakea look
at the practices that had developed over time and
determine how to build an environment that would
make a best effort to capture any unsafe conditions
before
theyescalatedintoanaccident.
HereisfurtherexcerptfromtheNTSBreport…”A
safety management system necessitates a cultural
change in an organization, where the safety of
operations is the objective behind every action and
decision by both those who oversee procedures and
those who carry them out. The system
leads to
standardized and unambiguous procedures for each
crewmember, during both routine and emergency
operations. Duties and responsibilities are specified
andsupervisoryandsubordinatechainsofcommand
delineated, again for standard and emergency
operations. Each crewmember, as a result,
understands precisely what he or she is to do, and
say,in
criticalphasesofoperations.Inaddition,safety
managementsystemscallforthecreationofplansfor
responding to a range of possible emergency
situations, with crewmember duties and
responsibilitiesspecified.
The National Transportation Safety Board
determines that the probable cause of this accident
wastheassistantcaptain’sunexplainedincapacitation
and
thefailureofthe
New York City Department of Transportation to
implement and oversee safe, effective operating
proceduresforitsferries.Contributingtothecauseof
theaccidentwasthefailureofthecaptaintoexercise
his command responsibility over the vessel by
ensuringthesafetyofitsoperations.”[3]
Theelementofthefindingsthatpointtofailureof
oversight for safe operating procedures essentially
point out that the management as opposed to the
vessel crew were responsible to implement a safe
operating system. While the crew is ultimately
responsibleforthevesselinallcases,itisinteresting
to note that the results of this finding led to the
recognition that an international standard of safety
management would be necessary, even if on a
“voluntary”basis.
The Staten Island Ferry obtained its VDOC from
theAmericanBureauofShipping(ABS)in 2005and
has successfully maintained both its VDOC
and the
vesselSMC’ssincethen.
4 COSTACRUISESANDTHECOSTA
CONCORDIA
The ability to analyze the events leading up to this
tragicaccidenthasbeenmadeveryclearasaresultof
the comprehensive technical report from the Italian
MinistryofInfrastructuresandTransportdatedMay
2013. The
findings of the report, contain the
constructiveelementsofcasualtyreportingascanbe
found in the case of BC Ferries, and Staten Island
Ferries. It is from these findings that the marine
researcher or educator may be able to provide the
foundation for a thorough lessons learned type of
analysis.
This much however is known…The Costa
ConcordiacertainlywasinpossessionofavalidSMC.
Costa Cruises most certainly was in possession of a
valid DOC, of which the option to maintain it
voluntarily would not have existed. What is also
fairly certain is that the grounding occurred from a
combination of human element errors. In addition
there was either a significant deviation from a
companypolicyregardingsafevoyageplanningoran
absence of company procedural detail in qualifying
whatistobeacceptablesafevoyageplanning.
Anexcerptfrom the technical report summarizes
the situation from the objectivity of
an investigator
“…It is worth[while] to summarize that the human
element is the root cause in the Costa Concordia
casualty, both for the first phase of it, which means
the unconventional action which caused the contact
with the rocks, and for the general emergency
management.
Itshouldbealsonoted
thattheCostaConcordiais,
firstofall,atragedy,andthatthe32deadpeopleand
the 157 injured, depended only by the above
mentioned human element, which shows poor
proficiencybykeycrewmembers.
Accordingwiththeevidencesfoundattheendof
the present investigation, it is necessary to
put in
evidence that Costa Concordia maintained full
compliance with all the SOLAS applicable
regulations, matching therefore all the related
requirements oncesheleft the Civitavecchia Port on
theeveningofthe13January2013….”[4]
Atthispointinthepaper,hopefullythereadercan
beginandseealthoughthe
circumstancesbehindhow
ISM, SMS, and fatal accidents, connect the three
examplesabove,themajorunderlyingthemeshould
beincreasinglyapparentthatthereisaculturalgapin
theorganizations thatmaybecontribute to whythe
elaboratesafetymanagementmechanismsaren’tfully
integrated in these operations to prevent such
accidents
fromoccurring.
129
5 ISMBEGINNINGS–THEHERALDOFFREE
ENTERPRISE
ThecapsizingoftheHeraldofFreeEnterpriseinMarch
1987isthesubjectofvoluminousstudy.
SomuchsothattheIMOwasmotivatedtoseeka
potential solution for worldwide implementation in
ordertocaptureacultureofsafety
managementthat
could be developed to avoid similar circumstances
thatledto this disaster.Theexcerpt below from the
formalinquiryisverysuccinctandsetthefoundation
for viewing safety management as a cultural
responsibility within a vessel crew and operating
company.
“…At first sight the faults which led
to this
disasterweretheaforesaiderrorsofomissiononthe
partoftheMaster,theChiefOfficerandtheassistant
bosun,andalsothefailurebyCaptainKirbytoissue
andenforceclearorders.Butafullinvestigationinto
the circumstancesofthedisaster leads inexorably to
theconclusion that
the underlying or cardinal faults
layhigherupintheCompany.TheBoardofDirectors
did not appreciate their responsibility for the safe
managementoftheirships.Theydidnotapplytheir
mindsto thequestion: Whatordersshouldbegiven
forthesafetyofourships?Thedirectorsdid
nothave
anypropercomprehensionofwhattheirdutieswere.
There appears to have been a lack of thought about
the way in which the HERALD ought to have been
organized for the Dover/Zeebrugge run. All
concernedinmanagement,fromthe membersof the
Board of Directors down to the junior
superintendents,wereguiltyoffaultinthatallmust
beregardedassharingresponsibilityforthefailureof
management.Fromtoptobottomthebodycorporate
was infected with the disease of sloppiness. This
became particularly apparent from the evidence of
Mr. A. P. Young, who was the Operations
Director
andMr.W. J.Ayers,whowasTechnicalDirector.As
will become apparent from later passages in this
Report, the Court was singularly unimpressed by
both these gentlemen. The failure on the part of the
shoremanagementtogiveproperandcleardirections
was a contributory cause of the
disaster. This is a
serious finding which must be explained in some
detail….”[5]
6 DOMANAGEMENTSYSTEMSWORK?
Fromtheperspectiveofamariner,andaneducator,
findingtherightmessagehowtosuccessfullysellan
organizational culture change is a daunting task. In
the case of a safety culture,
there is a tremendous
amount of material and themes to explore when
teachingaboutthe“whys”ofbeingcommittedtothe
intent of safety management. Probably the biggest
challenge to the recipient of this teaching is how to
balancebeingcommittedtotheintentoftheISMcode
orbeing
committedtocomplyingwithitifthatisall
theculturepermits.Hereiswherethepsychologyof
howpeopleperceivevaluegetsuncovered.
Thisalsobringsanalltoocommonconundrumto
thediscussionofwhyafterdecadesofinvestmentin
technology, studies, academy curriculum, and
systemicmanagementprogramsare
therestillsucha
high percentage of human factor related casualties
despitetheinvestmentinmitigationsystems?
Inordertoanswerthequestion,athoughtprocess
should include the concept of moving from
compliancetocommitment. Taken initsmost literal
meaning, it suggests that the well intentioned and
justifiably
successful regulatory framework as it
currently stands for maritime operators has
unintentionally resulted in a situation where some
shipboardpersonnelviewtheseregulationsasmerely
a requirement without a necessary appreciation for
whytheyexist.Notinallcases,butsummarilythe
burden of proof to this idea lies in the
existence of
continuing marine casualties with a large human
elementcausalfactor.
Thus,itappearsthatasea goingofficerpotentially
viewshisorherroleinperformingthesefunctionsas
solely an act of “compliance”. In other words, just
making sure the paperwork is satisfactory so the
attending port
state control, vetting auditor, or port
captain can confirm the “check in the box” of
completionandcompliance.
Italsosuggeststhataseagoingofficershouldbe
more aware of the benefits of “commitment” where
they have a deeper understanding of why these
procedures need to be fully developed and
understood.Essentially,becommittedtotheintentof
the regulatory framework instead of determining it
satisfactorytomerelycomplywithit.
InanexcellentPhDthesis,CaptainS.Bhattacharya
uncovers many of the “gut” feelings about the
effectiveness and reality of implementing safety
managementsystems.Tothepointthatthe
readercan
understandhowtherecouldbeamuchmoreholistic
“buyin”acrosstheindustry.Inthethesisheconducts
researchamongoil tank vesseloperators specifically
within the realm of how ISM is implemented.
Althoughthecomparisonofoiltankerstopassenger
vesselsdoesnotfitinwiththe
statedobjectivesofthis
paper,thefactthatISMcomplianceismandatoryfor
their international trade allows some relevant
comparisons to be considered. His excerpts are as
follows…
“…Research shows that proper and up‐to‐date
documentation is an essential part of ship
management. It not only ensures managerial
compliancebutisalsocrucialfromthecommercialas
wellasregulatoryviewpoints.Thenegativeimpactof
bureaucracyin the implementation of the ISM Code
inthemaritimeindustryhasalreadybeenpointedout
inthereviewoftheliterature.Anderson,forexample,
in his research pointed out how excessive
formalization
ofmanagementprocedures resultedin
unnecessarypaperwork(Andersonetal.,2003).Such
bureaucracy does not contribute to the
implementation of the ISM Code. A number of
industrycommentators(seeforexampleLloydsList,
2002d; 2006b; 2007e) also identify bureaucracy as a
majorhindrancetoeffectivepracticaloperationofthe
ISM
Code. Research in shore‐based industries has
also indicated that in many organizations,
implementation of SMSs resulted in unnecessary
bureaucratization often taking the focus away from
effectivemanagementoforganizationalsafety(seefor
exampleFricketal.,2000).
130
Interviews with ship managers showed that they
did not always believe the seafarers paperwork.
Nearlyeverymanagerwhowasinterviewedpointed
outthat most seafarers simplyticked boxes in work
permits or blindly filled in checklists. In their
interviews the managers commented that they
believed that some of the paperwork
was fabricated
andmerelydepictedwhatshouldhappenratherthan
whatactuallyhappenedonboard.
One manager, for instance, said: ‘I have a hunch
that this Master (captain) of Ship‐X never follows
procedures,butIhavenomeanstoverifythat.Allhis
paperwork looks too perfect... But there is
nothing
much that I can do... paperwork is important but
sometimesthereistoomuchgapbetweenpaperwork
andreality.’
Criticism over sea farers non‐compliance to the
requirementsofSMSandlackoftrustintheveracity
ofthepaperworkiswidespread.Asignificantsection
ofmanagers andsuperintendents even
believedthat
some captains and chief engineers were routinely
falsifying SMS paperwork. They felt that as a
consequence the management was unable to
appreciate what happened onboard the ships. Thus
they feared that their personal standing in the
company or the company’s reputation could also be
compromised. One manager, for
instance, revealed
how captains disregarded company’s SMS in their
day‐to‐daytasks;citingonecase,hesaid:
‘I had one captain who welded on deck without
my permission when the ship was loaded with
Naphtha. His paperwork was always false… Now
what can you do sitting in the office? ...we
(management) can hardly control what happens on
ships’.[6]
The views suggest an appreciation that unsafe
practiceandnon‐compliancecannotbepreventedby
the bureaucratic means alone, yet the system
remained vital to the way in which managers
understood and implemented the SMSs. The reason
givenforthiswas
thatbyensuringtheproductionof
paper trail, the managers had objective evidence of
theirsystemworking,andgiventhedistancebetween
the office and workplace this was perceived to be
importantforthereasonsgivenabove.
7 WHATDOWEDOABOUTIT?–THE
PSYCHOLOGYOFVALUE
Itwould
beunderstandabletoaskwhatcomesnext.
By exploring the various casualties above and how
they are linked by causal factors, and by
understandingatwhatlevelsthecrewandcompanies
implementamanagementsystem,theanswertowhat
happens next should lie in how we as educators
present the
expectations of management systems in
general. It is necessary to instruct all mariners both
young and old alike in the specifics of what is
expected of them in performance of their jobs.
However,thestudentsandcadetsoftodayhopefully
will become the Captains, Chief Officers, Chief
Engineers, Ship Mangers and
Company
Superintendentsofthefuture. Therefore, the idea of
teachingtheWHYofsafetymanagementshouldtake
moreprominenceovertheHOW.
Forexample,thepsychologyofva lueorethicshas
a long history of contemplation. It can be linked to
axiology,ormoralphilosophy,andcanbeexplained
at
a high level by the writings of historical
philosophers such as Immanuel Kant (1754‐1804) or
JohnDewy(1859‐1952)evenfindingitsoriginsinthe
writingsofPlato.[7]
Teachingtheseafarer toembrace whollythe idea
of safety management should include how to move
beyond what is scientifically empirical.
In other
words, take the example of the check the box
mentalityandmovetowardthejobofconvincingthe
studentofwhatisethicalorjustplaintherightthing
todo.
Should a Captain or Manager be a fully
introspective psychologist? Feels like it sometimes,
doesn’t it? Realistically
we can start with a sort of
sociology where value theory is based on personal
values. And strive to educate practitioners of safety
management of the sense in making safety a value
that is held in common within the shipboard
community.Realisticallynotjustmakebelieve.From
heretheconceptof
intrinsicversusinstrumentalvalue
comesintoplay.
Intrinsically,ISMisagoodthing.Itdefinessafety
management and it’s the law. However,
Instrumentally, ISM is a means of achieving
something else, such as the highest state of safety
awareness possible onboard a vessel. The key is to
turn ISM and
SMS from something of questionable
intrinsicvalue(aswiththeincidentsofhumanlapses)
tosomethingofmuchgreaterinstrumentalvaluethat
is held as a common belief in the community.
Admittedly this is not an easy task, if it is even
possible.Stealingiscommonlyheldasreprehensible,
and murder
is universally condemned amongst the
human race however it still occurs. However, the
majority of the world population holds the
condemnationofthesethingsasacommonvalue.
Onvesselsandinoperatingcompanies,oneother
way to tangibly promote more realistic compliance
might be to promote a bottom up
management and
implementation of the SMS. As leaders, an
atmosphere of collaboration amongst the company
andcrewisessentialtothe‘buyin’quotientofthis.
Aseducators,we shouldrecognizehowvitalit isto
instill in our students this expectation of a shared
instrumentalvaluein keepingvesselssafe.
And that
there is an expectation that personal, ethical
responsibility of their behavior extends to how they
interpret the culture of safety on board a vessel. By
startingatthispointtheremaybeatruewaytoeffect
a cultural change in how safety management is
viewedbythe
peoplewhohavetoimplementit.
REFERENCES
[1]Transportation Safety Board of Canada (2008) Marine
InvestigationReport‐FerryQueenoftheNorthStriking
andSinkingGilIsland,BritishColumbia–M06W0052
131
[2] and [3]‐National Transportation Safety Board United
States (2003) Marine Accident Report Ferry Andrew J.
Barberi–NTSB/MAR‐05/01(PB2005‐916401)
[4]Ministry of Infrastructures and Transports, Marine
Casualties Investigative Body Cruise Ship COSTA
CONCORDIA Marine casualty on January 13, 2012
Reportonthesafetytechnicalinvestigation
[5]MarineAccident
InvestigationBranchU.K.(1987)Herald
ofFreeEnterpriseReport ofCourtofInquiry–ReportNo.
8074(p.14)
[6]Bhattacharya,Capt.S–(2009)–ImpactofISMCodeon
Management of Occupational Health and Safety in the
Maritime Industry – School of Social Sciences, Cardiff
University–(pp.
162‐165)
[7]Dewey,J(1894)–TheEgoasCause–(pp.337‐341)
