Incidents, Accidents and Crew Behaviour

In this article we have asked Nick Wilcox of CAE to consider how human behaviour can cause incidents and accidents, using enclosed space incidents as a framework to discuss behaviour.

Enclosed space incidents involving crew who have received training and are aware of procedures continue to occur on a regular basis often with fatal consequences. Occasionally there may be weaknesses in training and procedures but it seems clear that other factors are influencing experienced and well trained crew to enter enclosed spaces in dangerous circumstances.

Safety as a Motivator

In typical enclosed space incidents crew members will enter a space to carry out work,in spite of the fact that it may be inherently dangerous, without complying, or fully complying, with established procedures. They are aware it may not be safe and should be de-motivated to enter an enclosed space, but still we see dangerous practices.

This suggests that safety or the absence of safety may not be a motivator or demotivator by itself; rather it is a hygiene factor, i.e. something that should just be there.

A definite motivator for crew is concern for their shipmates. This is apparent in many enclosed space incidents; too often we see that those who try to rescue the first victim become victims themselves. About twothirds of casualties are would-be rescuers. So clearly crew are motivated by different things and motivating factors affect their behaviour. This is recognised in many incident reports.

However, the reasons behind accidents in enclosed spaces are often categorised as “inappropriate behaviour”, a label that is not sufficient to explain why it happened.Accident reports also often refer to deviations from established procedures. But whatactually leads to procedures being violated and inappropriate behaviour?

About Procedures

Procedures are intended to be the best and safest way to do things. They have been developed and improved, preferably with input from the crew. They should be easy to understand, include all necessary technical information and should be designed from a practical perspective to complete the job safely. When used and there is sufficient time assigned for the work, work proceeds smoothly and without incident.

However procedures do not create safety by themselves; the people using them do – or don’t.

When mistakes are made, we have a tendency to enhance procedures usually by making them more detailed.

This may be particularly the case on ships. Seafarers are practical people and the immediate response to an incident is to look at the practical issues surrounding procedures and training.

Surely if procedures and training are improved then all will be well?

Whilst this approach is suitable in most cases it can on occasion actually decrease safety, since procedures get more complex and the ime taken to carry out a task is increased. More complex procedures may therefore lead to a position where more mistakes are made due to complexity, and where procedures are bypassed in order to save time. In effect the procedure leads to inappropriate behaviour.

It follows that thought must always be given to the human factor – how people behave – when considering changes to procedures or training, and when considering the reaction to any incident.

Procedures – Why Do Crew Not Implement Them?

No normal person goes to work to do a bad job, or to expose themselves deliberately to unnecessary risks. Most people try to do as good job as they can to fulfil the expectations of colleagues, managers and, not least, themselves.

If the time available is not sufficient, the procedure is not realistic, tools do not fit, parts and information are missing and so on, people will still do their best to carry out the tasks by improvising, making shortcuts, modifying or inventing procedures.

What happens thereafter is interesting. They will often see that it worked fine; there was no bad outcome. So the next time they will do the same, maybe expand the deviation slightly, and again there is no bad outcome. Until one day they have moved too far away from the prescribed procedure and there is an accident. This is sometimes called “drift to failure”.

Consequently, when people make mistakes in complex systems, like the operation of a modern commercial vessel, we must see it as a symptom of problems deeper in the system. There may be goal conflicts, such as commercial pressure versus safety, conflicts with other procedures, physically impossible tasks, etc.

When practitioners were asked why procedures are violated, the answers with the highest response rates were:

• The work gets done faster (56%)
• There are too many procedures (50%)
• The procedures do not work the way they are intended (38%)
• I have to do it because I have so much work to do (26%)
• I have no knowledge about the existing procedures (14%)

(Antonsen, 2009)

It is of note that only a small percentage claim not to know about the procedures, and this raises questions about the appropriateness of training as a response to an incident.

Let us return to behaviour. It reflects our attitudes, such as “I know best, don’t tell me how to do this” or “I don’t dare to tell them that this is a bad procedure”. The sum of the attitudes in an organization can be said to make up the safety culture. If the negative attitudes mentioned above are dominant, there is an unsatisfactory safety culture that may contribute to accidents.

Finally, why is the number of enclosed space accidents not decreasing? The dangers are well known, training and procedures are in place so these incidents should be becoming increasingly rare.

Perhaps these incidents are a symptom of a failure to properly adopt and implement the idea of a safety culture. Is increased commercial pressure, neglect of behavioural issues during training and increased complexity in our systems contributing to procedural failure? Many individual companies are serious about safety and adopting the concept of safety culture and these companies are leading the way for the industry, but perhaps enclosed space incidents are a sign that having a safety culture is not yet the prevailing industry position or that safety culture is not well enough developed across the industry?

So What Can We Do About It?

Telling people to follow the procedures, punishing or firing them when they don’t, does not work. Calling it “complacency” does not help; it‘s a fuzzy expression consisting of many factors. Telling them to adopt a safety culture will not work – it’s a complex concept.

Management Commitment

Management must show in practice that safety has priority and needs investment in safety culture, equipment and training.

Involvement in Design

Involve the seafarer in the design of the procedures.

Monitor the Gaps

When deviations from procedures occur, monitor the gaps between procedures and practice and get an understanding of why there is a gap. A few examples of questions to raise:

• Was there sufficient time assigned to do the job?
• Were the procedures matched to the demands of the real work?
• Did the crewmember have the necessary technical knowledge to do the work?
• Ask the seafarer why he did the job in the way he did?

In hindsight we often have the tendency to see mistakes and errors. But we need to understand why the seafarer found the decision not to follow the procedure logical and correct there and then; not until then can we attack the problems deeper in the system.

The Safety Culture and MCRM Courses

Training in programs, such as Maritime Crew Resource Management (MCRM)*, aim at modifying attitudes and thereby improve the safety culture. Modifying attitudes takes time and requires that the messages are repeated over and over again. Refresher courses are therefore a critical success factor. MCRM courses emphasize the human factor and address the importance of topics such as speaking up when something seems to bewrong, effective communication, dangerous attitudes and decision making.

Traditionally, deck and engine officers attend these courses, but to counteract the increasing number of accidents in enclosed spaces, all seafarers involved in such work should participate in MCRM training or corresponding, adapted to this category.

Safety Culture Analyses

A safety culture analysis can reveal hidden behaviour problems in the organization and allow an improved focus on relevant factors in an MCRM course.

Learning from Success

We also must learn from success, something we are not used to. When dangerous work goes well, what did we do to achieve that? Why did it work so well? Is this success highlighted to the people doing the work?

Enclosed Spaces – Practical Training and Drills

In general, practical training and drills seems to work well. The new SOLAS regulation “Mandatory Drills For Entry In To Enclosed Spaces” now makes enclosed space drills mandatory, which is a step forward and will hopefully reduce the number of accidents. However, unless behavioural issues are recognised and addressed by companies the training itself may have a lesser impact than would otherwise be the case.

Behaviour – Is it the Individual or is it the Company?

The next time you have to deal with an accident, incident, or near miss where ‘inappropriate behaviour’ has occurred or procedures have been improperly implemented it may be an opportunity to think about the reasons for the behaviour displayed. Are you dealing with a rogue individual or is there something else happening that may be rooted within the organisation? If it’s an organisational problem how do you respond? Can behavioural change be treated in isolation or must it form part of a systematic, organisation wide, programme for change?

Dealing with behaviours is not easy and there is no silver bullet. Changing how organisations behave – adopting a safety culture for example  – takes time, effort and money to achieve. 

With business partners ever more demanding of a smooth service, ever increasing claims costs, and increased regulatory oversight it is clear that operating a ship is not going to get any easier going forward. Can the industry as a whole and your company in particular continue to afford the consequences of inappropriate behaviour?

* MCRM (Maritime Crew Resource Management) is designed to develop nontechnical skills that address human error and unsafe performance. The training is provided by CAE, which has been at the forefront of CRM training for mariners since the origination of BRM.

Thanks to Nick Wilcox for this article.

nick.wilcox@cae.com

www.cae.com/mcrm/