Looking to a holistic view of safety

Shifting focus to management decisions and practices is pivotal as the failure to look beyond individuals’ roles in accidents at sea means they are doomed to be repeated. Professor Helen Sampson, director, Seafarers International Research Centre

Professor Helen Sampson, director, Seafarers International Research Centre. Credit: SIRC

On 6 January 2018, the vessels Sanchi and CF Crystal were involved in a widely publicised collision resulting in the loss of 32 lives. We don’t know yet what led to this tragic event but we can be confident that the investigation will begin with questions about the judgements of the respective bridge teams.

When things go wrong at sea, attention inevitably turns to the actions and decisions of the particular seafarers involved. Regrettably, however, there are too many occasions when it remains there and we fail to take proper account of the many underlying factors relating to the event. Given that such incidents can rarely be wholly attributed to the personal characteristics or failings of individuals alone. This usually means that in some form or other the event will reoccur in the future.

Some years ago I had the pleasure of being involved in the PhD supervision of a former captain, Mohamed Ghanem. In the course of his career, Mohamed had seen accidents repeated in very similar circumstances and was perplexed about how these could occur in a context where careful accident investigation is common. He decided to undertake a content analysis of maritime accident investigation reports to see if he could identify a problem with their approach or method.

In the course of his data collection he soon identified a pattern. In his thesis, Mohamed demonstrated that maritime accident investigation reports, and particularly the key synopses of these, disproportionately dwell on the actions of vessel personnel. This remains the case, even when the underlying causes of incidents are clearly identified.

This could also be said of accident investigation reports, and indeed managers ashore, and as a consequence of our collective failure to appreciate the overwhelming significance of the broader causes of accidents we can expect their repetition.

At sea, seafarers will continue to fall asleep aboard vessels that carry insufficient personnel. They will continue to be injured because they have ‘chosen’ not to wear unsuitable personal protective equipment (PPE) and those who are placed under pressure from shore-based managers will continue to err on the wrong side of caution when tasked with ‘getting the job done’.

To go further in eradicating unwanted events related to the so-called ‘human element’ we need to move away from the assumption that the individuals involved are deviant and understand that, more often than not, their actions are the entirely predictable outcome of local circumstances. Instead of focusing so overwhelmingly on altering natural human behaviours we should arguably take much greater account of them in our management decisions and practices (about crewing levels/PPE procurement/the application of pressure).