Published in Sagar Sandesh Maritime Weekly's Dec 12 (12-12-12) edition
Source:http://www.sagarsandesh.com/epaper/
-Whereas the Titanic collided with an iceberg, the Costa
Concordia hit an underwater rock
-Trust in technology may in both cases have affected the
attitude of the navigators of such ships
By Capt S Bhardwaj
Titanic was supposed to be the ‘unsinkable’ then; Costa
Concordia was also a masterpiece of modern technology. Despite more than 100 years
of regulatory and technological progress in maritime safety, accidents do
occur.
Both the cases involved state-of-the-art cruise ships -
although the same state and the stage have obviously changed dramatically in
the 100 years in between.
Whereas the Titanic collided with an iceberg, the Costa
Concordia hit an underwater rock. In both the incidents the ships were
subjected to an unexpected and massive flooding.
While the maritime technology has changed beyond
recognition between 1912 and 2012, human factors and organizational factors
have not.
Organizations have, of course, changed in the way they
carry out their work, due to increased horizontal and vertical integration made
possible by ubiquitous information technology.
But the thinking and attitudes of management have changed
less and may possibly not have changed at all, at least when it comes to such issues
as risk taking and prioritization of issues relating to operational safety.
The purpose is rather to show that accidents still happen
for the same underlying human and organizational reasons, despite the
technological progress in the past 100 years and despite all safety regulations
and precautions. It is remarkable that certain underlying conditions are still
the same today as at the time of the Titanic.
It is even more remarkable - and worse, regrettable -
that the accident investigations and the reactions to accidents more or less
are the same now as they were 100 years ago.
Authority gradient
and its influence on communication
The term “authority gradient” refers to the distribution
of decision-making and the balance, or imbalance, of authority and power in a
group or organization, usually in relation to a specific type of situation.
Although it is rarely considered by the maritime industry, it plays an
important role in, e.g., health care or aviation. It is used to describe how
easy or difficult it may be for someone with a lower authority to question or challenge
somebody with a higher authority. The authority gradient is itself influenced
by a number of other factors, such as education, social background, gender, age,
professional roles and perceived expertise.
Cognitive
hysteresis - resistance to revising a situation assessment
The term cognitive hysteresis – or psychological
fixation - describes the situation where people fail to revise their initial assessments
in response to new evidence, particularly evidence that diverges from the expected
(Woods et al. 2010). While the initial situation assessment may have been
appropriate at the time it was made, the cognitive hysteresis means that
neither the assessment nor the chosen course of action is revised even if an
opportunity for that arises.
A similar case of the Titanic or the Costa Concordia may
have contributed to a situation where the masters held on to an imprecise or incorrect
picture of the situation. He might have been so convinced by this wrong mental
picture of the situation that it would have required some external questioning
by his officers to force him to realize that the situation was different from what
he assumed.
Unanticipated
consequences of new technology:
Another reason for
underestimating risks may be reliance on new technology. The Titanic was considered
a masterpiece of naval architecture in 1912. This might have led to the belief
that a collision with an iceberg could be survived and that the ship would stay
afloat even with severe structural damage to the hull.
In 2012, the Costa Concordia was equipped with
significantly better technology. The navigation equipment alone provided an
accurate position of the ship at any time on the sea chart and also showed the
predicted future positions given the current course and speed.
Trust in technology may in both the cases have affected
the attitude of the navigators of such ships.
PIC Courtesy:http://news.nationalgeographic.com/news/travelnews/2012/01/pictures/120118-travel-costa-concordia/
Organizational
influences (latent conditions)
Today ISM gives “overriding authority” to Master. Even
Titanic master received a letter which he had to sign and return. The letter
stated that “You are to dismiss all idea of competitive passages with other
vessels and to concentrate your attention upon a cautious, prudent and ever watchful
system of navigation, which shall lose time or suffer any other temporary inconvenience
rather than incur the slightest risk which can be avoided.”
But there was also a conflicting message from management.
In the Titanic accident report, Lord Mersey, the Judge heading the
investigation, commented “Its root is probably to be found in the competition
and in the desire of the public for quick passages rather in the judgement of
the navigators”.
A similar dilemma can be found in the case of Costa
Concordia, where the company advertised that the ship would sail a “touristy”
sailing course close to land. The case is not simply that organizations (the
blunt end) give one message - like “safety first” - but neglect to follow-up on
it. The case is rather that organizations want to have their cake and eat it
too, by emphasizing both safety and productivity. This creates a psychological
and social conflict at the sharp end, where the outcome is uncertain.
In shipping operations, as in any other industry, time
and resource constraints affect the day-to-day routines. The time and the
measures taken to ensure safety operations have to be balanced with economical
considerations in the commercial operation of a ship.
The desire to arrive in time with the ship has indeed
often played a fatal role in accidents, such as Herald of Free Enterprise
in1987 (DoT 1987), Estonia in 1994 (Joint Accident Investigation Commission
1997), the MSC Napoli in 2007 (Marine Accident Investigation Branch 2008) and of
course the Titanic.
Maritime accident
investigation & persistent human factors issues
Accident investigations very often seem to be constrained
by the principles of What-You-Look- For-Is-What-You-Find and What-You-Find-Is-What-You-Fix
Maritime accident investigations have traditionally looked for one or more
distinct causes and tried to address them one by one, as if they were
independent of each other. The near universal
assumption, expressed by the causality credo, is that every effect has a cause,
and that the cause usually can be determined to be a failure or malfunction of
a “component” - be it technological, human or organizational.
According to this logic, if we can find and fix the
failure or the malfunction, then the risk will be reduced or even eliminated
and safety therefore increased.
The causality credo, however, limits the scope of
investigations to concrete and tangible causes, but neglects a host of other
factors that are less conspicuous and have a more indirect influence. As the comparison
of the fates that befell the Titanic and the Costa Concordia however shows,
accidents seem to happen for the same underlying human and organizational
reasons even though they are separated by a century of improvements to
technology and safety regulations.
In the wider perspective, the really important question
is therefore not why these and many other ships have foundered, but rather why
these reasons remain and why accident investigations and the reactions to them
are more or less the same now as they were 100 years ago.
One explanation is that safety thinking that focuses on
things that go wrong or could go wrong, such as near misses, incidents and accidents.
The alternative perspective, called Safety-II, focuses on
the situations of everyday work where things go right. In this case the purpose
of safety efforts is to facilitate the performance adjustments that are
necessary for everyday work to succeed, i.e., not only try to avoid things
going wrong, but also try to ensure that they go right.
This cannot be done without understanding how things
happen, including the many human and organizational factors that determine how
work is carried out, for example the authority gradient, group think, cognitive
hysteresis, unanticipated consequences of new technology, latent organizational
conditions, and the ubiquitous trade-offs
between efficiency and thoroughness.
If no one is looking for the human and organizational factors
described in this write-up, no one will find them. And if no one finds them, no
one will do anything about them. Yet investigations of accidents in today's
complex work environments cannot afford to look only at “component”
malfunctions and failures. Actual safety improvements will not occur until we understand
how functions depend on each other and at how seemingly subtle changes and performance
variability can lead to out-of-scale outcomes.
Acknowledgements:
Jens-Uwe
Schröder-Hinrichs & Michael Baldauf (Maritime Risk and Safety (MaRiSa) Research
Group, World Maritime University)
E. Hollnagel,
University of Southern Denmark, Odense, Denmark.
The similarities
- Both the masters were very experienced and had
immaculate service records prior to the accidents. They had spent their entire
professional life at sea without larger accidents.
- Both of them were aware of the potential dangers, but
felt that the risks were so small that they could easily be controlled.
- In the case of the Titanic, no officer on the bridge
objected to the navigation of the ship. So far, no information has been published
to show that officers on the Costa Concordia disagreed with the manoeuvres of
the master.
- In both the incidents, the shipping companies (White
Star Line and Costa Crociere respectively) either tacitly approved or even
encouraged the masters' decisions to prioritize performance over safety.
- Both accidents resulted in emergency situations for
which the ships were not built (beyond design-base accidents). Both scenarios
were also considered as being highly unlikely.
- In both accident scenarios, difficulties during
evacuation occurred.
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