A no blame culture? Reflections from ashore on human factors in shipping accidents
Carolyn Graham, a PhD Student from the Seafarers’ International Research Centre at Cardiff University, ditches her popcorn and muses on transport accidents having just watched the Tom Hanks-led movie Sully: Miracle on the Hudson.
I recently watched the movie Sully: Miracle on the Hudson which caused me to reflect on a few examples of the treatment of seafarers after a maritime accident. I was particularly moved by Tom Hanks’ portrayal of Captain Sully’s professionalism and maintenance of dignity and strength during what must have been a very trying time. I think the film captured the humanity of those involved, particularly the captain and crew of the aircraft and the first responders; the air traffic controller who thought he had lost the plane and the rescue boats and helicopter operators. Of course I remain conscious that this was a movie, but the fact that it was a relatively recent event and everyone who had had the experience fortunately survived to tell the tale, made the movie more credible and we can accept the “story.”
The purpose of this article however, is to reflect on what the movie meant for me as a researcher into seafarers’ health, safety and wellbeing, with special focus on commercial cargo ships. The plot of the movie was the untold story, the story from Captain Sully’s perspective and what occurred behind the scenes during the investigations. As the investigators did their job, (and perhaps a movie from their perspective would cast them in a different light), they seemed to have been focussed on human error (incorrect decision to land on the Hudson) as the major purpose of the investigation, because the main cause of the bird strikes was conclusive. While the experience turned out in Captain Sully’s favour, I had cause to reflect on the many seafarers who were not so fortunate. Seafarers have been criminalized and imprisoned for accidents as they present the most obvious targets. This is a major issue for the shipping industry which have led to international campaigns against criminalization of seafarers.
Shipping and aviation share many similarities as global transport industries. Many of the human factors, issues and challenges that the aviation industry faces are also faced in shipping. One of the key areas is human factors awareness and training such as teamwork among the cockpit crew, from which shipping gained its inspiration for its own bridge teamwork training. However, shipping seems to receive less public support and understanding than the aviation industry in times of disaster. I believe it’s because air transport is more conspicuous, the crew are real faces that interact with passengers so their impact is immediate and personal. By contrast, when I sit at my computer and shop online and a ships’ crew brave stormy seas to get my product to me, I don’t see this: My concern is to have my item delivered in good condition and in the period of time stipulated.
Out of sight, out of mind
I am not alone: most, if not all of us do not necessarily think about how our items arrive. I recall, while working at a maritime agency, a colleague overheard me preparing a speech to be delivered on the occasion of the “Day of the Seafarer” and there was a mention of piracy. That reminded her of an experience she had. She told me she had ordered an item (a handbag) and when it did not arrive in the stated time, she called the supplier, of course annoyed, as to the reason for the delay, upon which she was told that pirates had captured the ship and a replacement item was on its way. How much more remote for those who are not affiliated with the shipping industry! Such is the nature of shipping – out of sight, out of mind.
Perhaps this explains the less than sympathetic responses from the authorities when a shipping accident occurs and the environment is threatened, particularly if there is an oil spill. I am reminded of the prominent case of the Captain of the M/V Prestige disaster in 2002. What I found most heartbreaking is that after being jailed, released and acquitted in 2003, the previous ruling of no criminal responsibility was cancelled by the Spanish Supreme Court and the Captain was sentenced to two years in prison in 2016. Fourteen years must have taken a mental toll on the Captain. Living with the disaster and criminal charges ever looming is a kind of prison sentence in its own right.
Fortunately for Captain Sully, everyone survived with no major injuries and there was no oily marine life to be shown on prime time TV! In an ironic twist, the birds were gassed and eggs oiled to prevent a recurrence. Sully’s experience and total conviction that he did the right thing, and the support of his colleagues, led him to ask the right questions that exonerated him. We hope that the matter has been settled for Captain Sully.
Maritime investigations are deemed to be carried out objectively listing major causes, and including a human element analysis, usually reported as contributory causes. This was introduced in the industry as a way to address human factors issues, but in a no-blame manner so as to promote learning.
A no blame culture?
It was reported that the mayor of New York, upon presenting Captain Sully with the Keys to the City, also replaced a copy of a library book lost on the flight: ironically, he was reading Just Culture: Balancing Safety and Accountability, by Sidney Dekker. The shipping industry’s pursuit of a no-blame (just) culture, asks that seafarers cooperate and report incidents to encourage learning. However, research shows that many seafarers are afraid to speak out. They withhold information and live in a state of mistrust, conscious of their precarious position. Criminalization does not help to promote a no blame culture. Words and deeds must align for shipping to move forward to a place where the guilty are identified; and the innocent are not made to suffer. In this respect, both shore and sea must unite in this effort, as while shipping is isolated and remote for the most part, those who are called upon to adjudicate are on land with much less (sometimes no) awareness of the vagaries of life at sea. Greater knowledge and awareness of the shipping industry is needed for those ashore. While for the most part the cargo is goods, rather than people (except for passenger ships), this cargo is transported with care and with anxiety that they arrive “on time and intact” – seafarers handle over 90% of the goods traded worldwide.
Another thing that stood out for me from the movie is the fact that in emergency situations the rules do not necessarily work (this was also shown in the Deep Water Horizon disaster). Captain Sully followed the check list but experience and judgment in the moment dictated another response. He acted out of a genuine care for his passengers to make sound professional judgments and do the best in the worst situation; after all, his life was also at risk. I believe this is the same for many seafarers. Developing a just culture would assist in a more humane response if shipping disasters happen. This would not allow the guilty to go free, but it would prevent the unnecessary punishment the innocent.
Disclaimer: These views are in no way reflective of the institution and department with which I am affiliated.
Dear Mrs Graham,
A very informative and incisive article !
I do agree that the human factor is much undervalued in shipping. particularly in view of the unique demands placed on a ships crew. I believe there is no industry in the world where the workforce is expected to spend 24/7 from 2 up to 9 months at a time on their workplace, far away from normal medical care and normal social interaction. MLC and other regulations notwithstanding the special circumstances of working at sea, the sometimes accumulating stress and sleep deprivation caused a multitude of unavoidable and inherent factors such as : shifts, ship and port operations, climatic conditions, time zone changes, inspections, piracy or even at times numbing routines put a considerable strain on the crews effectiveness and mental and thus physical condition.
The risks to the health and safety of the crew and therefore the integrity of the maritime undertaking to date remain unmonitored.
With the MARTHA project a first scientific effort has been created to try and map the fatigue levels amongst seafaring crew. However much more needs to be done. Todays wearable and predictive data analytical technology allows a much more proactive monitoring of the effects of tress and fatigue on the crew’s safety, health and well being. Sometimes what is possible today is even approaching or surpassing the quality of the medical care available to shore based workers. Because of the nature of the living and working conditions on board a vessel the monitoring of the effects of stress and fatigue are more easily correlated to the working conditions, vessels position and trading than in other industries.
A lot is being written about the digitilisation of shipping – I believe at the forefront of this should be how the latest available IT medical technology can improve the well being and safety of the crew at sea !
The stakes both at a personal crew level, at an environmental and financial level for all involved are simply too high !
Yours
Marc Van Mael
Care4C
Antwerp
Dear Marc Van Mael,
Thanks for your comment and further information. Yes the issue of fatigue is another grave concern and it is good that research is aiming to map the causes and consequences. I like to use the following quotation that sums up the situation:
“Merchant seafarers have chosen a dangerous occupation in which they are exposed to risks in a combination rarely encountered in other occupations” (Nielsen 1999: 121).
It is a sad state of affairs and it seems as if the elephant in the room will not make the agenda any time soon. That elephant being minimum manning levels, particularly in light of current discussions about unmanned vessels. But this may only shift the problem to even fewer seafarers and perhaps more paper work. Criminalization and other risks are not going to be solved by further reducing numbers.
I think there should be an administrative department on ships. This does not need more than one or two junior officers, depending on ship type, size, trade etc. to take care of the paper work, deal with some aspects with shore staff etc. They may also assist otherwise at busy times such as entering and leaving ports. This may help with some aspects of fatigue or at least demonstrate some care on the part of owners. But then again, what do I know? These are just the wishful musings of someone interested in seafarers’ well being and not someone in the business of shipping who has to answer to shareholders.
Ms. Carolyn has beautifully tried to fill the gap between the pre and post effects of a maritime accident by beautifully relating it to the movie. Sully undoubtedly opened doors for introspection with regards to mental and conscious trauma which a seafarer goes through in the process of being investigated for the disaster. All are not as lucky as Capt Sully to escape the brunt of investigation without any taint on his epaulette. As past case studies suggest in most cases of maritime investigation, it is human error which was considered as the root cause of the accident.
Excellent article.
Many years ago, I worked for a company that owned ships and aircraft.
A plane landed heavy due to windshear and punched the landing gear through the wings; there was no fire, the pax and crew evacuated down the slides, one passenger broke a leg. The plane was a write off
In the same week a container ship hit a reef and was aground for a couple of days, there was no pollution, no damage to cargo and no injuries, but the ship required repair.
One Captain was congratulated, the other was offered early retirement due to a medical condition.
I applaud the author of this article. The “out of sight, out of mind” concept is something I have always said. Unfortunately folks don’t see the face and humanity behind the crews on board vessels that deliver goods that their lives utilize in ways that are not imaginable to the everyday person. Sad more understanding is not afforded to our amazing seafarers.