TITANIC TO COSTA CONCORDIA – USING THE ISM CODE IN THE TRUE SPIRIT OF THE SYSTEM APPROACH

Time, like an ever-rolling stream keeps moving.  Technology advances.  Civilization brings more and more rules.  Every tragedy from the Titanic to the Herald of Free Enterprise to the recent sinking of the Costa Concordia demonstrates one thing that does not change – human nature has its weaknesses.  Technology, to an extent, can produce the best of missiles but the man behind the launching mechanism retains the control and continues to be relevant.  Better educated, exposed and aware, perhaps, but still vulnerable to human frailties.  When organizations adopt the system approach, they set in place an atmosphere of continual improvement.

“A bad system will defeat a good person every time” – W. Edwards Deming.  This reminds me of a quote from the Cain Mutiny, which in essence says, “Navy is a master plan devised by the genius for execution by idiots”.  This master plan is the system, which should be so created that there is no need to blame the individual.  Every time the system fails, the management reviews and acts to work on the procedures that comprise the system.  Improve the system enabling better protection of the individual.

It is ironic that individuals who are assigned the designing and then implementing of the system often consider it a burden – little realizing that the system approach takes management away from asking, “Who” to asking, “How and Why”.  This results in further development of the system rather than blaming the individual who was simply working within the system.

In the maritime world, the P&I clubs may well be paying the insurance dues only after an individual is blamed, but the ISM Code in contradiction does not encourage the blame culture.  Good management personnel understand this.  Both the ISM Code and the process-based management system standard, ISO 9001, take management away from the blame culture and require continual improvement of the system.

Management, which can connect the clauses 4, 5, 8 and 9 of the ISM Code will understand and appreciate the fundamentals of the Code.  These members of management will reap dividends in terms of “cash in the bank”.  The term, “cash in the bank”, coined by QMII over 25 years ago, implies fewer to no accidents, resulting in greater customer satisfaction and an increase to the bottom line.  In the maritime world, the difference between a detention and a catastrophe really is the cost the company pays – the loss in revenue, the cash in the bank lost.  It implies loss of life, which in bare terms costs the organization.  Loss of a vessel can ruin the company.

If it is as simple as the correct implementation of the process-based approach, then why does management not get it?  Is it because the maritime industry is so drowned in day-to-day activities that it is more concerned with avoiding being detained, somehow getting away from Port State Control (PSC) scrutiny, to be unable to implement the ISM Code in the real sense?  Alternatively, is it that the old-fashioned top management (after all, those who go into management are a generation or two behind those who actually go to sea and operate the vessels) are not fully exposed to the true meaning of the system approach?

This analysis is not new.  Justice Sheen investigating the loss of the Herald of Free Enterprise found a “disease of sloppiness” and negligence at every level of the corporate hierarchy.  What did that mean?  It meant the system was not working.  In present-day man-made tragedies, we, too, conclude the system is not working.

Shore management and those at sea should already know the value of a correctly implemented process-based management system (ISM Code in conjunction with ISO 9001:2008).  The implementation of the Safety Management System (SMS) to prevent detention is not acceptable.  It should be one of the benefits of a good system. Aligning the system to just meet auditor requirements or take measures to prevent PSC actions is weakening the system.  The system will do that, however, the system should have a more honest, larger purpose where it welcomes nonconformities (NC)to enable management (both at sea and ashore) to fulfill their obligations under the ISM Code (clause 9).  Correction of NCs, followed by Root Cause Analysis does not end the cycle.

I have drawn this graph above to show the benefits of respecting NCs (CARs). As the data base builds information can be obtained from the data to objectively analyze it and get the trends and predict potential NCs. When a system is first implemented, the number of NCs will increase. This is because the system is now recording the deficiencies. As the data base builds the analytical ability of the system is able to get the desired information for the managements to resource the system (be it in hardware, equipment, training or manpower) and most importantly to recognize potential NCs. This then positively affects the bottom line as now we are tackling potential NC and not being reactive to NCs. There is a point in the system development of an organization where the NCs drop and the PARs (Preventive Action Requests) increase indicative of the employees having matured and embraced the system. This is the place where the management also sees innovative ideas coming up and the management taking a more socially responsible role.

Preventing detention too often becomes the Master’s primary responsibility to the shore based management.  For PSC activities not to reveal NCs is a daily short-term goal.  Actually, this is counterproductive to the expectation of the Code and the system approach in general.  It encourages “hood winking” the PSC officers.  In my experience at sea and in my interaction with seafarers I have come across incidents of seafarers being paid ‘bonuses’ to get a clean audit report. If management takes that path, true safety cannot be achieved.  The PSC officers are stakeholders in maritime safety at sea.  Why have the PSC officers come in?  They meet a public outcry and demand following the numerous tragedies over the years.  They detain vessels in order to prevent disaster at sea from occurring.  What would the management prefer – a catastrophe or a detention?  Which is less expensive?

In the selection of Top Management (TM) at sea, be it the Captain, the Chief Engineer or the Hotel Captain (on passenger vessels from the Titanic to Costa Concordia) – if the Master does not perform or does not conduct him-self professionally or as per expectations, whose fault is it?  Management ultimately picks the crews.  The hiring procedure needs to be targeted.  Those at sea are performing to the best of their abilities and working hard; it is their profession and life.  We must never forget that they are performing as per the selection criteria that management has set!  Often for seafarers the relationship with the vessel is from ‘gangway to gangway’. How does a company go about ensuring that its seafarers are equally invested in the success of the system? Some say that retention of seafarers is the answer. But is a high retention percentage indicative of a good ISM culture? The answer again lies in a better management system.  The Culture should filter top down. The blaming of individuals should shift to blaming the system in order to encourage a more open system.  There should be no fear in exposing NCs.

The only bad nonconformity is the one we do not know about.  A system should be created which welcomes nonconformities.  A detention is a NC, which has saved an organization from a likely catastrophe.  Detentions are expensive; therefore, the need to create an SMS in the true spirit so it ensures NCs are detected internally, well in time, enabling management to take corrective action to determine the root cause.  To do that after each mishap, management should not jump to the CHECK stage of the Plan-Do-Check-Act (PDCA) cycle.  

They should instead go back to the ACT stage and carry out better management reviews, leading to better planning followed by correct implementation (DO) of the system.  The system approach, correctly implemented, will lead to a system, which will work.  Moreover, when the system works, one of the many benefits will be few to no detentions.  The ISM Code is the basis for such a system.  An investment in a correctly designed system and the implementation together with active participation by management will ensure requirements are met.  When requirements are met, there will not be any detentions. Let us not prepare for audits, detentions and PSC exams.  That principle is incorrect.  Let management encourage those at sea, and those who manage the vessels from shore, (as the Superintendents, Port Captains, DPs and CSOs, etc.) to work together in the interest of a system which functions and leads to safety at sea.

The sinking of the Costa Concordia has brought into focus several SMS-related failures, from which timely and correct lessons must be learned to prevent the recurrence of similar catastrophic events.  These accidents will shape industry’s culture and motivate industry stakeholders to make vessel operations safer in an effort to continue to sustain the shipping business and ultimately create “cash in the bank”.

The ISM Code recognizes that human error is the cause of the majority of accidents.  The Code requires delineating responsibilities of the ship and shore side management, creating the system and then addressing the coordination of the ship-to-shore support.  If about eighty percent of marine incidents are caused by human error, companies then have the responsibility to create true organizational management systems, which help humans, prevent and mitigate such incidents.  The management system is documented to the extent necessary for effective planning, prevention, operation and control.  The most important parts of any management system are not documented as they involve leadership, care and coordination.

The fish-bone diagram above  indicates the principled working of a system. The inputs are worked on using the system to produce the desired output. The passengers coming on board will need the entire work spectrum indicated in the fish-bone diagram to work together under the Top Management exercising care and coordination for the output to be positive. For the satisfied passengers, to continue to patronize the company because, their expectations have been met in terms of the holiday, safety, and security and pollution prevention.

The fish bone diagram above has the vital rib – Care and Coordination – implying active and constant participation of the top management. The PDCA cycle at the Act stage (please see diagram above) requires the TM to act based on the review of the system. Audits are not meant to deliver changes or improve the system. If audits and auditors could improve a system, then auditors would be the CEOs of the shipping companies! It is the management that improves their systems. For this, they must understand their systems and lead the implementation of the system by example.  To do this, management must admit they also need to be trained.

The correct implementation of the SMS, based on the ISM Code, will ensure that ships operate safely.  The Code addresses the key provisions such as SMS objectives, safety and environmental protection policy, company responsibility and authority, designated person, master’s responsibility and authority, resources and personnel, shipboard operations, emergency preparedness, reports and analysis of nonconformities, accidents and hazardous occurrences, maintenance of the ship and equipment, documentation, company verification, and review and evaluation.  All of the provisions of the Code are designed to work interactively and in harmony with each other to enable the management system to be effective.  However, none of this can deliver the desired results without the total involvement and commitment of the company’s top management. Blaming individuals will only correct one person and not the system.  To improve the system, the root cause should be considered.  The management must take the blame for having a poor hiring process and lead the change by re-designing that process.  When the Captain at sea fails in his role, management must read it as the process having failed, not having been designed correctly.  It requires going back to the PLAN stage of the PDCA cycle.

One of the main risks that any shipping company encounters is the potential disconnect that can occur when the procedures in the SMS are not being followed by shore side personnel, seagoing officers and crew.  The worst that can happen to a company is when those ashore believe that the procedures are being followed, when in actuality, due to, for example, over documentation or lack of awareness and training, they are not.  Seafarers in our courses share experiences of over-documentation in certain companies where the ‘paper’ eventually takes more importance that the actual procedure. This disconnect again is indicative of a system not functioning.  It is indicative of a cookie cutter system based on generic templates (a common culture in the maritime industry).  The designing of a system must be based on the “As-Is” or current state.  If consultants are used to assist in designing the system, beware of those who promise to do it cheaply sitting in their offices and providing master solutions!  If you accept these, then as TM you have already sown the seed of a weed.  Do not expect it to give you roses!  Good investment at the PLAN stage of the PDCA cycle is vital, in terms of both money and time.  Investment in designing the correct system based on the existing state is vital to the success of the system.

Any major marine incident investigation, like the Costa Concordia, should focus on the ability of a company to effectively implement their SMS procedures and whether or not there were any gaps in how the SMS procedures were applied.

If a company believes it has a perfect system and rests on its laurels, it is doomed to failure.

Why mariners and shipping companies should welcome audits not hate them?

INTRODUCTION

In my experience, Mariners have never been fond of audits! Worst the companies that run the ships have often victimized honest Master’s if during their tenure too many Non Conformities (NC) are reported, even if they relate to resources!  The only bad NC is the one the organization does not know about, and yet the organizations do not want to know!

A NC, comes from an audit and therefore the audit is an unwanted intrusion into the working of the vessel and the company, and now with the VIMSAS (Voluntary IMO Member State Audit Scheme) audits the Flag States have started disliking audits or at the best accepting them as a necessary evil!  NC drives Correction and Corrective Action (CA) and the Preventive Action (PA) is data driven. Wisdom says therefore audits should be welcome, and yet audits are feared.

Even the camaraderie on board a vessel is affected adversely as by the term “audit”- because the truth could be an utterance which gets their colleagues in trouble, or an audit may discover or uncover they are doing something “wrong”. The blame culture in the merchant ships is a reality. Something goes wrong- you blame someone! Why, the P & I clubs may not pay, if blame is not attributable to an individual.  The entire system encourages the blame culture. In this article I want to initiate a discussion wherein the maritime industry shies away from the blame culture and meets the objectives of the ISM and ISPS Codes in operating vessels safely, securely and meeting the environmental requirements. Companies should be lead by Flag States to not ask “who” when things go wrong, but instead lead their inquiries to “why” and “how” of the system failures. Individual failures are a consequence of the system failing to select correct individuals for a job!

TOP MANAGEMENT COMMITMENT

Quality is the responsibility of each individual. Having said that, we should ideally never pass responsibility down the chain of the management to ships and the crews who man them. We may pass authority bundled with resources. Top Management at each level must take responsibility for the system performance. Continual improvement has to be the underlining current. Starting with the IMO to Flag State to the Company and the ship each must be a stakeholder in the system working. Lack of care and coordination by the Top Management (TM) is roughly 90% responsible for establishing an environment of fear for audits.  By using the system and being participants in it at each level the system operators will use and improve their system, ensuring everyone understands that identifying opportunities for improvement (recognizing problems/ NC) will never be met with harshness or punishment; on the contrary, they will be valued.  Through this development of the system, a confidence emerges that the system will allow its people to produce outcomes, which meet requirements. The system will enable sailing ships of all kinds with the numerous cargoes across the globe fulfilling the demands of the economy in a safe, secure, socially responsible manner ensuring and protecting the environment.

It is the mature participatory involved confidence of the TM in itself and those who lead the various maritime procedures and processes, which will alleviate much of the fear and apprehension, associated with audits.  TM have to commit themselves and lead by accepting that audits are a vital input  to be valued for what it is: an independent look at the system to confirm how well it allows its users to meet requirements.  TM as improvement opportunities identified during day-to-day work should then welcome any findings.

The other 10% of the solution resides with the Auditor/Audit Team.  A well-trained auditor understands that their role (as mentioned above) is to look for evidence of system conformity.  Not of NC! Many a maritime auditor is not qualified and or has not imbibed the doctrine by correct training wherein the auditor should seek conformity and not go on board with the aim of somehow finding a NC. Where the system does not appear to meet requirements, the auditor must serve the audit client by providing detailed, objective evidence explaining why not.  Maintaining this integrity gives the Auditees no reason to feel defensive or that they have any reason to fear this valuable interaction. TMs must demand qualified auditors to perform audits.

SOME REASONS FOR TM’s LACK OF COMMITMENT

As, to an extent, mentioned above, the poor quality of maritime auditors is one of the reasons for a lack of TM commitment. A large force of the maritime industries auditors comes from mariners. They merely, because they are mariners and understand the environment and the industry become auditors. Like any profession, auditing has its own concepts and training. It is a science mixed with an art. It requires ethics and maturity wherein the audits are performed to meet the objective not an ulterior objective. This can be a challenge considering the global nature of the industry. Maritime Quality experts have not created the opportunities to assist their leaders in appreciating how the bottom line is positively affected by addressing NCs and better still predicting potential NCs and changing processes before a NC occurs. A process based system, as required by both the ISM and ISPS Code (as also the ISO 28000 standard), basically based on the ISO 9001, will ensure the system does not even wait for audits to recognize NCs. Too many of the TM would rather delegate their responsibility for ensuring quality instead of the authority to make it work. The TM commitment cannot be championed by anyone except the TM. It is the TM who have to walk the talk and lead the employees in developing and using the system. When have we had a company or a Flag State actually declare the state of the safety and security implementation to the employees, customers and other stakeholders and how they plan to improve it?

It is only when the maritime professionals commit themselves and use the process based management system to implement policy and the (measurable) objectives in the organization by ensuring the interactions as required by the ISM Code will the cross functional teams use the resources to best advantage.

Management systems are instinctively understood and respected by organizational leaders when they show how the core process converts the needs of customers into cash in the bank, while the support processes sustain the core process. Leaders can then explain the obligations and benefits of their system to the employees.

SELECTION, INVOLVEMENT AND RETENTION OF MARITIME MANPOWER

Another issue that the maritime industry has is the shifting and uncertain man-power situation. Companies are never able to retain those who serve at sea, these results in often, non-committed mariners, who come on board to do their tenure and not use the system. They are individuals only committed to themselves! So the companies are committed to themselves! The plot thickens when auditors are brought in. Teamwork using a process based system requires total commitment from each link in chain starting with the seaman to the Captain and on to the TM at company and Flag State level. Further, it requires the commitment from charterers, customers, P&I Clubs, PSC (Port State Control), supplier and so on. There is an element of social responsibility too involved. This combined commitment can only come with stable man-power. The industry therefore, may as a RCA (Root Cause Analysis) of many of its problems, find that retaining stable work force at sea may be one remedy to bring in commitment. Then and only then can each member of the team be held responsible including the TM, for delivering the desired results, meeting the objectives and improving efficiency.

Auditing should not substitute self and supervisor monitoring. When auditors are the only eyes for the management it is an inefficient state and indicative of the system failure. The Master at sea, the managers in the shipping companies office- particularly the DP, CSO, Superintendent and so on and those responsible for these duties at the Flag State level should all be supervising and be the first set of eyes. Monitoring should involve  the people who do the work and supervise the work and it is they who should be  observing how well their processes are fulfilling their objectives. The first set of NCs coming from internal sources will remove the fear of audits. Monitoring is therefore essential for quickly correcting processes that deviate beyond their normal range. Process monitoring should result in fast improvements so the system helps employees even more to determine and meet the process requirements. It is organizations which lack the culture of the system approach who blame individuals for all their flaws and faults and then rely on the occasional visit by their auditor. Is it any surprise that this visit is feared!

INVOLVING THE TEAM: AT SEA AND ASHORE

Clause 12.1 of the ISM Code 2010 now necessitates at least an annual internal audit. It had to be rubbed in, why? The audit would not be the only means, if the spirit of clause 12.2 of the code had been implemented with enthusiasm,  to evaluate the effectiveness of the system. Further if the results (clause 12.5) of the audits are required to be brought to the notice of all, it would invove every member of the team. In all this the company is trying to meet the objectives as required by clause 1.2.1. The feedback of facts and problems must flow and the system must use it as an input to improve the system continually.

The company must involve the employees by ensuring the system encourages self monitoring and employee suggestions, the management reviews are an integral part of the system and the results/ outcomes shared widely. Further customer feedback, as also feedback from other stakeholders must be an input to the management review. Nonconforming products and audit reports should be considered as an input to improve the system

FEAR OF AUDITS INDICATES A DYSFUNCTIONAL SYSTEM

The very first indication to management of a dysfunctional chain is the undercurrent fear of audits in the system chain of management!  Further systems that need and totally rely on auditors to be effective are dysfunctional. The system is the responsibility of TM. They need to know how well the system is helping them and their employees to determine and fulfill objectives and other requirements. By demanding that auditors supplement the flow of information from their system they are short-circuiting, this vital process and consequently weakening their systems. Dependence on auditors to improve the system is a major flaw in the mercantile marine, which because of the main asset, the ship, often operating far from their physical location becomes the only means of assessment. This it should not be. The Master and his crew should be encouraged to be the main eyes and supervisors of the management. How to bring them on board should really be the commitment of the TM. Suggestions and dependency on auditors is the starting point of the fear culture and a false measure of efficiency.

Auditors add value by examining evidence of how well the system is helping its users to predict potential NC y analyzing data and getting useful information from it. This information should provide the trends and analysis to make decisions on resources and measures to improve efficiency and cut loss before it occurs. Auditors add value by reporting NCs objectively, based on actual requirements and supported by the evidence observed. That should be the only expectation from a good auditor: a well defined objective NC.

EXPECTATIONS FROM & THE ROLE OF FLAG STATES

Flag State Administrations and Registered Organizations (RO) as also Registered Security Organizations (RSO) should support the auditing system by not getting into conflicts of interest. When for example an RO represents the Flag State for certifications, and chooses to be the consultant and trainer, a compromise on fruitfulness and objectivity of the audit comes in. Independence of the auditing institution must be a commitment of every stakeholder in the maritime industry. It will prevent ENRON like situations

CONCLUSION

Audits to any of the codes are carried out by mature auditors to confirm the system is working as desired. The objective is not to somehow find a NC! Once a NC is discovered, it should be respected as the starting point to initiate the CA process and therefore should be welcomed. Independence of the auditors is as essential as the total commitment of the TM to the process based management approach to implementation of the ISM, ISPS Codes and other relevant standards as ISO 28000 for the mercantile marine to remain viable prevent loss and prevention.