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.