14-10-2017 Why accidents really happen, By Richard Clayton, Lloyd’s List
Accidents happen; they always will. Ship operators respond in two ways. They either address the obvious cause or, when the damage becomes reputational, they seek to understand the deeper causes and address those. After a collision involving a gas carrier in October 2015, Japan’s K Line LNG took the latter option. It proved to be a far-from-comfortable experience, yet with professional help the outcome has been positive.
The report that followed the investigation into the collision between the LNG carrier Al Oraiq and the general cargo vessel Flinterstar off the port of Zeebrugge concluded that the incident occurred because the bridge team on the gas carrier wrongly assessed the traffic situation and the vessel’s speed and distance from a buoy.
But behind that bald statement was a series of observations that revealed a worrying disregard for best practice procedures. The coastal pilots “did not attempt to work with the ship’s bridge team”, the report noted; they restricted the master’s and officer of the watch’s access to critical navigational information, and took operational decisions without consulting them. The sea pilot on board the general cargo vessel was “engaged in a casual conversation” rather than monitoring the traffic situation.
The bridge team on the gas carrier “had very little situational awareness” and failed to request the coastal pilots translate VHF radio communications in Dutch. The bridge team on the general cargo ship was “insufficiently focused on watchkeeping duties”.
Even the nautical regulations came in for critical overview. In Notices to Mariners issued by Flanders Hydrography, LNG carriers were awarded “an exceptional status… right of way under almost any circumstance”. This had led bridge teams on such vessels “into using this assumed exceptional status at their own discretion, not seldom leading to close quarter situations in restricted fairways”.
The VTS operator at Traffic Centre Zeebrugge decided against proactively offering advice or instruction to the bridge teams on either vessel because “in the past [such communication] has often been ill received by pilots off the Belgian coast, and has led to several high-ascending discussions, to the extent that VTS operators at Traffic Centre Zeebrugge have refrained from offering advice… to vessels in their monitored block.”
Like almost all maritime accidents and incidents, this collision came about because of a failure of communication at several levels. Al Oraiq was managed by K Line LNG Shipping (UK). It was not the first time K Line ships had been involved in avoidable incidents. Even though the vessel’s bridge team was not wholly responsible for this collision, K Line was sufficiently shaken to confront its demons head-on. Why were these accidents happening? What could be done to tighten up procedures? Was training at fault, or complacency, or were the regulations confusing?
The company turned to Norway for a solution, and brought in Propel, which specialises in identifying and addressing the cultural shortcomings that lead to accidents.
The diagnosis phase lasted for seven months. Propel’s team conducted interviews in shoreside offices and on board ship. They sought out the unfiltered comment of the people who worked at every level of the business. What they uncovered was a culture that pushed safety concerns behind the need to appear to be safe. There was no incentive to point out safety shortcomings; there was a wider ‘distance’ between ship and shore than in competitor companies; the leaders of the business were not perceived to be role models; and decision-making was poor when under pressure.
In brief, trust, which acts as a glue in well-run businesses, was in short supply.
Propel analysed K Line’s safety data. They looked at how seafarers observed colleagues, and believed this company’s shortcomings were not unique. Propel partner Didrik Svendsen suggested to Lloyd’s List that “today half the world fleet is in a state of cover-up”.
“No one talks about what’s going wrong. If people shared information,” he said, “they could stop accidents happening.” Instead, the industry operates through procedures and regulations that can’t do much more than identify who made mistakes. “When lawyers are involved you have to find someone to blame.”
Propel introduced K Line to eight different behaviours that reduce the risk of accidents and four levels of safety culture. After the diagnosis came a two-day workshop during which the corporate mission was revised and purpose clarified. Five values were identified, together with a fresh set of goals for 2020, and a roadmap to achieve them. Leaders both on board and ashore were engaged.
“The most important value is ‘proactive’,” Mr Svendsen observed. “Ship management is very reactive.”
The result has been extremely encouraging. K Line is now two years into the implementation of its KARE project, which has full commitment from senior managers, shore-side operations staff, seafarers at all levels, and customers.
As a result, K Line LNG (UK) managing director Yuzuru Goto, left, says he now sleeps well at night.