Near-missing the mark

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A fatal accident has prompted renewal of a call for shipping to adopt a blame-free system for seafarers to report near-misses.

While there were several other contributory factors in the incident that occurred last year in a containership's lift-shaft, investigators noted the company's safety system suffered from poor communication between shore and ships that left management unaware of developing problems.

Near-miss reporting, in particular, was relatively low in comparison to the number of actual incidents on the company's ships and on the ship in question there had been no reports at all in the six months prior to the fatal accident. The report by the UK's Marine Accident Investigation Branch (MAIB) says there is "widespread evidence that for every accident there will normally have been several near-misses".

Under-reporting of near-misses or hazardous incidents has been cited as a problem throughout the industry, the reluctance of those involved being attributed mainly to the fear they will be penalised. In other industries such as aviation where near-miss reporting is standard, concern has grown in recent years that the fear of internal disciplinary action or criminal prosecution stifles disclosure of potentially critical information in near-miss reports and as a consequence safety throughout the industry suffers.

This has led to the development of the "just culture" concept, not just in aviation but in other industries like energy and healthcare and more recently shipping. Designed to promote free and frank reporting of mistakes without fear of penalty, it has won a growing number of adherents but has yet to be fully accepted and is treated with caution by some who point to the lack of a clear and universally accepted definition and the mistaken belief that safety can override justice.

The International Civil Aviation Organisation (ICAO) did, however, adopt a resolution last year calling on governments to recognise just culture in a bid to curb post-incident criminal prosecution of aviation workers. And, as the recently published report into the death of the Chief Engineer on the UK-flag containership notes, a just culture has also been recommended by the International Maritime Organisation (IMO).

In the 2010 version of the International Safety Management (ISM) Code the IMO defines a just culture as one in which people are encouraged to provide essential safety-related information without fear of negative consequences. A report last year by the UK's Maritime and Coastguard Agency (MCA) said a just culture is founded on two principles: human error is inevitable and organisations should shape their policies and processes around that fact; and individuals should be accountable for intentional violations of safety procedures or policies.

It has also been defined within aviation as, "A culture in which frontline operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated."

The MAIB report into the fatal accident notes the containership operator had a system of near-miss reporting but had also adopted a "zero tolerance" policy on breaches of safety rules, with dismissal one of the penalties. Its twin objectives of increasing near-miss reporting and of disciplining crew members including safety officers were, the report says, "confusing and contradictory".

The report added, "The policies were inconsistent and did not reflect the 'just safety culture' described in the ISM Code. The message to personnel was unclear as to whether reporting a near-miss would have a positive or negative outcome."

The company involved has, among other safety initiatives, subsequently placed "anonymous mailboxes" on its ships to encourage crewmembers to report near-misses while maintaining its zero tolerance policy on breaches of safety rules. It has also been recommended by the MCA to develop a plan to achieve a just safety culture on its ships.

While a just culture might be successfully implemented throughout a company, there is as yet no guarantee that it will shield it and its employees from criminal prosecutions. Recent cases in which air traffic controllers in Japan and Italy have been found guilty have been criticised as examples of the persistence of criminalisation of aviation workers who are as, if not more, exposed to the risk of prosecution as seafarers.

Seafarers have also been the focus of an industry-wide campaign calling for their fair treatment by governments, with the IMO's legal committee recently drafting a resolution that would, if adopted, urge states to turn existing guidelines into national law.

The main difference between the two groups is that in aviation, safety is the over-riding reason why companies and their workers are prosecuted, while in shipping (with the exception of passenger ships), it is the environment. Aeroplanes crash and kill passengers, ships spill pollutant cargoes or bunkers. In both cases governments and victims seek retribution and redress, riding roughshod over industry complaints of criminalisation.

Appealing to governments to adopt a less punitive approach is likely to be frustrated by their reluctance to be seen to be soft on safety or pollution, unless they can be convinced that fear of prosecution in its stemming of the flow of vital warning signs is a worse evil.

Companies too, faced with the risk of prosecution or loss of business, want to be known, both internally and externally, to be taking an aggressive stance. Like governments, they are likely to say they have a zero tolerance policy that imposes suitably severe punishments such as instant dismissal for serious violations of laws or company rules.

Sending mixed messages, however, can lead, as in the case of the containership operator, to confusion among employees, uncertain as to whether they should risk their jobs or even imprisonment by admitting to errors or, by remaining silent, endanger themselves and their colleagues.

Spreading a culture of any sort throughout an organisation requires a high level of commitment from the top and a sustained effort by middle management. When it is something as relatively new and sophisticated as just culture, it is, as the MCA report acknowledged, even more challenging.

Andrew Guest for BIMCO

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