Update Jul 2007

How do we reconcile a Blame Culture with a Continuous improvement culture at the same time?

A look into the future of reporting practices
Today we are still living in a blame culture in the maritime industry. In the case of Port States, this is getting worse. So how do we manage internal controls and continuous improvement under this conflict between blame culture and continuous improvement culture?

When there is a danger of any recorded information being taken out of context, this information must stand up to scrutiny when tested within the blame culture in which it may be judged. Such information that can be taken out of context must be visible and must be easy to identify and clarify before it can be used against us. Information that demonstrates competence must also be visible and must serve to enhance continuous improvement. Finally the convenience of modern electronic messaging and content management must be used to enhance the speed at which action is taken in a dispersed enterprise and to increase personal productivity.

The scenario
Three small leaks were found on a hydraulic line supplying hydraulic oil to the valve actuators on deck. The leak was in way of a pipe support.

  1. The leak seemed to be from surface corrosion.
  2. The leak was repaired immediately.
  3. It was deemed likely that other leaks from the same surface corrosion could occur all along the hydraulic actuator lines and at night could create a serious hazard to crew members going forward in wet conditions or in the dark.
  4. Measures and procedures were taken to avoid operating the system at times when the deck was wet and dark and if it was necessary to do so, to check the lines before allowing the adjacent access way to be used.
  5. The quality manager found it appropriate to put a request in for a change in configuration of forward access on new buildings and other vessels with similar configuration to mitigate this kind of risk by use of a different way to access the forward decks or alternatives.

How will reporting look in the future: Common factors in the priority of reporting action
(This discussion is strictly about the notification and co-ordination process and not the physical process.)

There are common factors in the priority of action to be taken and these factors apply to all situations whether the observation/occurrence is generated internally or by third parties. When systems are used to manage information, the priorities of the system are to assist in the following:

  • First priority is to report the observations/occurrences so that all potentially affected processes are protected from further risk.
  • Second priority is to show observations/occurrences against the processes or other focal points they affect while they are still outstanding and most importantly, set in motion intermediate measures to mitigate risk. All these need to be conspicuous at the time that users interact with the system to carry our related activities. At this point, in cases where major processes, may be jeopardized such as discharging, then a risk assessment can take place for all processes affected by the occurrence or the probability of re-occurrence, as in this case.
  • Third priority is to put in hand the remedial action/closeout process whereby the appropriate departments are notified (Planned maintenance, MS, purchasing, crewing and DM) according to external or internal inspection priorities. This step may involve a number of other steps. If the root cause is obvious and the occurrence has been reported by an external auditor then the root cause and remedial action need to be communicated to the external auditor. If the root cause is not obvious, but the apparent cause is clear, then a root cause analysis is needed and this takes a parallel path to the remedial action.
  • Fourth priority is to follow-up on the status of all outstanding items and see how the observations, temporary measures, risk assessments, etc., relate to each other and to make sure interim risk mitigation steps are carried out.
  • To manage outstanding items without losing track of what is outstanding and what has been closed. This requires proper linking of related objects. In the example of the hydraulic leak, the procedures and warnings when starting up the valve actuator system must remain outstanding while there is still fear of leaks from other points in the lines. Since this is an impractical measure during loading or discharge, the measure cannot be permanent and must be accompanied by different measures during cargo operations. The pressing up and testing of the system is a PMS system activity, while any ordering of spare lines required to be replaced is in the purchasing system activity. When the remedial actions are completed, the intermediate measures must also be closed. So the links between instructions to the crew for forward access, and instructions for operating the hydraulic system must be demonstratively connected to the closing of the system testing and repair activities. Furthermore, the lessons learned and the potential long-term improvement to this vessel and other vessels must remain outstanding until suitable conclusions are reached by the teams involved. In between these steps are risk assessments and sometimes root cause analyses that are also related and must be closed at the appropriate time as well as linked to the events that instigated them.

Fighting the blame culture
Blame cultures will seek to prove that we are incompetent. They will either seek to indicate willful negligence or lack of managerial control.
n the above example, if no measures are taken to show that either the leaks are unlikely to re-occur or that their reoccurrence will not pose a risk to forward access or to loss of containment, then competence may not be easy to demonstrate. If the leak is not mentioned but traces or repairs are seen by external inspectors, there is always a chance of management quality being questioned. If, however, the leak is mentioned and measures are taken to eliminate the leaks, while the risks they introduce are anticipated and mitigated, the ship''s operation remains under control and competence is likely to be clearly demonstrable.

The role of statistics
Statistics are useful in showing trends of all the different observations and occurrences, such as accidents, incidents, defects, etc., and how the trends change over certain periods. They also serve as a good comparison of the internal and external observations which will need to be compared to allow for item 12 of TMSA.
As statistics are gathered more useful comparisons can be made by comparing findings such as the willingness to report compared with crew training programs, or human error findings with experience in rank, etc.
Systems must be able to handle all the above requirements in a way that enhances safe operation instead of creating further bureaucracy.

The way people handle risk and opportunity is the essence of management quality
The Task Assistant makes it easy for companies to monitor internally how decisions regarding reporting and remedial action are made and therefore progressively monitor and improve their own decision making processes.

It does this by its unique Task Orientation. By richly indexing all items circulated within the system, as a by-product of people's work, the system makes it very easy, using maritime common sense, to string together the expected actions following any need to make a decision. Unlike conventional document management systems and applications every activity is connected to activities it affects via the rich internal indexing. In this way the system clearly allows each user to get a picture of every situation without having to enter and exit many different applications. This is especially important on board where there is only one master. No vetting master or quality master or maintenance master who can learn multiple different applications. The convenience assured by Task Orientation makes it possible to continuously improve decision making without adding any administrative work. Above all the task assistance makes it possible to see which written records, when seen in isolation or out of context, may jeopardise the credibility of a company under the prevailing blame cultures.