Are audits and investigations improving safety?
Nippin Anand
Author - Are We Learning from Accidents? | Culture, Risk, Learning and Decision making | Host of the podcast Embracing Differences
For those who are critical about audits and investigations as a way of improving safety, this short video clip from Kristine Vedal St?rkersen at the Norges teknisk-naturvitenskapelige universitet (NTNU) offers a great place to begin with some serious questions.
Are audits really improving safety and if so what aspects of safety and at what cost?
This video shows how audits generate unnecessary bureaucracy which in turn undermines the safety of ships. With a single-minded focus on eliminating harm (zero), audits have led to all sorts of unforeseen problems including a culture of underreporting, trauma, stress and fatigue to meet with the goals and targets, a cynical attitude towards auditors, and a breakdown of trust between different subcultures across the maritime ecosystem.
Counterintuitive as this may sound, Kristine’s research shows that safety audits have also led to unsafe practices. In line with Kristine's research, I have observed firsthand a navigation officer carrying out paperwork on the bridge instead of keeping a lookout. Upon checking, he said he was preparing for an audit in the next port.
In another instance, a ship officer was asked by a safety inspector to increase the font size on the muster list so everyone was aware of their duties in an emergency. A fair non-conformance but at what cost? The ship officer along with an able seaman were relieved from from their cargo duties to amend all the muster lists while the ship was loading hydrocarbons in port.
These are not unique problems or isolated examples. This is the state of regulations and controls in the maritime world.
If you cannot measure it ...
The other aspect of audits is the primary focus on measurement and control of risk and often at the expense of understanding and relating with people. No one denies that trust and relationship are the key to managing risk and yet, every initiative begins with measuring and controlling the risk. One wonders how many of us, in an attempt to bond with our families, begin with measuring trust with our children and spouses?
In one audit, I so wanted to put on the record a positive observation about a crew member’s behaviour in the audit report but I was firmly told by the captain, ‘no thanks, no one really reads all that. We appreciate your feedback but it doesn’t need to go in the report.’ What counts is what gets counted and in an industry that has lost a balanced perspective on risk and safety, what gets counted does not always count. ?
Kristine’s video also leaves us with a question. When ships run aground, is our approach to investigations any different from audits? I don't think so. While on the one hand audits create this unnecessary bureaucracy that pushes the maritime ecosystem to the edge of the limits of safe operations, investigations punish this overstretched system with even more controls and processes. The cumulative problem of audits and investigations has taken us so far from away from their intended purpose that today ships run aground not despite but because of an excessive and unnecessary bureaucracy of safety rules. (Also recommend reading Proving Safety and Papersafe by Greg Smith )
We underestimate the power of symbols
If this not about getting better at measuring performance then what is it? I think the problem is so much more deeper and so well hidden that we cannot even see it anymore.
Let me share a story with you. I often travel through the Heathrow airport in London. As you enter the Southern lounge of the airport, you will notice a pair of tall and dark horse lamp shades at the lounge entrance. To date, no one at the reception has been able to tell me why those horses have been sitting there for so long. And yet, every time I suggest to the staff that they should get rid of those horses, they would either laugh at me or get upset in disbelief.?
Safety audits and investigations continue to overburden the maritime ecosystem with unnecessary and unwanted bureaucracy but the moment you challenge the need for those processes, we are in the same situation as those sitting at the reception desk of the airport lounge. ?
The religion of safety
Safety is a deeply religious industry and the symbols and slogans of safety (compliance, safety first, danger of death, Zero harm) are sacred to those who belong to this cult. Most well intentioned people buy into this cultic language and become trapped in the language of ‘saving lives’. Safety claims to be a scientific discipline but observe carefully the symbols of safety and question the hidden message in those symbols. Ask yourself what these symbols communicate to us and what is kept hidden? What is so scientific about these symbols?
True Science is a humble and ongoing inquiry into the unknown. The pursuit of certainty and measurement while being silent on the discourse of critical thinking, listening, building relationships, engaging with dissenting voices and questioning with an open mind cannot be Science.
If we don’t learn to spot those dark horses, we will forever remain trapped in this unwanted bureaucracy with its single minded focus on ‘saving lives’. The unfortunate problem, as Kristine’s message highlights in this video, is that this has nothing to do with saving lives. We have merely shifted the risk from one part of the ecosystem to another and apparently many believe that we are making progress.
About Nippin
Dr Nippin Anand is a former master mariner (ship captain), an anthropologist, a social psychologist and the author of the book, Are We Learning from Accidents? based on the true story of the Costa Concordia accident. Nippin's passion lies at the intersection between anthropology, social psychology and neurosciences and understanding how people learn, unlearn and make decisions in groups.
Nippin is the CEO of Novellus, a UK based company. He and his colleagues use a range of visual (semiotic) methods to help organisations improve their decision making and cultural intelligence.
Founder & CEO | QSE – Safety & Operational Excellence | konkrit – Ready-Mix Concrete Consulting & Training
4 小时前Yes for businesses that have heavy focus on Continuous Improvement as a Culture. And no for most companies trying to comply to requirements. .Which side of coin you want to be.
Safety & Health Activist | Innovator | Investigator
7 小时前Reporting the evidence & facts from workplace accident investigations and workplace H&S audits Nippin Anand; if the person writing/presenting the report & findings is too scared &/or is being influenced to NOT present evidence based facts = they’re in the wrong job…??
Director, Verda Consulting. Supporting your business through enhanced safety performance.
9 小时前As always Nippin a thought provoking article. I see the energy put into audits and the resulting actions far outweighing time engaging and understanding our people. The opportunity to connect becomes hijacked by motive and ritual. A fear of 'failing' or upsetting the senior leaders takes people away from their focus on managing risk. Checking that 'things' are in place as opposed to hosting conversations is preferred. Regulators have their own challenges. Many I speak with are themselves driven by similar pointless measures and spread very thinly. Let's face it, with most being government agencies, budgets and understanding of safety by those at a ministerial level are unlikely to be supportive towards safe operations. Regulators have a tough deal. Often trying to keep the peace for fear of being accused of being too heavy and doing too little that it's a tick and flick exercise. That relationship rarely gets mentioned.
"Quality Techno Legal" : A Maritime and Logistics Expert & Lawyer with two decades of Top Management experience to set up companies.Well networked personality & trainer. A ship recycling & ESG implementation expert.
13 小时前I have been working with the Alang ship Recycling Industry since last 10 yesrs. In the last few years we are monitoring ship recycling yards. We have done wonders along with the commitment of the Yard owners & workers to improve safety culture with regular training, audits and investigation analysis used for continuous improvement. Recently a very senior Marine Expert in ship building during the visit to Alang pointed out that the safety culture was even better than the best ship building yards in India.
Retired Head, Maritime Training and Human Element IMO (UN), Managing Director, FinMar Consultants Ltd
19 小时前Thanks Nippin. I am an atheist when it comes to THIS religion. Keep up the good work. Best wishes.