SAFETY CULTURE – FIVE ORGANISATIONAL VALUES AND BEHAVIOURS

Many organisations talk great things about safety and seemingly have systems in place to make things happen safely.  However, my view has always been is that organisations tend to only think this applies at the lowest levels, the engineers and operators delivering tasks, the reliance on procedures and regulations rather than a just culture and certainly not really something leaders need to worry about.  This is in spite of duty of care legal obligations to boards and top-level organisations and the fact, certainly in more developed nations the senior executives can end up in court when it all goes wrong. 

In examining this issue, I thought I would use an example of my time as a junior officer in the Royal Navy to show how the absence of a real safety culture can make a real difference in day to day activity.

SITUATION

HMS Invincible was sailing in the Adriatic Sea, in late 1995, as part of the NATO force involved in supporting Peace Keeping operations in the Former Yugoslavia (now Slovenia, Bosnia, and Croatia).  As we departed the operational area to return to the UK my air operations role was declining, and I was surprised to be summoned to the bridge one morning and then to be told that I was to be part of an investigation into the loss of the Port anchor.  As the picture above clearly shows an aircraft carrier anchor is not an insubstantial piece of equipment so losing it, inadvertently, is clearly a big problem and one which could cause substantial damage to the ship notwithstanding the inability to use the anchor for its normal purpose.

So in company with the Navigating Officer (a career seamanship expert) and the Weapons Engineering Officer we set off to investigate the loss, with a remit to work out why it had happened.  As with most such investigations we started by looking at the way in which the anchor was attached to the ship both in terms of the cable (chain) and devices which serve to keep the anchor tightly attached to the ship (movement being a problem).  The diagram to the left shows the direct cable shackle attachment and how a pin with a lead pellet holds it closed.  

The diagram to the right shows the layout of the forecastle (front) of the ship and the various elements that should serve to hold the anchor cable tight and the back up method (strop) that goes through the above shackle to hold things in place.

The key item in this case was the blake bottle screw slip which is used as a device to hold the cable taught when the anchor is fully retracted and allows the power to be withdrawn from the capstan (along with the other slips).

So having determined the key elements we then set to working out either when the anchor had last been used maintained in the direct recent past of the loss.  It turned out the whole anchor cable system had been reeled out in a previous port visit to Majorca.  Everyone involved stated the whole event had been carried out in accordance with normal practices and been correctly supervised by both the Petty Officer in charge and the Ship’s Officer who had checked the cable deck layout on completion. Our first view was that given the way the system was set out - the cable layout on the forecastle was intact including the strop – that the focus needed to be in the anchor shackle and pin.  After interviewing all of those involved in refitting the cable and anchor we determined that this had been the issue and that there had been some flaw in the way the pin and lead pellet had been refitted which during some rough weather had caused the pin to fall out and the anchor to be lost.  We could not, however, fully determine the exact mechanism.

A couple of days after the first investigation we were asked to reconvene as more information had come to light.  It seemed that there had been some discussion over the way in which the cable had been re-attached to the ship (in the cable locker) and that on inspection this had not been done correctly.  As a result the cable had been attached one link (yes, one 18 inch link) too loose and this meant that by the time the anchor had been re-connected on the forecastle the seaman team connecting everything up had struggle to tighten the Blake slip sufficiently to hold the anchor entirely tight to the ships side.  Rather than investigate further the team leader felt it was ‘good enough’ and the supervising officer had not been informed or noted the problem on inspection.  When out at sea the anchor had thus been able to move, especially in bad weather, mechanically shifting the lead pellet and thus the anchor had detached (of note the starboard anchor system had nearly failed too).

The outcome for the two supervisors was not good and both were reprimanded on the basis of a failure to discharge their duties effectively and in the junior case for not reporting on the problem securing the anchors either at the time or to the first investigation.

WHERE WAS THE SAFETY CULTURE?

Whilst one can quickly see that the supervisor made errors in the areas of procedure, checking and reporting what cultural issues existed at the time to create the environment for the initial problem to manifest and the subsequent failure of the first investigation.  The 5 values and behaviours below (different but based on UK Military Aviation Authority guidance) give us some ideas of why the environment was not conducive either to understanding safety or investigating problems. 

1.         Leading.

In the case of the seamanship area of the Royal Navy at the time, safety was not something routinely discussed, reported on or even had an underlying policy.  Those at more junior levels were just expected to use their common sense and experience to did things correctly.  If they didn’t they would be at best, given a dressing down or at worst be put on a charge for failing to do their job correctly.  The management expected the job to be done quickly and correctly and there was little in the way of procedural guidance or regulation to use - the pictures above from the Royal Navy Seamanship Manual were about it.   Outside of experience, as a junior officer, senior management would have little engagement with such tasks or indeed with those conducting them on a day to day basis and there was little or no process to learn from problems or even investigations like the one above.  There were no surveys or regular fora to discuss safety and certainly senior leaders didn’t get to see anything so mundane 

2.         Enquiring

In the case of the average junior seaman they understood their role only in as much as they had been trained and that they needed to do what they were told by their supervisor.  Challenging assumptions or highlighting safety issues was neither part of a process or even expected on a day to day basis.  In the case of the investigation the junior members of the anchor maintenance team were barely spoken to in respect of the problems.  As such they were not encouraged to come forward to give their view of what had or might have happened.  They were silent participants who were never engaged in process improvement activities and certainly never felt that it was their place to support safety improvement activities.  Had they been involved in such a way from the outset perhaps they would have been the barriers to the problem highlighting where things had gone wrong or where corrections might be required.

3.         Changing (through evidence)

There has typically been nothing flexible or particularly changed about the conduct of seamanship or related activities either at the time or in the previous 50 years at least..  Processes for such seamanship activities such as anchor set up and handling were built in a different age but were seemingly not subject to regular review or change in the event of an issue/accident.  Perhaps this was justified but perhaps a review of process or more detailed study of how the system should go together would have provided maintainers and operators with a fool-proof systems.  Interesting at the time of the investigation was that little if no focus was had or required on the documents that supported the activity, whether these were fit for purpose or even who should be involved in delivering the required maintenance activity.

4.         Just

A just safety system allows for individuals to make errors and provides for the fact that human beings are fallible.  Whilst there is always a need to have some form or reckoning for malicious or deliberately poor standards and practices perhaps starting with a premise that someone needed to found wanting was probably not the best way of working.  This was certainly the case for this investigation.  The previously highlighted attitudes towards communicating problems or highlighting issues surely served to reduce the enthusiasm of those interviewed to answer questions accurately.  In fact was the nature of the supervisory and investigation system such that it encouraged those involved in the activity to keep quiet and not admit any particular individual error or failing.  Nothwithstanding this there was, of course, no excuse for providing mistruths but it remains unclear to me, to this day, about whether anyone actually lied.

5.         Reporting

Basically, and has highlighted above, there was no real regular reporting system for safety reporting in the seamanship area at the time.  Plenty of official reports and the odd investigation but nothing on the level that was already in aviation during this period or a focus in using investigations to provided lessons for future development or perhaps, a design change.  In the case of anchors why did the anchor strop not actually get fixed to the anchor itself, rather than the anchor shackle, which would have prevented the loss entirely.  The use of a open reporting system, with non-fault review and investigation is an entirely better way to deal with both simple and complex engineering safety issues in what are challenging environments.

CONCLUSION

Safety management is more than just lower level reporting and the following of procedure at the sharp end.  It is a totality that needs to embed itself from the CEO or Service Chief all the way down the the management chain.  All must engage and have visibility of what is important and this must be clearly communicated to all concerned. Moreover all must be willing to admit, without prejudice, when they have made a mistake and how best things might change to make things better.