When it comes to learning, one should think carefully about expressions like ‘normal work’, ‘everyday work’, ‘what goes well’ or ‘success’.
In a world increasingly becoming focused on measurement, control and reputational risks, positive psychology can easily become a spin. Be gentle, focus on what you can fix and leave the rest. And do not question the nature of power.
In my view, the two questions we should be asking in every accident, near miss and non-event are:
👉 Where is power located?
👉 What is the nature of power?
Let’s begin with Ever Given – the Taiwanese container ship that went aground and blocked the Suez Canal. Two local pilots in total control of the ship executing hard over helms instead of giving the helmsman a course to steer. At the time of grounding, the ship was navigating at almost twice the permissible speed in the Canal. On the bridge of the Ever Given, expertise was siloed and localised with the pilots. The master and the bridge team stood there passive and helpless.
We observe a different pattern of power in the case of the bulk carrier Wakashio that went aground near Mauritius. Despite not having the appropriate navigation charts, the captain decided to steer closer to the land in search for phone signal. The duty officer brought his mobile phone on the bridge and made private phone calls in the presence of the captain. Nearer to the time of grounding, both the captain and the chief engineer were present on the bridge and at one stage, all three of them were busy making calls to their families. As the ship was heading into the shallows, the chief officer assumed that the captain was monitoring the ship’s position. The captain was under the impression that it was the chief officer’s responsibility as the ship was under his watch. Here we see a complex dance between legitimate authority and technical authority along with personal needs being prioritised over professional duties.
As we speak, there has been a collision in the Singapore Straits between two bulk carriers – Cape XL and Huge Kumano. Early indications suggest that this could be another VTS assisted collision. The VTS operators – not because of their expertise but due to their bureaucratic authority – directing the ship captains in the world’s busiest straits. Are we going to question the competences of the VTS operators? I’m not sure. Instead, chances are that the captain will be reprimanded and the officer will be administered a jab of soft skills.
As we advocate a shift from accidents towards ‘learning from what goes well’, ‘normal work’ or ‘success’ we should also learn to ask sensible questions about what constitutes normality or success.
In learning, our biggest challenges are rarely technical or operational. Instead, it is how we relate with each other and how we exercise power. Unfortunately, almost all accident and learning methodologies are silent on ethics and power.
