I have a special relationship with enclosed spaces. Even the image of an enclosed space makes me phobic. As a young deck boy, I would avoid going into enclosed spaces, make all sorts of excuses, manipulate paperwork, and beg my senior cadet and bosun to swap roles whilst taking on a ‘supervisory’ duty standing by outside the tank.
As I moved ranks, I discovered that there were more people who shared my fears. Claustrophobia remains a taboo that no one speaks about in a male-dominated culture. After all it is only a handful of people on a ship. Who wants to be the panicked chicken on the ship?
After my sailing career, I joined a classification society as a safety inspector. There was no way I could avoid entering enclosed spaces in this role but there again, I found innovative ways to avoid facing my fears. At times, I would just dip in and out of the tanks and on other occasions I would request a seafarer to inspect on my behalf. I just couldn’t get inside those dark, slippery, and creepy spaces. They freak me out even in my dreams.
For many years, I have studied enclosed space related accidents and near misses. I even wrote a chapter about enclosed space accidents in my book, Are We Learning from Accidents? My biggest concern all these years has been that the way we frame ‘enclosed space risks’ as an industry has taken us so far away from the reality of the risk. In fewer words, our language is our problem.
We blame the seafarer after every accident, but we don’t take the time to reflect on our own selves, our models and our assumptions about the risks. The increased number of enclosed space accidents over the years is a testimony to our ill-founded framing of the risks and our stubbornness to face the mirror as an industry. Without reframing our thoughts, we stand little chance to bring the desired change.
In this article, I present some thoughts about where are as an industry and what is missing in our approach towards managing enclosed space risks. I don’t have all the answers, but I do have some questions that I would like you to ponder upon.
Unknown risks: Every ship is unique and every operation presents its own challenges. Often, even in a few cubic metres of space you will find an adjacent bulkhead, a cofferdam, a cargo hold or another tank that may silently inject toxic gases or deplete the oxygen in the space. The seafarers acknowledge the ‘unknown risks’ and ‘hidden surprises’ and yet they become seduced into the language of control. How do you control that which you don’t even know? But we are not supposed to talk like this. Instead, we are taught that we should continuously monitor and be careful of the hazards whatever that means.
Question: How can we talk about measuring and controlling those risks that we do not even understand?
Bi-products of risks: Notice a typical checklist or a risk assessment template. It always goes from left to right or from the top to the bottom. That is how checklists, method statements and permit to work systems are designed. Worse still, the end result whether at the bottom end or the right-hand side of the form is the same. Risk should be controlled. We never ask the question – what new risk are created by those controls? What are the bi-products of our decisions? We never dare to leave the risk in ‘red’ as is. We can address the problem of continuous monitoring by deploying more deck hands but there are only so many people on a ship. We can publish lessons learned, alerts, flashes and bulletins but we never ask what are the repercussions of burdening people with information overload
Question: What new risks are we creating when we have controlled the risk? Where and how do we discuss those emerging risks in our forms and checklists?
Risk perception: Just last week I facilitated an encloses space workshop with a group of seafarers, regulators and ship managers. Whilst the manager was clear that they would never allow bunkering, crew change, surveys and tank inspections at the same time, a seafarer responded by saying that if he followed the advice of this ship manager while the ship was in Singapore or Rotterdam (during demanding operations), he would be fired by the company. What excites the ship manager is so normal in a seafarer’s world. Clearly the reality onboard does not match with what the ship managers think and expect.
Question: Where in our checklists and procedures do we make space for individual and group risk perception? How do we get the ship managers to think from the seafarer’s perspective and vice versa?
Enclosed space fatalities: A review of industry reports and incidents shows that there is a significantly higher percentage of seafarers in high rank positions who succumb in enclosed spaces (up to 65% senior officers as against 6% young people). This is an indication that spending resources on designing better processes and re-training of the seafarers are not only ineffective but also counterproductive. There is nothing more demeaning to a seafarer than being sent on to a training course for a skill that he has learned through years of practice.
Question: How can we address cultural influences and psychological biases (such as overconfidence, under-confidence, habits, heuristics, groupthink and peer pressure) through education and induction programmes? Are we even using the right tools to resolve the risks at hand?
Commercial pressure: Much of high-risk activity is performed under intense commercial pressure. Yet a typical response to the problem from the shore side is that ‘the seafarers should get better at planning.’ Planning cannot be detached from perception. Perception is the basis for planning. If I don’t see the risk, how am I supposed to account for it? If I am regularly calling 5 ports every week, crew are consistently fatigued, last minute changes to the ship’s itinerary have become a norm, it is fair to say that the risk has been normalised. What is there to account for in planning once the risk has been accepted and normalised?
Question: How do risk assessments and toolbox discussions account for the risks that have been tacitly and unconsciously embedded in the culture? Are auditors and investigators equipped with the cultural and psychological competences to engage with the seafarers?
The instinct to save the others: For so many years now, the industry has been grappling with admonishing people who instinctively fall for saving their mates during rescue operations and succumb to death. And it is often the senior officers with significant rank experience who fall into this trap. Apparently, this is not a problem of incompetence. Such instinctive reactions make us for who we are as human persons. But instead of acknowledging and addressing these issues through emotive storytelling and experiential learning we opt for more training and process interventions.
Question: Human beings are non-rational and more than 95% of our decisions are made in a non-rational mode. How does it even make sense to address non-rational decision making using rational methods?
Hierarchical culture: The maritime industry has a longstanding reputation for hierarchy and power distance. It is not uncommon to have crewing patterns that exhibit and even reinforce hierarchy and power distance. And yet, we seem to have an unquestioned belief is Stop Work Authority, Stop the Job, ‘Speak up’ and similar safety interventions. Safety interventions are based on the myth of individualism – bravery, courage, autonomy, liberty and the courage to speak up in the face of an adverse situation. None of this holds true in the existing demographics of the maritime world. Here is a previous LinkedIn post on the problem with ‘speaking up.’
Question: Is it even realistic to expect a bosun on a 9 months temporary contract employed by a third-party manning agency to refuse tank entry in the middle of a critical operation? Why do we put so much faith in safety intervention tools?
Phobia and trauma: It surprises me every time I read an accident report involving enclosed spaces. We are silent about the recurring themes of panic, distress, trauma, anxiety and the phobia associated with enclosed spaces. Apparently, by ignoring the non-material and emotive aspects of what makes us humans we give even more space to hedonic and material language of risk management. Despite years of unsuccess, we remain convinced that more paperwork, more digital apps, real time information, system performance, greener KPIs, training and certification will save people from dying in enclosed spaces. How can we ever measure phobia, distress and trauma?
Question: Why do we not consider sharing the raw stories of the seafarers to the surface to create the desired impact for learning and change? Here is one such story of a young seafarer who survived a near-fatal injury at sea. Perhaps such stories need to be brought in the open and shared within the maritime community.
Measurement and control: Much of risk management is anchored to the myth of bureaucracy. The world is stable, the future is predictable and if we try harder to foresee what lies ahead, we can control the risk. Is that so? We are living in the most uncertain times in our living history. By now we should have realised that the more we control the risk with our predictive armour, the more uncertainty we induce in our ecology. We need to measure what is sensibly measurable, but we also need to become aware of those risks that we simply cannot control, only tackle!
Question: What language do we have to speak about the risks that we cannot control? Does it matter?
For how long will we continue to blame the seafarer for enclosed space fatalities? I invite you to pick up an accident report and read the conclusive pages (for example, the Nozomi enclosed space fatality report issued by TSIB, Singapore). The report reads as if the seafarers get up in the morning and choose to end their lives by entering into enclosed spaces.
I find it interesting that the stubbornness of the industry to learn from accidents is framed as the ignorance of the seafarer.
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