In March 2017, I travelled to Sorrento to meet with Francesco Schettino, the captain of the passenger ship Costa Concordia that capsized off the coast of Italy. I was plainly curious to understand his perspective about the accident. During our four days of interaction, I discovered that Francesco had a strong opinion about why people don’t speak up even when there is an imminent danger. His theory was that they simply cannot comprehend the situation. In other words, how do you speak up if you do not know what to say?
I was left disturbed by the idea. It appeared naïve and oversimplistic. How could it be possible? Dominant theories and prominent experts have not focused on this, so who was this man to make such a bold statement? What did he know about human factors and, above all, why should I even trust someone who has such a low credibility in public face?
Psychological Safety in High-risk Industries
In high-risk industries, the dominant view of why people do not speak up to someone higher up in hierarchy, even when faced with an imminent threat, is the absence of ‘psychological safety’. In the words of Professor Amy Edmondson psychological safety “is a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes”.
Conversely, when people don’t speak up, voice their concerns or opinions, go along with the most powerful voice in the room, feel humiliated, ridiculed, or abused in a risky situation – these are all considered signs of a psychologically unsafe space.
In high-risk systems, professionals regularly make decisions under time pressure, work with missing information, face unclear goals and perform under varying conditions. Typical examples include the aviation, health, maritime, oil and gas, and nuclear sectors. The hierarchical organisation of teams means that people in lower ranks sometimes feel reluctant to voice their concerns. Not surprisingly, many disasters have traditionally been attributed to a reluctance to ‘speak up’, even in the face of a clear and present danger. Air accidents sometimes fall into this category and the explanation goes something like this:
1. The disaster occurred because the co-pilot did not question the judgement of the captain.
2. The co-pilot knew the correct course of action.
3. The co-pilot didn’t speak up because he was psychologically incapable of questioning authority.
4. If the co-pilot had spoken up, the crash would not have happened.
5. We now train co-pilots to speak up and have created protocols to facilitate this and punish them for not doing so.
6. As a result of this, these kinds of human error accidents will not occur.
The solution proposed is to encourage people in lower ranks to be assertive and challenge those in a position of power. To create a safe workplace, errors should be detected and reported upwards. Despite four generations of crew resource management (CRM) courses in the aviation world (and now in wider industries), we remain trapped in the same deadlock. There is some truth to it but is it that simple?
The Bad-tempered Captain
Back to the Costa Concordia case. The argument that the junior officers were often terrified because of the Captain’s presence on the bridge came up on various occasions in my research. Some seafarers who have worked with Francesco and have attended my workshops even called him a ‘bully’ or a ‘monster’. One of his shipmates expressed being shocked upon hearing the news that Francesco was being promoted as a ship captain by the company.
But accident investigations can be a relentless hunt for the bad apple, and for simple explanations. That the captain with a strong character can become a ‘cause’ is a lazy explanation, and I have difficulties buying into this argument. It tells us nothing about the situation or the conditions at work. But even if we were to accept such an explanation, the thought that the safety of a multi-million-dollar ship carrying more than four thousand passengers and crew is contingent upon the temperament of a single person should be worrying for any organisation in the business of high-risk operations. Francesco had an accomplished career and was promoted through ranks to become a ship captain.
Should someone whose disposition causes so much concern to his colleagues be promoted to the highest rank? What does this tell us about the peer evaluation processes and the organisational structure in general?
Competence and Trust
The Costa Concordia case provides an opportunity to rethink why people don’t speak up in high-risk systems. It became evident during our research that the problem is far more deep-rooted. The data from the Cruise Line International Association revealed an unprecedented increase in both the supply and demand for cruise ships between 2003-2013. The global demand for cruise ships increased by 77%, and within Europe as much as 136%. Similarly, the global supply of cruise ship capacity increased by 84%; in the Mediterranean alone, it surged up to 160%. Understandably, all this led to an acute shortage of staff in the cruise sector.
The operators responded by expediting the training process and sea staff were promoted faster than usual. Mass recruitment at the entry level meant that young seafarers with limited work experience were having to work alongside seafaring professionals with extensive work experience.
When this happens, speaking up is no longer simply a matter of mustering courage or owning mistakes. It is about the expertise to understand and deal with novel situations and the ability to operate as one team. Without this, the leader of the team finds it difficult to trust team members to perform their duties independently. In short, the issue is of competence and training standards of new entrants, and it is the problem of an entire industry. With many experienced pilots having left the cockpit for good, might we see the same in aviation on restart?
At the time of the accident, the most senior officer onboard the Costa Concordia was almost half the age of the captain and with significantly less work experience. Similar patterns emerge when we examine accidents in other high-risk systems. In the case of the Ethiopian Airlines flight, the co-pilot had clocked a mere 200 hours of flying experience, alongside a pilot with 8,000 hours. And in the case of MH 370, the co-pilot was on his first flight aboard a Boeing 777 as a fully approved pilot and it was his first assignment without a training pilot overseeing him. These accidents may reveal an interesting insight about how teams within high-risk systems are organised.
Trust that is otherwise kept intact between team members during critical operations to guide, steer, approve and challenge one another’s actions and decisions goes out of the window when the required level of competence is missing in the team. Though in-charge, the leader needs input from other members of the team to perform successfully. But in hours of crisis or during non-routine tasks, there is no back-up and no one to fall back upon. At the opposite end, the subordinate wants to speak up and raise his or her concerns to the leader but is ill-prepared for the situation. Preparing entry-level recruits for high-risk operations, singling out areas of concerns, escalating issues and earning the trust of team members requires quality education and training that maritime institutions operating in deregulated markets are not geared up to handle. And all this leads to a breakdown of trust between team members.
There is a good chance that the subordinates’ concerns will not be taken seriously by experienced members of the team because of his or her perceived lack of competence. This implies that there could be a lot of psychological safety in the space, but trust may still be absent between the team members. Once again, a systemic problem calls for policy-makers and leaders to revisit their business and skill strategies, not another training course focused on seafarers to manage power relations at work. The question we asked at the outset – why won’t they speak up? – loses meaning. Perhaps a more meaningful question would be to ask, what should they say, how and when? And, crucially, how will they know what to say?
Across high-risk industries, the ability to perform as expected from an individual (and a team) under varying conditions and novel situations should still be placed at the heart of competence development programs. People need the knowledge and skills to recognise and understand problems. There are clearly benefits in enhancing the non-technical skills of professionals so long as such initiatives do not become a replacement for competence development.
This is not to say that psychological safety is an unhelpful construct. On the contrary, it is a very helpful concept in most aspects of work such as planning, pre-briefing and debriefing, and meetings. The point is to understand the distinction between the issue of competence and trust between team members on the one hand, and psychological safety within a team on the other, and to realise when not to overuse the latter.
The article was first published in the Hindsight magazine of EUROCONTROL issue 32. Check out this and many more articles on human factors by folllowing the link below: https://www.skybrary.aero/index.php/Hindsight_32