The previous year witnessed two experienced ship captains being humiliated and eventually criminalised. Accidents, with no evil intentions, were turned into acts of crime. So strong was this perception that even veteran captains and the so called ‘experts’ within the profession found it difficult to understand the ‘erratic’ behaviour and ‘selfish’ actions of the captain in one case, let alone the general public. This analysis is not intended to defend the behaviour of these professionals or make their actions morally acceptable. Professionals have to act mindfully, taking responsibility for their actions and directing their behaviour in meaningful ways. Rather, we seek to understand what makes the position of a captain so prestigious, and yet so susceptible in the wake of an accident. Why is it that not only the maritime community but also society at large becomes unforgiving to the captain whose vessel has met with an accident? And to what extent does our existing approach to the investigation and enquiries that follow these accidents shape those unforgiving opinions, both within the industry and in the public domain?
The Captain’s role
Let us begin with what it means to be a ship’s captain. There is no end to the stories of supreme command and control in this position. The confident and daring Captain Edward Smith, having done all he could do to save the crew and passengers, opted to stay at his post until the sinking of the Titanic. Captain Karan S. Mathur of the Erika apparently lost control but still maintained command and Captain Apostolos Mangouras of the Prestige, along with two crew members, chose not to be airlifted in extreme weather conditions when sinking became imminent.
Tradition has it that the captain is the company’s representative on the vessel and the captain’s subordinates are ‘mates,’ unlike ‘first officers’ in aviation. The complement on ships consists of the captain and the crew; the captain is not considered part of the crew. In the past, the company superintendent could advise but ultimately it was up to the Master to decide. The superintendent was aware that his knowledge of shipboard operations was limited and excess interference in matters of operations might have implications for risk and safety. The management of risk and safety is to a large extent a matter of technical know-how – a matter for the Master. But technical know-how alone does not guarantee command. If it did, professors, technicians and software engineers would be on a par with the captain.
A ship is a complex system of interdependencies in which system components (humans, processes and technology) work in harmony, both sequentially and in parallel, to achieve certain goals. The engines run and the rudders respond as the helmsman applies the helm to turn the ship to the intended course. Of course, the helmsman should be adequately trained in taking orders from the captain, and the captain should be equipped with the knowledge of navigation and ship handling. The vessel should be kept shipshape by appropriate standards of maintenance and the company should supply adequate resources as needed. But this interdependence, as Charles Perrow describes it in his book Normal Accidents, can either be loosely or tightly coupled. A loose coupling means there is sufficient time, slack or redundancy within the system to rectify problems or correct an error of judgment without any serious implications to vessel or crew safety (for example allowing the vessel to sail to the next port with one engine down due to redundancy in the system, or being able to delay ordering of spare parts because there is no urgent requirement). The balancing of safety and commercial goals is based on a careful cost/benefit trade-off.
Tightly coupled systems do not allow the luxury of back-up and redundancy. Even minor disruption to the interaction between components may put the entire system in danger (for example navigation in dense traffic areas or functioning of dynamic positioning systems during diving operations). The safe functioning of a tightly coupled system is contingent upon a centralised hierarchy of command and control. These systems do not allow the liberty of slowing down to think, reflect and decide what next. As a result, the ability to make accurate instantaneous decisions based on technical know-how while balancing safety with commercial goals is central to tightly coupled systems. This ability can be termed heuristics, rule of thumb or simply professional judgment and it sets professionals apart from ordinary people. But heuristics alone do not explain the attributes of a captain, as lorry drivers and crane operators also must act on reflexive decision making. Years of technical know-how and excellent decision making capabilities are both essential to becoming the iconic hero of the marine profession.
Professionals and professional identity
Technical know-how acquired over time is a strong source of identity in many professions. In the maritime industry it is commonly referred to as ‘seamanship’. It forms the basis of the work situation, market situation and the status of (maritime) professionals in the public arena. In work situations, it means that professional judgment takes precedence over rules and procedures, particularly in operations where interdependencies are tightly coupled. The ISM Code Section 5.2 and Collision Regulations Rule 2 (b) have readily acknowledged the limitations of the world of procedures and rules. There are too many unexpected events and uncontrollable variables in the real world for rules to cover every situation. Professionals must be trained to think and act in ways that go beyond following procedures and instructions.
Given that such skills are scarce and irreplaceable it also means that the market rewards maritime professionals accordingly. Professionals in other industries benefit from similar work and market situations, for example airline pilots, surgeons and drilling crew on oil platforms.
The public arena
The status of a ship captain is also acknowledged outside the professional community. Both history and fictional narratives play an important role in shaping such perceptions. But as with everything, respect for the profession comes with certain expectations – in this case, of ensuring maritime safety and resilience. In general, the expectation is fulfilled. Ships do not in general collide, run aground or pollute coastlines on a frequent basis despite the ever-increasing density of maritime traffic. The prestigious status of captain also carries an immense societal expectation, whether the Master is aware of it or not.
Shaming and blaming professionals
In the wake of an accident, the same professional identity which is otherwise a source of resilience and prestige also gives rise to accusations of ‘negligence’ and ‘human error’. Partly, this is the result of how we understand and investigate accidents. The outcome does not match the intentions and the outcome is morally wrong and psychologically disturbing. Society seeks the ‘causes’ of accidents, and investigators hardly ever look beyond the tightly coupled situations that are closest to the outcome. The tighter the coupling of interactions that lead to an accident, the more detailed is the investigation of professionals and their judgments.
The issue that faces most captains involved in an accident is to justify their actions against ambiguous expectations of rules and regulations such as the ‘ordinary practice of seamen’; ‘special circumstances’; ‘safe speed’; ‘ample time’; and ‘good seamanship’. What is good seamanship and safe speed, once you have already met with a collision, and how do you justify that your actions and decisions were in accordance with good seamanship if your vessel has already run aground? With the benefit of hindsight, professional judgment and common sense becomes known as ‘human error’. Litigation and law suits thrive even more on such murky phrases, as blaming professionals for their actions (or inactions) becomes much easier against the background of rules, regulations and ‘objective evidence’ that serve well to establish ‘the facts of the case’.
However, practical challenges, goal conflicts, incomplete knowledge at the time of making decisions, commercial pressures and manning constraints are seldom considered in detail when establishing these ‘facts.’ Working effectively in a demanding resource-constrained environment requires considerable professional ingenuity. This involves constant improvisations, trade-offs, negotiation, adaptability and resilience. But in the case of an accident, these professional abilities are distorted into fallibilities in court. Systemic issues within the organisation, are presented as the foibles of an incompetent captain, ensuring that the organisational reputation is not undermined by the actions of an individual worker.
Too many experts, too little expertise
The exaggerated responses of the maritime community to an accident, are not helpful either. It is as if the professional identity of every individual in the community has been challenged. Any association with those involved in the accident would imply approval of their decisions and competences.
On average, maritime professionals spend their entire lifetime within the industry, starting at sea and progressing to shore-based opportunities. Until recently, most shore-based positions were reserved for those with adequate seagoing experience. This provides a high level of experiential knowledge that is an immense source of resilience in the system, but more expertise also means more opinions and judgments about those involved in accidents. Temporally outdated perceptions and contextually irrelevant experiences of ‘safe distance’ and ‘good seamanship’ are brought up on social media to criticise those involved in the accident, when in truth no two professionals can agree on what is safe and what is good. And if so-called experts and professionals cannot agree what should have been done or what actions were reasonable, how can we possibly expect the general public, with its iconic image of the all-knowing captain, to come up with a fair explanation? The gap is eventually closed by bringing the public over to the professionals’ and experts’ side. All this has serious and far-reaching implications for those involved.
Another line of inquiry with accident investigations and ‘expert’ judgments is that it focuses excessively on the failures of those closest to the accident – for example, that the collision resulted because the watchkeeping officer ‘lost situational awareness’ or the Master should have slowed down to ‘safe speed’ when he encountered restricted visibility. Issues that appear to be less immediately related to the accident, such as organisational factors, are not subject to the same level of scrutiny.
It all depends how the timeline of an accident investigation is decided and on what basis. If we seek to find answers within the confines of bridge and engine room, we may choose to focus only on the past 24 hours recordings on the Voyage Data Recorder (VDR), on the period from the start of the voyage, or at the most from when a crew member first joined the vessel. However, the major contributing factor may be a substandard design chosen for cost reasons when the vessel was originally built thirty years ago, or cheap travel arrangements that led to an overtired crew member long before hours of rest could be officially recorded. The purpose of the ISM Code in addressing the latent and organisational factors that contribute to accidents seems to be lost when it is required the most. But the existing system serves extremely well for a company that wants to save its reputation in the wake of an accident – get rid of a few ‘rotten apples’ and safety is restored.
Many captains I have come across, active and retired, have been highly critical of recent cases where the captain chose to abandon the vessel much before the rest of the crew and passengers were able to do so. Interestingly, the same professionals also admitted that both technological advances and detailed micro-management have shifted the balance of power from ships to the shore end. This is not necessarily the intention; it is the unintended consequence of the restructuring of work. The status and position of a captain is seriously undermined when an assertive young manager in the office demands an immediate response to an email query. In one instance, a chief officer was asked not to make too much fuss about shifting a few hundred metric tons of weight from a lower deck to a higher platform on a drilling unit. Micromanagement from less experienced middle managers or those with outdated operational knowledge can lead to serious breakdown in communication when technical complexities are not understood by those in decision making roles ashore, and yet intervention is considered necessary.
The offshore industry was quick to realize the production pressures and the need to transfer decision-making ashore, and found a solution to this issue by replacing the term ‘captain’ with ‘offshore installation manager’. Here is a paradox. While public opinion – and to a large part, industry opinion as well – is still based on the outdated perception of the days of Titanic, production pressures have significantly altered the role of a captain. What we see as unwillingness and inability to command may well be a result of the erosion of decision-making and degradation of the profession due to enhanced control from ashore.
Human factors or social structures?
When a Master gets a few hundred metres too close to the shore, the self-proclaimed human behaviour experts (and there are many!) are swift to assign the problem to ‘human factors’. The first question is whose fault was it? How close was the vessel to the coast and why on earth was the captain attempting such an insane manoeuvre? We are convinced that the problem lies with the pesky human and his perception of risk and safety. But even if we take this position, why do we design and operate capital-intensive systems in such a manner that catastrophic failures can result from the fallibility of one human – whether deliberate or not?
Even this is only a partial explanation. If an investigation is carried out according to the spirit, rather than the letter, of the ISM Code, these same human factors should be examined as part of the general structure of authority within an organisation. A systematic study of success and how success stories are shared across the company, incentives, sanctions, reporting lines and accountability should give us a fair understanding of an individual’s risk perception, and how it is shaped by company expectations. The question to ask is what motivates people to go that extra mile (or that few hundred metres too close to shore) – sustainable business objectives or merely fulfilling the expectation to perform faster-better-cheaper-safer? If bureaucracy and control leave only limited room for professional judgment, then it becomes imperative to examine the constraints imposed on decision making in the wake of an accident, simply because this is when the need to exercise judgment is felt the most. Unfortunately, investigation reports rarely go into this level of detail, even though most are full of the terms ‘safety culture’ and ‘leadership’.
Are we learning the right lessons?
Major accidents offer tremendous potential for learning from failures. But this opportunity for learning is easily lost if human fallibility is viewed as the ‘cause’ behind accidents. This is an egregious, overly simplistic and naïve understanding of human factors. Part of the problem is that, unlike other high-risk industries, the marine industry does not value the human and behavioural sciences in the same manner as engineering sciences.
As members of a prestigious professional community we must act responsibly in expressing our opinions and values in the wake of accident – even more since the perception of ordinary people is highly dependent on our opinions. It is unfortunate that professional misjudgements (or mistakes if you prefer) are increasingly being judged as negligence and crime. This is compounded by the fact that neither the judge nor the jury understands the complex and challenging nature of the maritime profession. Today, the responsibility borne by a ship captain rarely comes with the corresponding authority, and exercising authority can be challenging in an international labour market characterised by questionable labour laws and weak institutional support.
Both professional judgment and technical know-how are immense sources of resilience in high risk work. History has proved countless times that professionals are willing to give up their lives to restore safety when everything else fails. We need to avoid making the Master the single point of failure within the system, but at the same time there is a serious need to empower the master-on-the-scene and treat their judgment with utmost respect, given its role in ensuring safety and resilience within the maritime industry.