by Geoffrey Gill 12 March 2013
It is important we learn from the Costa Concordia accident. But new lessons are unlikely to emerge and it is more likely that the common failure to apply existing Rules, Regulations, Policies and Practices (RRRP) will emerge from the investigation, including the International Safety Management Code and its attendant Safety
For example, passenger evacuation from the
grounded Costa Concordia was impeded and inefficient because passengers
had not received muster instruction and guidance within the few hours
from boarding until the grounding. This, despite an informed maritime
industry knowing for years that ships generally are at greatest risk
from collision, allision, and grounding when close to land, such as when
leaving port, than when under way on the open sea. Given this
knowledge, one asks why were the conditions on Costa Concordia necessary
to trigger the new common sense policy requiring mandatory emergency
drills be conducted prior to a passenger vessel departing an embarkation
RRPP: the Panacea?
Danger lurks to the extent that new and existing RRPP will be accepted
and relied upon as adequate to the risks and, trusting in that reliance,
the industry will proceed “business as usual.” But reality is that RRPP
are not a panacea capable of remedying risk and human error within the
maritime domain, despite politicians’ and regulators’ enthusiasm for
reacting to media orchestrated popular concerns as well as even the
well-intentioned separate efforts on the part of maritime management.
At least one trade journal has reported existence of a culture of
Italian passenger vessels sailing close to shore, a practice of such
long standing as to have received the Italian title “inchino.”
Shipboard morale benefitted from close passage off towns where many crew
members lived and public relations benefitted from passengers’
enjoyment of the novelty of the experience. Under such circumstances,
credulity is strained when management disavows knowledge of its masters’
participation in the practice. Inchino may present little risk if
performed at a safe distance stated in promulgated RRPP. But existence
of such RRPP does not, of itself, ensure adherence.
Given the implied beneficent purposes of inchino, more likely than not,
human nature together with cultural and personality factors suggest that
over time shipboard justifications would result in the prescribed safe
distance observed being progressively decreased and so shrinking the
margin of error initially factored into the determination of what
distance a safe distance would be and so coming ever closer to land
hazards. What initially may have been idiosyncratic behavior becomes
shared as more and more sharp end practitioners perceived a benefit from
coming closer to the island without experiencing peer or management
criticism or punishment. This type of gradual RRPP erosion is styled
“normalization of deviance,” a pernicious undermining of RRPP.
Deliberate violation of RRPP, especially of those that are inartfully
worded or are perceived as incompatible with the operational
environment, is not infrequent. The violators’ rationales include a
misguided desire to advance the company’s economic interests, lack of
peer or managerial criticism as well as the personality of the violator.
Therefore, RRPP adherence cannot be presumed, even where simulator or
audited competence is confirmed.
Even in the absence of violations, there is the potential for violation
“coming out of the blue.” A recent study, where sheep are persons
normally disinclined to violate RRPP and wolves have no such scruples,
reveals the propensity for RRPP violation:
Sheep in Sheep’s’ Clothing (confirmed non-violators) – 22.5% of respondents, guardians of the standards.
Wolves in Sheep’s’ Clothing – 33.8% of respondents have not yet violated but would violate if circumstances are “appropriate”.
Sheep in Wolves’ Clothing – 14.1% of respondents are violators but not happy violators.
Wolves in Wolves’ Clothing – 29.6% of respondents would not hesitate to violate RRPP.
Strikingly, 77.5% of respondents either reported violating or would have no qualms violating when the opportunity arrives.
The maritime domain is unique in its long tradition of mariners’
recognition and pride in their professional knowledge and competence
combined with an environment in which the variety of potential risky
circumstances is so extreme that no catechism of RRPP can account for
all situations. The rigidity of RRPP must be balanced against a
flexibility that encourages critical thinking and exercise of sound
judgment. This necessity is recognized by Rule 2(a) of the COLREGS that,
though inartfully worded, allows recourse to “the ordinary practice of
seamen or … the special circumstances of the case.” There is real danger
that overly detailed and embracive RRPP, however well intentioned,
undermine development of necessary judgmental skills. The issue is well
stated by a shipmaster quoted as saying: “… when you are at sea, you
have to be able to think, and you can’t [think] when you must slavishly
look up [written procedures] in a book. … No matter if your own
thought is better or not, you have to do what is written.” Unlike
biblical Pharisees bound to the letter of a law, mariners require and
deserve reasonable latitude allowing them to accomplish their primary
duty of vigilance to protect the lives and material assets entrusted to
The challenge that RRPP inhibit critical thinking runs from the sharp
end operator upstream to management, where there may be misplaced
reliance that RRPP, with little more, satisfies management’s
responsibility to ensure a functional Safety Management System. The
folly of relying exclusively or excessively upon formal RRPP as
providing an appropriate level of safety can be demonstrated from the
2007 sinking in Antarctic waters of the Liberian flagged passenger
vessel Explorer, fortunately without casualties. The vessel was in
compliance with class requirements for a vessel of her age, type and
geographic operating area. However, the classification society and SOLAS
rules were unrealistic in view of the harsh Antarctic conditions
regularly to be encountered.
RRPP innovation is easiest in response to particular past or presently
existing situations, where relevant facts are discrete and known. But
effective RRPP must address future eventualities to minimize their
adverse occurrence and mitigate their consequences if they do occur. A
curious and informed mind, willing to explore future possibilities and
proactive risk assessment is required for drafting prophylactic RRPP and
also a willingness objectively to determine with what response the RRPP
are received by those persons intended to apply them and how the RRPP
function in practice, i.e. an impact and sustainability assessment.
Remarkable strides have been made, since Titanic’s loss one hundred
years ago, in bridge-to-bridge and ship-to-shore (and vice versa)
communication, ECDIS, ARPA, AIS, GPS and the like, as well as ship
design and construction. And promulgation of well-intentioned safety
oriented RRPP has flourished.
Remaining relatively consistent, however, has been the shipboard
authority gradient (despite various incantations of bridge/crew resource
management), a degree of nautical daring-do, and organizational
competition between protection and profit; the latter no doubt
exacerbated by the current challenging economic situation. And while
there has developed greater awareness of scene-setting errors and
omissions upstream from the front line operator and greater
understanding of cognitive limitations, there has been no corresponding
advance modifying cognitive limitations of human behavior, such as
confirmation and other biases, situational awareness assessment,
assimilating information of varying reliability and relevance from
multiple sources, dealing with multiculturism and decision making, to
name but a few.
When considering what “new” lessons may be learned out of the Costa
Concordia casualty, worthy of consideration would be a critical
examination of maritime domain RRPP and their limitations and also
expanded operator and management education addressing cognitive factors
and how those factors influence what occurs on the bridge, in the engine room, and in the boardroom.