Rebuilding safety culture through gamification
YUZURU Goto is very careful when he talks about the incident that led to the sinking of the general cargo ship Flinterstar in the southern North Sea in October two years ago.
Luckily there were no deaths, but there were a lot of questions asked abut how the situation arose that two vessels, both with pilots on board collided in the roads to Zeebrugge.
Mr Yuzuru is managing director of K-Line LNG UK; and it was one of the company’s 210,100 cbm Q-Flex gas carriers, Al Oraiq that collided with Flinterstar, resulting in the sinking of the latter.
Mr Yuzuru admits that the company, which has 8 gas ships, had challenging times with smaller incidents ahead of that moment which, while there was no loss of life, was nonetheless a potential knock on the company’s commercial bottom line, and not to mention reputation.
One of the issues was communication and trust in the bridge, with a situation where people felt unable or unwilling to speak he says. The accident report from the Belgium authorities mentions that the pilots on board the vessels were not talking English, with the Al Oraiq bridge team unaware of decisions, and not challenging them.
“We did a diagnostic project and the incident pushed towards what we call the “K”ARE project to impact organisational culture and safety leadership,” says Yuzuru who feels it is important for industry to talk more openly and honestly about safety.
By Yuzuru’s admission this meant recognising the need to understand the personality profiles of, and then changing the historical culture, of masters and other senior officers, creating an ability to do new things, notably respond to advice. It also meant giving junior officers and crew the opportunity to speak out.
New answer to an old problem
In the Nautical Institute, an association where many ships masters express their concerns, there is a strong focus on safety culture, and the fear of retribution if a team member speaks out.
Problems with crew, junior and senior officers having the confidence and knowledge to create a thriving and active safety culture are not hard to find.
In the recent edition of the Nautical Institute’s Navigator magazine an accident report from the US points to practices onboard a chemical tanker that led to officers not questioning the lack of use of inert gas ahead of tank cleaning. The result was an explosion and death.
“From the start, the three senior officers on board had created an atmosphere of fear and intimidation. Junior crew members felt unable to question unsafe decisions made by their superiors and were actively prevented from reading safety, quality and environmental protection management documents. The senior officers also failed to train their subordinates in the technical skills they needed to work proficiently. When the CO ordered an unsafe cleaning process that ultimately led to an explosion and the loss of the vessel, junior officers did not have the knowledge or the confidence to question it.”
The vessel mentioned was probably the Bow Mariner which blew apart in 2004. A detailed account of events can be found here.
Loose lips don’t sink ships
The K-Line crew are multinational and from a manning agency, however turnover is relatively low with the same officers used repeatedly according to K-Line.
But Yuzuru is candid about why he feels cautious when talking openly about a need for a new industry focus on safety culture “We still feel that if we are open we will be punished by our customers” he says.
K-Line LNG UK’s customers are some of the largest energy majors and the K-Line vessels are already subject to a very stringent vetting regime. This is a regime that many feel does not recognise openness and learning. There is still a blame culture where it remains hard to learn from near miss observations.
This is why K-Lines LNG turned to Propel, a Norwegian safety consultancy with a new way at looking at the problem.
What K-Lines is doing with Propel is not creating a new system where crew members and shore staff are told how to be safe by reading manuals and instructions. That is covered under its regulatory requirements and by striving to achieve perfect vetting. What the company is doing with Propel is trying to create a real desire within staff to find safety interesting, compelling and something they want to achieve.
Propel was born out of some high level intense research into safety culture in Norway. It has already worked for companies like Torvald Klavenes, AP Moller Maersk and PGS. To date the company can boast over 70 clients according to Propel Partner Didrik Svendsen.
The company’s initial research came from confidential surveys of thousands of marine personnel which led to Propel being able to recognise eight inter-related behaviour traits, which when correlated, increase the likelihood of an accident.
There are, says Svendsen, three strategies which while not being revolutionary are seen as key to improving the maritime environment.
The first is on the prevention of errors by doing it right in the first place, and then how to manage a crisis if these unseen or unreported errors do lead to a situation. Then there is the issue of managing the failures, which even if they do not result in an incident, do need redress, and preferably without recrimination.
The maritime industry, as with much of society, lives in a blame and liability culture; the criminalisation of crews is the glaring evidence of this. There is little or no incentive to report errors or near misses, says Svendsen, who believes it is a fight to get this and then to stop a potential flaw from escalating. “By opening up you create learning.”
In many cases when an accident does occur, a subsequent investigation often reveals that someone already knew about the problem, but not spoken about it. This may be because of fear or uncertainty of how, says Svendsen, so one of the goals Propel is aiming for is to open up that block.
Playing the game for real
K-Lines LNG UK has now moved to stage two of its “K”ARE project with Propel’s help and is introducing a new tool to ensure an increased safety culture they have created remains alive. Staff members in the office wear yellow wrist bands, highlighting a part of the eight stages that they have identified as crucial for better safety attitude.
The company has also taken to gamification, using an interactive video game to allow shipboard staff to effectively make bad decisions in a safe environment.
The game is similar to one of those first person “shoot-em up” games where the the game is seen from the players point of view as he or she makes decisions. Get it wrong and your LNG tanker or other vessel may be grounded, get it right and you gain points and move on. In this way it is safe to make a potentially dangerous mistake while at work on the ship. There is also potential to make the game multiplayer and “live.”
The company knows that while giving an officer or crew member a training course, a training book will educate them, there needs to be continuous focus on keeping the safety culture alive. That is why “K”ARE project manager Soeun Choi has been visiting the vessels to build up the new safety culture and ensure continuity.
Hence the gamification. With crews increasingly online and aware of video games this kind of decision making simulation is a natural progression.
“We are using digital tools to change culture” says Svendsen. “This makes it easier for them to see and talk about situations before they become serious”.