Who should lead the organisational change?

Peter Gibb All Members, Public

In January 2015 the car carrier Hoegh Osaka capsized after leaving Southampton.

The Marine Accident Investigation Branch (MAIB) opened an investigation into the accident. Its report into the incident was published on 17 March 2016.

(Extract from Wikipedia article)
“The investigation found that plans for the loading of the cargo had not been changed despite the change in itinerary. No calculation of the vessel’s stability had been made, a practice found to be common across many operators’ fleets. The weight of cargo on board was underestimated, the actual weight being 265 tonnes greater than that calculated to be on board. The investigation found that the cargo had shifted as a result of the the ship listing; it was not the cause of the list. The ship’s ballast water system was not fully serviceable, with all but one of the gauges for each ballast tank being unserviceable, a situation that had existed since at least July 2014. It was possible to take manual readings of the amount of water in each ballast tank. The chief officer was in the habit of calculating how much water was transferred between tanks by timing the pumps and using their capacity of 7 tonnes per minute. Some of the straps used to secure the cargo to the deck were found not to meet regulations in force at the time, only being half as strong as they should have been.”

As far as I can see in the MAIB report, there is not one conclusion or recommendation or action taken that can be attributed to the company management. If one doesn’t understand Human Factors (HF) or Crew Resource Management (CRM) or whatever else you want to call it, you would think that the only place that can do anything to prevent this occurring again is onboard the vessels. In the report it even states that one of the actions taken by the ship management company has been to issue an advisory notice to all of its masters and crews, including for “the Masters and crew to not come under any perceived commercial pressure”. Surely this is the wrong way around? What can Masters and crew do, to not come under any perceived pressure?

It should be “the company should not put the Masters and crew under any ‘commercial pressure’ that might be perceived as such”.

‘I hope you have found this article useful. It has given me another valuable example to use with my clients, when examining how they could implement changes in their organisation in such a way that helps them to avoid making mistakes.’

If you want to know more about Human Factors please don’t hesitate to email me. I will be doing a workshop on behalf of the Chartered Management Institute this summer on the subject of “Human Factors – what is it and why is it important to business growth?” Check the calendar or petergibb(Replace this parenthesis with the @ sign)safenett.com to be added to the invitation list


About the Author …
peter gibb round Peter Gibb | SafeNett
Peter is director of SafeNett Ltd. He is a member of the Chartered Management Institute, and a founder member of Business and Management Wessex. Peter has a number of local and international clients with whom he works as a facilitator, trainer and coach, helping individuals and teams identify and implement excellence. When asked what he ‘actually’ does, his answer was “training mistakes out of people”!
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