What Safety Critical Operations Failed with the Costa Concordia?

One of the most common failings in safety-critical operations is an inability or unwillingness on the part of leaders to listen to perspectives from people lower down the reporting line, according to Nippin Anand, CEO of Novellus Solutions.

This is a “huge problem” in many organisations, said Anand, who pointed examples of this including the Boeing 737 MAX crashes as well as the Volkswagen emissions scandal.

“The key factor I see is that we are not really paying attention to perspectives and voices that are coming from below,” he said.

“I think we have little time and space for that. There is a single-minded focus on shareholder value, which is accompanied by a compliance-based approach to everything.”

A combination of these factors do not allow for consideration of differing perspectives, according to Anand, and he said many leaders (and human beings in general) haven’t come to terms with really listening to different perspectives.

“That’s the starting point and the most difficult thing in most organisations,” said Anand.

Another important consideration is what communication channels are available to listen to employees who are further down the reporting line.

“Some companies would say that we have many channels. But the question I would ask is, ‘how would you know those channels are actually working?’” said Anand, who is a licensed master mariner and an internationally recognised specialist in human factors and safety management.

He said the case of the Costa Concordia was a classic example of when conflicting and competing goals of an organisation are pushed down to the last person in the chain.

On 12 January 2012, the passenger ship Costa Concordia collided with rocks and capsized off the island of Giglio, Italy, resulting in the loss of 32 lives.

While it may sometimes be enticing to get closer to a shore to enable a better view and experience for passengers, Anand said there also needs to be a strengthening of control mechanisms in order to enable a safe transit close to the shore.

“Or do you just create safety management systems and control interventions for the sake of controlling the last person in the chain?” he said.

“In the case of Costa Concordia, we see there were conflicts within the system and different departments with different goals, and these were pushed onto the last person.

“The sales department is pushing you in one direction. Chances are the HR department has another view, and the safety department has another one.”

This approach is counterproductive as Anand said it leads to the creation of unrealistic controls, which can impact people in a way that subsequently leads to mental health issues at work.

With major incidents such as the Costa Concordia, Anand also said organisations need to allow to time for reflection and thinking in order to learn from such incidents.

“When you look deeper into these accidents, you find something very interesting in that there is actually very little learning in terms of transmitting this information at the organisational level to get people to engage and talk about those things and learn from them,” he said.

“We’re not very good at that. We try and avoid those discussions as much as possible, and this also comes down to a strong blame-oriented accident investigation process – and investigators do go for that route.

“That’s the default we have to date. And the reason for that is to help preserve order in society, and Costa Concordia is a classic example of finding a scapegoat to blame – in this case the captain became the one main cause of the accident.”

Organisations must understand there is little meaningful organisational learning value that will come from this approach, and Anand said there are better ways to learn.

“Those other ways will come from low threshold events that happen all the time: near misses hazard observations, non-compliances, but also as Hollagnel would say when things go well just questioning all the time why things are going well,” he said.

Article originally published by the Australian Institute of Health and Safety.

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