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Sociological factors influencing the practice of incident reporting: the case of the shipping industry Syamantak BHATTACHARYA December 2008 present Lecturer, International Shipping and Logistics Research Centre for Maritime Logistics, Economics and Finance School of Management, Plymouth Business School, University of Plymouth S.Bhattacharya@plymouth.ac.uk Dr. S. Bhattacharya Lecturer International Shipping and Logistics Group Research Centre for Maritime Logistics, Economics and Finance School of Management University of Plymouth Drake Circus, Plymouth Devon PL4 8AA, UK Tel +44 (0)1752 585 662 Email s.bhattacharya@plymouth.ac.uk www.plymouth.ac.uk

E-mail Address Full International contact details

Brief professional biography

Syamantak Bhattacharya is a Lecturer in the Business School of University of Plymouth where he teaches Port Policy and Management. His research interest lies in Globalisation, State regulation and management of occupational health and safety, Employment practices, Industrial relations and Labour. In 2009 he completed his Ph.D. study on the impact of the ISM Code on the management of occupational health and safety in the maritime industry from the Seafarers International Research Centre in Cardiff University with full funding from the Nippon Foundation. He has presented several papers in international academic and professional conferences, such as WES and IAME. Prior to moving to academia he held senior managerial position in a private shipping company in Singapore. Before settling ashore he sailed on international oil tankers for over 13 years including for two years as a shipcaptain. Syamantak can be contacted at: s.bhattacharya@plymouth.ac.uk

Title Sociological factors influencing the practice of incident reporting: the case of the shipping industry.

Purpose The purpose of the paper is to present the ways in which underlying social and organisational factors and employment relations underpin the practice of incident reporting in the international shipping industry.

Design/methodology/approach It uses qualitative case study method involving fieldtrips to two shipping organisations and sailing on research voyages on two ships of each of the organisations. It draws empirical data using semi-structured interviews, notes from fieldwork observations and documentary analysis of company policies, procedures and practices.

Findings The paper reveals that in the two companies studied there were significant gaps between the policy and practice of incident reporting, which were present primarily due to the employees fear of losing jobs. It argues that these findings were manifestations of deeper sociological issues and organisational weaknesses in the shipping industry. In particular ineffective regulatory infrastructure, weak employment practices, the absence of trade union support and lack of organisational trust were the key underlying concerns which made incident reporting notably ineffective in the shipping context.

Originality/value While the weaknesses in the practice of incident reporting in the shipping industry were reported in the past, previous studies did not offer further explanations. This paper addresses the gap and provides another illustration of the need for looking into deeper sociological underpinnings for practices in the workplace. The author also hopes that the study will have a positive impact on the policy makers in the shipping industry.

Keywords: Incident report; shipping industry; employment relations; fear of blame; trade union; organisational trust.

Paper category: Research Paper

Sociological factors influencing the practice of incident reporting

The case of the shipping industry

1. Introduction The significance of incident reporting stems from the notion that safeguarding workers from workplace hazards is a continuous learning process. It is thus considered as one of the central elements in the management of workplace health and safety (see HSE, 1997). It enables organisations to learn lessons from an incident by analysing its underlying causal factors so that similar incidents may be prevented in the future.

In the shipping industry incident reporting is a regulatory obligation. The International Safety Management (ISM) Code, which is a piece of globally applicable legislation introduced to the industry in 1998, obliges the managers in shipping companies to ensure that shipboard incidents are reported, investigated and analysed, and subsequently the corrective actions are implemented with the objective to improve shipboard safety (IMO, 2002).

However, reports from the industry indicate that the practice of incident reporting is ineffective as it suffers from considerable underreporting. Maritime news articles, for instance, point out that seafarers fear of being held responsible for the incidents that they report results in significant underreporting (see, for instance, Sagen, 2006). Maritime accident investigation reports and other anecdotal evidences also indicate that such blame culture in the industry is the main hindering factor. While such views and reports are useful to get an overall impression of the practice of incident reporting in the shipping industry, there is a lack of academic study in the industry investigating how social relations of employment and organisational factors underpin the operational aspects of incident reporting.

This paper aims to address this gap by discussing the empirical evidence of the practice of incident reporting and analysing it in terms of the social relations between the seafarers on board ships and their managers in shore-based management offices of the same organisations. It also intends to place the finding in the context of employment relations affecting seafarers, as well as in terms of the wider context of the organisation and relations of employment in the shipping industry.

2. Incident & Near-miss reporting Heinrich (1931) theorised that the underlying causes for incidents which result in near-miss occurrences and those which unfortunately lead to more serious consequences such as fatalities and injuries are similar. Therefore analysing the causes of near-miss occurrences have equally significant benefits. In support of this argument Wright and van der Schaaf (2004) highlighted that as the number of workplace incidents, such as fatalities and injuries, are usually low it is important to investigate the near-miss incidents with the same fervour. The relatively greater number of near-miss incidents give the opportunity to get a more statistically reliable result and also give opportunity to investigate the root causes of a greater number of cases. The authors also pointed out that such an approach encourages a preventative attitude towards protecting occupational health and safety. A number of more recent empirical works (see for example Powell et al., 2007 and Alamgir et al., 2009) have supported this view. In the shipping context too the ISM Code follows similar arguments and identifies the importance of reporting and analysing near-miss cases with the same dedication as incidents.

Based on the common cause theory proposed by Heinrich (1931) an accident triangle ratio relationship between the different severities of incidents, such as fatality, minor injury and nearmiss occurrence have been another popular development in this field. It is now common to find safety literatures discussing that a single case of fatality equates to a greater number of minor 4

injury cases and to a much higher number of non-injury or near-miss cases. The UK Health and Safety Executive, for instance, states that when one major incident or over three-day lost-time injury occurs in an organisation it is likely that in the same organisation the workers suffer from around seven minor injury cases and around another 189 non-injury or near-miss cases (HSE, 1997, p. 8). However, there is a debate on the validity of such relationship. It questions the legitimacy of such claim and argues that the objective of reporting and analysing near-miss incident reports should be confined to the common cause theory and not extended to the ratio relationship (see Wright and van der Schaaf, 2004).

Even though incident reporting is viewed as an important element to safeguard workplace health and safety, studies indicate a number of concerns in its implementation. Research conducted in different industries such as steel, airline and railways have revealed a high case of underreporting. Powell et al. (1971) in their review of 2000 cases of industrial injuries and incidents revealed the extent of the problem. By observing reportable cases and comparing them with the number of cases actually reported by the workers, the authors estimated that as high as 70 per cent of the cases are not reported. Moreover it is also revealed that the rate of underreporting is inconsistent across industries. An analysis of the UK Labour Force Survey by Nichols (1997, p. 201) estimated that while in the UK agriculture sector the rate of underreporting of personal injuries is as high as 85 per cent, the corresponding figure in the energy sector is at a moderate 30 per cent.

Studies conducted in different industries show that the most common cause for underreporting is located in workers fear of the consequences of reporting. The workers apprehend that reporting of an incident or near-miss occurrence would bring them to disrepute or subject them to direct or indirect disciplinary actions because the managers would assume that they were responsible for it (see for example van der Schaaf and Kanse, 2004). 5

For instance, in the health care sector Lawton and Parkers (2002) work revealed significant underreporting and showed that incidents were more commonly reported only when patients were harmed, whereas, when incidents were recovered without causing harm to the patients the hospital staff showed reluctance to report. By analysing further the authors concluded that reporting was largely driven by a culture of blame and fear of litigation.

In the aviation sector, too, Elwell (1995) and OLeary and Chappell (1996) found a high number of cases of underreporting of operator errors. Their studies showed that as flight operators felt embarrassed to report their errors and feared that they would be punished as a result of reporting they chose not to report them.

The common concern across the industries thus is workers fear of the consequences of reporting. This as Carroll (1998) pointed out shows that underreporting is more common when the employees perceive that reporting of incidents would lead to blaming and disciplining particular individuals which is intended to encourage accountability (1998, p. 713).

To address this concern Reason (1997) is among those who suggested that management should facilitate anonymous reporting and offer indemnity against disciplinary proceedings to those who report incidents and near-miss occurrences. It has been evidenced in a number of empirical studies. In the area of health-care, research conducted by Stump (2000) showed that anonymous paper-based incident reporting system when introduced to an American hospital was a major success. Within the first six months of bringing in this change to the reporting procedure, the number of reported cases increased by more than five times.

The accounts from the shipping industry also suggest the presence of an industry-wide culture of blame. The 2001 annual report from the Maritime Accident Investigating Branch (MAIB) UK, for example, summed it up in its analysis in which it highlighted that seafarers routinely fail to report because regardless of the nature of incidents they fear of being blamed for reporting them. It stated that throughout the industry, mariners are genuinely frightened that if they were known to be reporting safety deficiencies, they would almost certainly lose their jobs (MAIB, 2001, p. 9).

The underlying factors leading to such fear, however, have not been adequately discussed in the context of the shipping industry. This paper attempts to investigate that by analysing its practice. For a better appreciation of the practice, first it is important to contextualise the research. In the following section the key features of the industry which influence the organisational and employment relations are discussed.

3. The international shipping industry: context of the study It is argued that while economic globalisation affects workplaces in industries around the world, its impacts in the shipping context are significantly more striking. Alderton and Winchester (2002) pointed out that regulating this industry has always been a challenging task primarily due to the remote location of the workplace. But this challenge was significantly exacerbated by the consequences of increased free market capitalism assisted by State deregulation. Till around the mid 1960s it was a common practice for the ship-owners to register their ships in the country of their domicile. That also led to employing local seafarers giving rise to a common national identity. Such countries are termed the Traditional Maritime Nations (TMN) and typically include UK, Norway and Greece. But since the 1970s increased market freedom allowed the ship-owners to shift the registry of their ships to countries, such as Liberia and Panama, which are commonly known as the Flags of Convenience (FOC). They chose to move from TMN to 7

FOC because the latter offered comparatively relaxed regulatory conditions. It meant that the ship-owners were no longer obliged to maintain their ships to a high standard.

The relaxed regulatory requirement on shipboard labour was an even bigger incentive for the ship-owners. This encouraged them to source seafarers from new labour supply nations, such as Philippines and countries in the Eastern Europe, on comparatively lower salaries (Alderton et al, 2004; BIMCO/ISF Manpower Study, 2005). Moreover they engaged in downsizing of shipboard staff, and offering them temporary contractual employment and relatively inferior working conditions. Studies have revealed how in the last 30 years shipboard crew have dramatically reduced and in some cases the peripheral yet important staffs such as trainees were completely withdrawn (Beth et al., 1984; Bloor et al., 2004).

As the ship-owners sourced seafarers from the wider labour market under poor regulatory oversight they offered rudimentary employment condition. In particular it involved short-term contracts which meant that the ship-owners enjoyed minimal obligation towards the seafarers and held no responsibility for their future employability. A large scale survey of 4,525 seafarers conducted by the International Labour Organisation in 2001 revealed that the majority of seafarers worked on contracts covering a single voyage or tour of duty, the length of which was typically between five and 12 months (ILO, 2001, p. 64). From the seafarers perspective such short-term contractual employment potentially made them insecure about their next employment (Alderton et al., 2004). Thus, such unprecedented freedom gained by the ship-owners allowed them to choose regulators and exploit the global labour market. It produced a vacuum in the regulatory front in the shipping industry and among other developments undermined the employment relations in the industry (DeSombre, 2000).

Moreover, such development which geographically dispersed the labour, capital and regulatory base left the industry much fragmented. It became common to find a ship registered in country A, owned by the ship-owner domiciled in country B, operated by seafarers from countries C, D and E, and trading between countries F and G. Among other impacts it undermined the scope of trade union to engage in collective bargaining or represent the seafarers or act as an intermediary between them and their managers on employment issues. Their absence deprived the seafarers from forming into an organised workforce and thus made it even harder for them to approach the managers collectively with their work related concerns (DeSombre, 2006; Lillie, 2004).

4. Research Method In order to understand the practice of incident reporting and analysing them in the social, organisational and employment relations context more effectively this study took a qualitative case study approach using semi-structured interviews as the main data collection technique and supplemented by the fieldwork observation and documentary analysis.

The benefits of case study using a qualitative line of inquiry to reveal the underlying factors in the context of a workplace have been widely argued. Whipp (1998), for instance, pointed out that each workplace needs to be looked at separately and thoroughly by getting under the skin of the organisation because an apparent single organisational problem often has its roots extended to a number of social issues. The hidden features of employee relations thus can only be revealed if detailed attention is paid to the individual cases. Following this argument, Kochan (1998) also pointed out that for a full appraisal of the social elements within a workplace or an industrial setting the case study approach is most suited.

The cases studies were conducted in two international shipping companies whose land-based management offices were both located in Europe. The larger of the two was a branch office of a 9

global ship-management company and operated around 25 tankers and dry-cargo ships around the world. The other specialised in a niche market of transporting petroleum oil products and operated around 10 ships in the European waters. Both fleets registered their ships with several flags, some with TMN while others with FOC. In each office between 30 and 40 people were employed and from among them 10 managers, who were directly responsible for administering the fleet in different capacities including for acting on the incidents and near-misses reported from their fleet, were interviewed. On an average these interviews lasted for an hour while the whole data collection process in each office took around five days. Besides interviewing, the company policy and procedures on incident and near-miss reporting and related correspondence between the management and ships were also studied.

Subsequent to the land-based part of the data collection, research voyages were undertaken on board two tankers from each company all four of which were registered with FOC. On an average 12 days were spent on each ship during which period a total of 67 seafarers were interviewed; 43 of them were from the two ships of the larger of the two organisations while 24 were from the other. In addition overt observation of their shipboard activities including daily maintenance work, navigational practice and safety drills was also conducted. The majority of the analysis for this study [1], however, is drawn from the interviews of 16 senior officers four from each ship. They formed the shipboard management team which was responsible for reporting incidents and near-misses to the shore-based managers. It comprised of the captain, who is the overall responsible person for the ship and its crew and particularly in-charge of communicating shipboard incidents and near-misses to the managers; the chief officer, who is the captains deputy and in-charge of the ships stability and carriage of cargo; the chief engineer, who is in-charge of shipboard machineries and all engineering staffs; and the second engineer, who is deputy to the chief engineer and oversees the daily operation of all machineries.

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Both organisations were in the shipping business for long and were well established. They operated safety management system which included incident reporting even from long before the ISM Code was made mandatory. The clients of the two shipping companies included the internationally known Oil Majors, such as Shell and Chevron. The four ships on which I conducted the study regularly traded Oil Majors cargo. It is widely believed in the industry (see Sagen, 2005) that regardless of the flag of a ship or the profile of a company, trading with Oil Majors is an indicator of high operating standard. Also, the publicly available information on safety record of the two organisations and their ships showed that their standard of safety was considerably better than the industry-wide average (see Equasis, 2007; Paris MoU, 2008).

Most interviews were recorded and later transcribed while hand-written notes were taken for those for which the participants did not give permission to record. Also a research diary was maintained in which the observations were noted. The large amount of data thus generated was transcribed and systematically coded with the help of the N-Vivo program. Around 30 codes were generated from the data which were then examined for their regularities and patterns for the purpose of identifying conceptual links and thematic guides (Coffey and Atkinson, 1996). Following that, these codes were grouped together into categories based on their common attributes which could then be discussed against the extant theories. The themes relating to the operation of incident and near-miss reporting included: (1) Complying with procedures; (2) Human failure; (3) Fear of blame; and (4) Job insecurity.

5. Findings 5.1 Policy & Procedures 11

The safety policies and procedures of both organisations were remarkably similar. They regarded incident reporting as one of the principle mechanisms to safeguard seafarers occupational health and safety. In particular, the policy statements highlighted that the purpose of operating incident reporting system was not to blame the seafarers but to use it to determine the underlying causes of each incident. They required seafarers to report all types of incidents, such as work related injuries as well as all near-miss occurrences to their managers and drew the managers attention to the importance of conducting effective analysis of the underlying causal factors and implementing the necessary changes to improve seafarers health and safety.

However, the written procedures in the two organisations did not appear to correspond with the companys no-blame policy. The examples of immediate and root causes provided in the company procedures manual instead encouraged the managers to identify the seafarers professional and personal weaknesses. The suggested immediate causes in the procedures of one of the organisations included: Failure to follow rules and regulations Failure to use personal protective equipment Failure to follow repair/maintenance instructions Influence of drug or alcohol Safety devices by-passed or inoperative

Likewise, the suggested root cause included: Inadequate Physical/Physiological Capability Inadequate Mental/Psychological Capability Lack of Knowledge Lack of skill Improper motivation 12

Moreover, both organisations also generated their own forms for reporting incidents. These required information concerning the events leading to the incident, the details of the damage or injury, the list of all persons and parties involved and the actions taken to mitigate the damage. In one of the two organisations the reporting form asked over 60 questions, most of which required either yes or no answers while in the last section of the form the questions demanded detailed account of the incidents. The questions included: Were regulations ignored to complete operation? Was the person/personnel pre-occupied with other thoughts? Were short-cuts taken? Did the person misunderstand instructions? Identity of the person authorising the work.

These questions closely resembled the suggested direct and root causes noted earlier. They indicate that for the purpose of identifying the underlying causal factors of incidents both companies placed heavy emphasis on locating seafarers flaws and weaknesses. Such approach was against the arguments presented in the research literature as discussed above. It, as Fahlbruch and Wilpert (1999) pointed out, is far too myopic because such fault-finding investigation approach diverts the attention of the management away from looking into the underlying causal factors of the reported incidents.

Furthermore, the descriptive section of the incident reporting forms required the captains to provide as much information as possible. It even demanded photographs and sketches to help explain the incident in detail. The company procedures claimed that such additional information helped them make effective insurance claims and meet the statutory requirements. The nature of the information required for reporting incidents suggests that there was limited opportunity for 13

the captains or others involved in the incidents to remain anonymous and thus subsequently face potential recrimination. It is apparent from the procedures laid out in the two organisations that the argument in favour of making the reporting of incidents anonymous (Reason, 1997) was not considered.

5.2 Lack of compliance During the interviews the managers from both companies insisted that their companys policy and procedures on incident reporting were longstanding and robust. They believed that if the system operated effectively it would make their organisation a safer place. One of the managers, for example, said: We have had it [incident reporting] since the 1980s. Reporting, analysing incidents, preparing statistics for the fleet and sending circulars to all ships are nothing new... you see, the system here is very mature.

However, most of the 20 managers interviewed shared their unequivocal disappointment in the actual practice of incident reporting pointing to the ways their seafaring colleagues failed to comply with the companys procedures. They suspected that the seafarers were holding back information on most near-miss occurrences and even on some cases of incidents. One manager in one of the companies, for example, pointed out: We do our best to implement it [incident reporting]. It is fully implemented here in the office... we have the expertise to look into the reports and dig out the root cause... statistical system... but the ship-staff dont follow everything we set rolling here we have a major problem of underreporting.

The managers further emphasised that the success of the operation of incident reporting relied entirely on the seafarers as only after they reported the incidents, could the managers get 14

involved. By extending this argument, the managers focused on persuading the seafarers to report more incidents and near-miss occurrences. Such persuasion was evident from the frequent letters and fleet circulars that were sent out by the managers to the captains urging them to send more reports.

As the managers did not have any means to know how many unreported incidents or near-miss occurrences there were, they turned to the popular accident triangle ratio relationship theory as discussed in section 2. Around 12 managers claimed in their interviews that as per the number of serious incident and injury reports which they claimed that the seafarers were compelled to report due to the seriousness of the cases the seafarers should be sending in many more reports on near-miss occurrences. They also felt that the seafarers were happy to report personal injuries or such other untoward events arising out of technical problems or mechanical breakdowns but chose not to disclose those events which could be construed as their professional failures. One senior manager carefully articulated his views and said: Their [seafarers] favourite is the obvious ones: accidents... then they report illnesses and injuries especially for which they required doctor visit and then the machinery breakdowns and finally loads of minor concerns... I feel a large portion of in-between block of operational errors mechanical issues and their faults and oversights are not reported.

These managers views coincided with studies conducted in different occupational fields. Stanhope et al. (1999), for example, conducting a retrospective review of case notes of 500 childbirths in two London obstetric units identified 196 cases of reportable incidents in accordance with the hospitals protocols. They found that however only less than a quarter of these cases were reported by the staff. Moreover, when the authors grouped the cases into

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serious, moderate and minor events, they found that the staff reported nearly half the serious incidents, only around quarter of the moderate events and just 15 per cent of the minor events.

While most managers pointed out that due to their persuasion they were beginning to receive more and more cases on near-miss occurrences, some were sceptical about this apparent success of their campaign. This latter group emphasised that although the lower section of the accident pyramid was beginning to swell, it was actually a case of manipulated reporting. They pointed out that ship-captains were sending more and more reports which were typical examples of supervisory issues but not those which for instance would identify shipboard operational failure. One manager in one company, for example, stated: All near-miss reports that our ships send are like 2nd officer seen on deck without safety shoes if he had slipped he would have broken his legs. I get like this all the time... we dont want these as these are disciplinary issues. There are more serious issues happening all the time, such as: mooring rope-parting, slips and trips, close quarter situations [in navigation]... but we never get to know of them.

On the whole the managers concluded that despite their efforts the reporting practice in their organisation was ineffective. They attributed the failure to their seafaring colleagues noncompliance with company procedures.

5.3 Fear of Blame The onboard senior officers however presented a completely different view on the allegation of non-compliance of the company procedures on incident reporting. While they acknowledged that they underreported, the reason that they presented for it was markedly different. In their interviews the senior officers clearly expressed their deep fear of the consequences of reporting incidents. They revealed that for every reported incident the managers demanded an explanation 16

and blamed the onboard staff. In the interviews the officers explained that after every reporting they were subjected to a series of intimidating interrogation from their managers seeking further detail of the events. An analysis of the paper copy of e-mail correspondence between the managers and senior officers of the last five reports on one of the ships corroborated this claim. These appeared as faultfinding exercises in which the managers established accountability for each event. Similar expressions were also captured in the interviews. One senior engineer, for example, expressed his anxiety about being blamed by the managers for an incident for which he felt no responsibility. He said: On this ship I had near death accident but it was not my fault. But they [managers] are asking for many explanations. After every reporting they keep asking why this, why that, and why like that that there is a tendency to locate the guilty person... In their analysis they blamed that I did not work as per the procedures and said that I did not have the necessary skills and leadership qualities maybe I am on their hit list ...if I can avoid I wouldnt report the next time.

In the same way, a captain remarked how reporting of incidents could also put their colleagues professional reputations at stake and explained his dilemma with a recent example. He mentioned how on one occasion while navigating through a busy channel an engineer made an error of judgement and disrupted the ships power supply. Subsequently, the ship lost control and came perilously close to colliding with another ship. By recollecting this near-miss occurrence, the captain said: It was very dangerous and should never have happened... it was definitely an incident to learn from but I did not report it because I knew that after reporting the managers would inquire and find out who that engineer was. Then they would have singled him out and spoilt his career.

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This contradiction of a no-blame approach between the incident reporting policy and practice needs further clarification. On probing this debate around half of the managers in their interviews were frank enough to admit to their ineffective no-blame initiative. They revealed that seafarers fear of being questioned about the reported incidents and subsequently being blamed was understandable. One manager, for example, explained: No blame culture is present only in theory it is very difficult we try but I must admit we fail more often than we should. It is a known problem there is all this planned approaches to incident reporting but I will be honest, it differs from reality.

This also corroborates the finding of Anderson et al.s (2003, pp. 180-190) study on the effectiveness of the implementation of the ISM Code. By enquiring the ship managers views from around 200 organisations through questionnaire survey the authors revealed that 60 per cent of the managers believed that their seafaring colleagues were reluctant to report. They felt that the seafarers were mainly concerned that by reporting they would either lose their jobs or that it would have a negative influence in their career.

The managers who were willing to discuss this issue in their interviews further revealed that the seafarers fears were in fact well grounded. They admitted that it was hard for them to disregard the contents of incident reports or near-miss occurrences when judging the professional performance of the seafarers, especially the senior officers. One of them used the example of seafarers promotion and said: No matter how much I try, I cannot promote a chief officer to captain who had had more than his share of accidents. Can you? Not that we wish to spy on them through this reports, it is just that I would be uneasy... we tend to overlook it for a regular reemployment but promotion is different I must admit.

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Regardless of how the managers viewed the purpose of no-blame culture in their organisation, what came out strongly from the analysis was their belief that shipboard incidents, injuries and near-misses were the direct results of seafarers lack of skill and training and their rule-breaking attitude. They appeared convinced that issues such as poor quality of seafarers training, their apathy towards work and their inherent tendency to take short-cuts from the companys stated operating procedure were the primary concerns. Such preconceived notion had an overarching influence on how the managers responded to the reported incidents. This was evident from the interview of all managers, one of who, for example, said: Look what we really want is a good quality crew, especially competent senior officers. But we dont get many of them. If you study our records [of incidents and near-miss occurrences] youll find that true; all accidents are because of seafarers lack of training or simply when they fail to follow our procedures.

This presented a paradox for the managers. On the one hand they were aware of the importance of exonerating seafarers from the fear of blame in order to promote reporting and knew that the purpose of reporting was to learn from the mistakes by locating the underlying reasons and progressively improving occupational health and safety in the companies. Yet, on the other hand, for the purpose of safeguarding the ship from deviant or under-trained seafarers they strongly believed in apportioning blame to individual seafarers. This contradiction was well articulated by one manager, who said: As a superintendent we are fire-fighters, we need to know the cause of the problems, which is the people in most cases... [Although] we strongly recognise that we are not here to blame them, we are here to analyse the reports and learn from the root causes, but I am sorry, my first job is to find what's going wrong... perhaps someone needs some extra training... Its a catch 22 situation, I am afraid.

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The archived records of the analysis of incident report in the two management offices also verified how nearly all analyses were concluded by identifying flaws with seafarers skills and attitudes. The deep-rooted cause of the 50 most recent incidents and near-miss occurrences reported across the two companies showed that in 42 of such instances the managers identified one or more forms of shortcomings on the part of their seafaring colleagues. The three most commonly found immediate causes were: seafarers failure to follow SMS instructions seafarers failure to use Personal Protective Equipment (PPE) properly seafarers improper position for carrying out task

While the three most commonly identified root causes were: lack of seafarers skill lack of seafarers mental capacity inadequate leadership/ supervision on ships

On most reports, the managers also stated that the seafarers needed further operational training and improve their safety behaviour which attest their preconceived attitude towards seafarers shortcomings.

The managers views presented in their interviews and what was suggested as the probable direct and root causes in the companys operating procedures and also the way the questions in the incident reporting form were designed have a close analogy with what were identified in practice. The main objectives of the whole exercise of incident reporting as followed in the two organisations was heavily skewed to ascertain the inadequacies in their seafaring colleagues. While it may be possible that the seafarers genuinely failed to abide by the company procedures, it is critical to note that right from the design of the forms the managers were determined to 20

locate faults with their seafaring colleagues. Thus it can be concluded that incident reporting in the two organisations was an exclusive and deliberate tool to make the seafarers accountable for all reported incidents. This provides a partial explanation to why these managers did not consider the need for offering their seafarers anonymity or an indemnity from disciplinary proceedings.

The managers conviction that seafarers are the main causal factor for shipboard incidents draws from the notion that majority of accidents are caused by human-failure (see for example the views of Weigmann and Shappel, 2003). It was evident from their fixation to allege seafarers irrational behaviour, lack of motivation, law breaking attitude, and misapplication of good rules as the causes of shipboard incidents. The appeal in pointing to human error as the cause for accidents is not new and is also found in the more scientific literature (see for example Ellingwoods (1982) assertion of the causes of structural failure). While it may fall outside the remit of such literature to appreciate the underlying social and organisational factors of accidents, but hastily classifying ignorance, carelessness and irresponsibility as the causes of 80-90 per cent of the accidents (1982, p. 112) is a shallow interpretation and indeed misleading.

Such theory has been severely criticised by a number of authors (see Kinnersley, 1973; Mathews, 1986; Nichols 1997, pp. 61-68 for a discussion). Over the years the critiques have argued that blaming the operator just because he or she is the last link in the causal chain of incidents is a myopic approach. They highlighted that when managers subscribe to the human error theory they are prejudiced to identify the unsafe workers. The authors warned that these are not only deficient or possibly even wrong approaches to analysing incidents, but, more critically, they compel investigators to deviate from identifying the crucial underlying organisational and social factors causing the incidents, such as the fear of reporting due to, for instance, the pressures of production.

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6. Discussion The findings reveal that the practice of incident reporting differed considerably from what was intended. Based on these analyses the discussion now brings to light the ways in which underlying organisational context influence the practice of incident reporting in the two organisations. In particular it discusses how the consequences of seafarers employment practices, trade union influence and organisational trust play significant roles.

6.1 Job Security The senior officers in the first company were employed on a short term temporary contract. On an average they worked for five months and went on unpaid leave for three months. Prior to every new assignment these officers, who mostly came from the countries in the Eastern Europe, were required to sign on a new contract. As pointed out earlier in the ILO study (2001) and later confirmed in other studies (see Kahveci and Nichols, 2006) seafarers engagement on fixed short-term contracts was not an exclusive feature in these two organisations.

Such employment practice, however, was not without consequence. It made the seafarers anxious about the lack of continuous employability. Consequently they tended to prioritise ways to keep their jobs and secure their future employment. Given the blame culture that the two organisations operated in, opting to be forthright about reporting incidents and near-miss occurrences was not considered prudent. This corroborates Quinlans (1999) argument on how precarious employment coerces workers to accept inferior working conditions, and among other impacts impairs their ability to communicate to their managers and negotiate for a better workplace.

The arrangement in the second company with regard to the employment of the senior officers, however, was different. It employed North West European nationals on a permanent basis on a 22

fixed work schedule which required them to work on board for around eight weeks in a 12-week period. During leave they were paid and in most cases these officers returned to work on the same ships.

Although such arrangement appears to offer these senior officers permanent employment, surprisingly, they too felt vulnerable about keeping their jobs. In their interviews these officers revealed their fear of being made redundant. They felt that the managers were planning to replace them by their counterparts from the East Europe who draw comparatively lower wages. To the senior officers this loomed as a permanent threat which is why they felt that they had to exercise greater caution in their day-to-day work including when deciding on which incidents to report or whether to report at all. One senior engineer, for instance, in his interview said: We are constantly worried as we keep seeing more and more engineers [from X nation] taking over [our jobs]... tomorrow I may be gone now the time has come for me to stay quietly, keep a low profile and of course not draw anyones attention by reporting an accident or something.

This was not a mere speculation by these senior officers. During the interviews the managers too acknowledged that their organisation was gradually replacing all West European senior officers. The BIMCO/ISF Manpower Study (2005) categorically identified this as the trend. It illustrated the way ship-owners globally are replacing seafarers from West Europe, North America and Japan by their counterparts from countries in the Far East, Indian sub-continent and East Europe.

Thus although the two groups of senior officers were employed under different types of employment contract their common fear was the lack of job security. They both felt equally dispensable. As identified earlier (ILO, 2001, pp. 31-48) the explanation to this in part lies in the

23

widespread laissez-faire approach adopted in the shipping industry which resulted in significant restructuring of its labour market.

6.2 Trade Union Studies show that active trade union involvement can play a major mitigating role in such employment conditions. Bohle and Quinlan (2000, pp. 438-442), for example, reviewing a wide body of literature on the factors supporting effective management of occupational health and safety revealed that trade unions help to organise the workforce and thus make them more confident to communicate workplace concerns including reporting of incidents to the managers.

Lewchuk et al.s (1996) empirical work on the impacts of workplace joint health and safety committee in Canada found that when such committees were supported by the trade unions they were more effective in lowering workplace injuries. They concluded that with effective union involvement there is increased likelihood for workers to communicate risk and present their views and concerns to the managers.

On the other hand, without the support from trade unions, workers fears and concerns about job security are more pronounced. Without the presence of active trade union they fear having no protection from managements decision on redundancy and such matters of employment relations (Turnbull and Waas, 2000).

There is evidence that suggests that trade union involvement needs to be supported by legislations as it is only then that its impacts are most effective. Walters (2006) in his discussion on worker representation in UK concluded that such regulatory provisions offer employees the basic floor of rights (2006, p. 104) to take support from the trade union and present their views and concerns in a representative manner. 24

However, unfortunately, the shipping industry in its fragmented state neither has any such regulatory provision nor does it enjoy the benefits of effective trade union support. This study showed that in both organisations trade union was considered as an external entity that could not intervene in the internal matters. A crewing manager of one of the organisations, for example, expressed the following which is the general appreciation of how the managers perceived trade union organisations. He said: There is a bit of presence of X Union [of a particular country] where they only discuss the wage scale... I can't imagine that they have any other role to be honest... on ships, we sometimes get the ITF Inspectors but that's about it.

The lack of an effective trade union was also evident from the seafarers perspective. In one typical response, an officer from one of the case studies mentioned: We dont know who they [the trade unions] are. Our union dues are deducted from our salaries and we receive a magazine in return... I personally have never met anyone.

The void and its consequences is aptly summarised by Lillie (2006) who pointed out that the changes to the shipping regulatory, ownership and labour nexus especially since the 1970s have individualised the seafaring labour. Without any effective regulation on the collective representation of seafarers and the lack of trade union support it has considerably weakened their ability to present their concerns to the managers.

6.3 Organisational Trust Studies also show that a relationship of trust between managers and workers benefits workplace operation including reporting of incidents. In a classical literature Beyond Contract: Work, Power and Trust Relations, Fox (1974) showed that the level of workers contribution in their job 25

is largely a reflection of the amount of trust their employers place on them. A high-level of trust from employers which is typically characterised by managers showing long-term obligations towards their workers including looking into their welfare, encourages the workers to develop a personal commitment at work. Such relationship leads to the convergence of the organisations and employees goals. On the other hand, a low-level of trust offered by employers encourages workers to measure their contribution centred on the idea of economic exchange (see Blau, 1964). It exhibits divergent interest between workers and managers in which both parties fulfil their short-term agendas. In such relationships, workers are typically given limited leeway and asked to comply with the managers specific work requirements. Such low-trust relationships between managers and workers generally result in both workers and employers limiting their obligations to the contractual requirements.

In the case of the two organisations studied the findings consistently exhibited a low level of trust between the managers and seafarers. For instance, it showed that the managers refused to trust their seafaring colleagues on the incident and near-miss reports. They felt that the seafarers were breaking rules as they were deliberately not complying with the companys policies and procedures and even falsifying the incident reports. The seafarers response reflected this lowtrust environment. They believed that the managers were likely to cause them harm and use the reports against their interest and were thus sceptical about the incident reporting system.

From this discussion it can be debated that the chances of seafarers to provide the level of intimate detail that the managers expected in the incident reporting system could be greater if there was a high-trust relationship between them. Arguably for the purpose of effective incident reporting a high-trust work environment is of major relevance in the shipping sector particularly because of the lack of other forms of support available to the seafarers. The explanations to the lack of trust are partially located in the nature of seafarers employment relations. Slovic (1999, 26

p. 697) in his work on factors affecting social construction of risk, pointed out that trust-building is one of the most fragile elements of human relationship which requires a long period to develop but can be destroyed in an instant. The senior officers work and leave arrangement in the two organisations as such did not help them build a relationship of trust with their managers. In both setups the officers intermittent work schedule along with the short-term contract in the case of the first organisation was as such not conducive to trust building.

7. Conclusion The study set out to identify the underlying factors affecting the practice of incident reporting in the shipping context. It revealed a significant gap between its principles and the way it was implemented in practice. The senior officers fear of losing job was the major contributing factor which caused this gap. This finding however is not unique as the practices exhibited are common with what is reported in studies from other industries. However, the discussion revealed that in the shipping context incident reporting is particularly challenging because the organisational and social supports which are considered as prerequisites for effective incident reporting were largely absent. The combination of weak employment practices, the void in the regulatory steer for representative participation from seafarers, the absence of trade union support severely limited the scope for effective implementation of incident reporting system in the shipping industry.

Furthermore, it is also important to note that the managers prejudice against rule-breaking and poorly trained seafarers made the problem insurmountable. Such attitude resulted in a deeply embedded low-trust relationship between the managers and senior officers which further exacerbated the concern. These multifaceted causal features thus arguably make effective incident reporting in the shipping context an exceptionally challenging task.

27

Admittedly the study suffers from certain weaknesses. The one that was most notable was the case study methodology. While it followed its principles in terms of selection it can be argued that the two organisations studied were the examples from the better end of the shipping industry. Their regular business with the Oil Major companies and their above average safety records are such indicators. Thus, it is possible that although the general concerns with reporting of incidents were identified, there are additional challenges faced by other organisations which are not captured in this study. However, arguably this methodology is also the strength of this study as it helped locate deep theoretical understanding of the underlying issues of incident reporting which outweighs the acknowledged limitations of the representativeness of the case study approach.

Notes: 1. This paper is derived from a wider study which investigated the impact of the ISM Code in the management of occupational health and safety in the shipping industry.

References Alamgir, H., Yu, S., Gorman, E., Ngan, K. and Guzman, J. (2009), Near Miss and Minor Occupational Injury: Does It Share a Common Causal Pathway With Major Injury?, American Journal of Industrial Medicine, Vol. 52 No. 1, pp. 69-75. Alderton, T. and Winchester, N. (2002), Globalisation and de-regulation in the maritime industry, Marine Policy, Vol. 26 No. 1, pp. 35-43. Alderton, T., Bloor, M., Kahveci, E., Lane, T., Sampson, H., Thomas, M., Winchester, N., Wu, B. and Zhao, M. (2004), The Global Seafarer: Living and Working Conditions in a Globalised Industry. Geneva, International Labour Office. Anderson, P., Nicholls, S., Wright, J. and Noonan, S. (2003), Cracking the Code: The Relevance of the ISM Code and Its Impact on Shipping Practices, The Nautical Institute, London. 28

Beth, H. L., Hader, A. and Kappel, R. (1984), 25 Years of World Shipping. London: Fairplay Publication Ltd. BIMCO/ISF (2005), BIMCO/ISF Manpower Update 2005, Institute for Employment Research, University of Warwick. Blau, P. (1964), Exchange and Power in Social Life, Wiley & Sons, New York. Bloor, M., Pentsov, D., Levi, M. and Horlick-Jones, T. (2004), Problems of global governance of seafarers health and safety, Cardiff: SIRC. Bohle, P. and Quinlan, M. (2000), Managing Occupational Health and Safety: A Multidisciplinary Approach, Macmillan Publishers, South Yarra. Carroll, J. S. (1998), Organizational learning activities in high-hazard industries: the logics underlying self-analysis, Journal of Management Studies, Vol. 35 No. 6, pp. 699-717. Coffey, A. and Atkinson, P. (1996) Making Sense of Qualitative Data: Complementary Research Strategies. London: Sage Publications. DeSombre, E. R. (2006), Flagging Standards: Globalization and Environmental, Safety, and Labour Regulations at Sea, MIT Press, Cambridge, MA. Ellingwood, B.R. (1992), Probabilistic Risk Assessment, in Blockley, D. (Ed.) Engineering Safety, London: McGraw-Hill. Elwell, R.S. (1995), Self-report means under-report?, in McDonald, N., Johnston, N. and Fuller, R. (Eds.), Applications of Psychology to the Aviation System, Ashgate Publishing, Avebury, pp. 129-136. Equasis. (2007), Public Website Promoting Quality Shipping.

http://www.equasis.org/EquasisWeb/public/HomePage, (Accessed 01 May 2007). Fahlbruch, B. and Wilpert, B. (1999), System safety an emerging field for I/O psychology, in Cooper, C.L. and Robertson, I.T. (Eds.), International Review of Industrial and Organizational Psychology Vol. 14, Wiley, New York, pp. 55-93. Fox, A. (1974), Beyond Contract: Work, Power and Trust Relations, Faber and Faber, London. 29

Heinrich, H.W. (1931), Industrial Accident Prevention, McGraw Hill, New York. HSE (1997), Successful Health and Safety Management, HSE, London. ILO. (2001), The Impact on Seafarers Living and Working Conditions of Changes in the Structure of the Shipping Industry, ILO, Geneva. IMO. (2002), International Safety Management Code and Revised Guidelines on Implementation of the ISM code by Administrations, IMO, London. Kahveci, E. and Nichols, T. (2006), The Other Car Workers: Work, Organisation and Technology in the Maritime Car Carrier Industry, Palgrave Macmillan, New York. Kinnersly, P. (1973), The Hazards of Work: How to Fight Them, Pluto, London. Kochan, T.A. (1998), What is distinctive about industrial relations research?, in Whitfield, K. and Strauss, G. (Eds.), Researching the World of Work: Strategies and Methods in Studying Industrial Relations, Cornell University Press, Ithaca. Lawton, R. and Parker, D. (2002), Barriers to incident reporting in a healthcare system, Quality and Safety in Health Care, Vol. 11 No. 1, pp.15-18. Lewchuk, W., Robb, A. L., and Walters, V. (1996), The effectiveness of bill 70 and joint health and safety committees in reducing injuries at the workplace: the case of Ontario, Canadian Public Policy, Vol. 23 No. 3, pp. 225-243. Lillie, N. (2004), Global collective bargaining on flag of convenience shipping, British Journal of Industrial Relations, Vol. 42 No. 1, pp. 47-67. Lillie, N. (2006), A Global Union for Global Workers: Collective Bargaining and Regulatory Politics in Maritime Shipping, Routledge, New York. MAIB. (2001), Marine Accident Investigation Branch Annual Report 2001, available at: http://www.maib.gov.uk/cms_resources/annual%20report%202001.pdf, March 2010). Mathews, J. (1986), The myth of the careless worker, Safety in Australia, Vol. 9 No. 4, pp. 1721. 30 (accessed 27

Nichols, T. (1997), The Sociology of Industrial Injury, Mansell Publishing, London. O'Leary, M. and Chappell, S.L. (1996), Confidential incident reporting systems create vital awareness of safety problems, International Civil Aviation Organization (ICAO) Journal, Vol. 51 No. 8, pp. 1113. Paris MoU. (2006), Port State Control Annual Report, available at:

http://www.parismou.org/upload/anrep/anrep2006low.pdf. (accessed 15 August 2007). Powell, N.B., Schechtman, K.B., Riley, R.W., Guilleminault, C., Chiang, R.P. and Weaver, E.M. (2007), Sleepy Driver Near-Misses May Predict Accident Risks, Sleep, Vol. 30 No. 3, pp. 331-342. Powell, P., Hale, M., Martin, J. and Simon, M. (1971), 2000 Accidents, National Institute of Industrial Psychology, London. Quinlan, M. (1999), The implications of labour market restructuring in industrialized societies for occupational health and safety, Economic and Industrial Democracy, Vol. 20 No. 3, pp. 427-460. Reason, J. (1997), Managing the Risks of Organizational Accidents, Ashgate Publishing, Burlington. Sagen, A. (2005), Why vetting improves the ISM Code, Lloyds List, 28 April, p 7. Sagen, A. (2006), ISM makes way for self assessment, Lloyds List, 21 June, p 6. Slovic, P. (1999), Trust, emotion, sex, politics, and science: surveying the risk-assessment battlefield, Risk Analysis, Vol. 19 No. 4, pp. 689-701. Stanhope, N., Crowley-Murphy, M., Vincent, C., O'Connor, A. M. and Taylor-Adams, S. E. (1999), An evaluation of adverse incident reporting, Journal of Evaluation in Clinical Practice, Vol. 5 No. 1, pp. 5-12. Stump, L.S. (2000), Re-engineering the medication error-reporting process: removing the blame and improving the system, American Journal of Health-System Pharmacy, Vol. 57 No. 4, pp 10-17. 31

Turnbull, P. and Wass, V. (2000), Redundancy and the paradox of job insecurity, in: Heery, E. and Salmon, J. (Eds.), The Insecure Workforce, Routledge, London, pp. 57-77. van der Schaaf, T.W. and Kanse, L. (2004), Biases in incident reporting databases: an empirical study in the chemical process industry, Safety Science, Vol. 42 No. 1, pp. 57-67. Walters, D. (2006), One step forward, two steps back: worker representation and health and safety in the United Kingdom, International Journal of Health Services, Vol. 36, No. 1, pp. 87-111. Weigmann, D.A. and Shappel, S.A. (2003), A human-error approach to aviation accident analysis: The human factors analysis and the classification system, Ashgate, Aldershot. Whipp, R. (1998), Qualitative methods: technique or size?, in Whitfield, K. and Strauss, G. (Eds.), Researching the World of Work: Strategies and Methods in Studying Industrial Relations, Cornell University Press, Ithaca, pp. 51-64. Wright, L. and van der Schaaf, T. (2004), Accident versus near miss causation: a critical review of the literature, an empirical test in the UK railway domain and their implications for other sectors, Journal of Hazardous Materials, Vol. 111, No. 1-3, pp. 105-110.

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Sociological factors influencing the practice of incident reporting: the case of the shipping industry.

Link Table
The following table links between the reviewers comments and the revised paper:

No. 1

Subject of the reviewers comments Tidy up

2 3 4 5 6 7 8 9 10 11 12

Add some material to contextualise the study Material can be drawn from pages 1926 The big picture to be made more explicit Ethnographic approach Details of data collection/ analysis method Who is responsible for reporting? More detail about the companies How were interviews split? What do senior officers denote? More detail in methods section Remove square bracket and quote reference

Comment number in the revised submission s3, 6, 7, 8, 9, 10, 12, 17, 23, 24, 27, 28, 29, 30, 31, 32, 34, 36, 37, 38, 39, 41, 42, 43 and 44 s13 and 14 s14, 35 and 40 s14 s16 s19 and 22 s18 and 19 s 5 and 18 s18 and 19 s 2, 4 and 19 s 22 and 45 s 25 and 26