The "bridge" between training and real world application
Notes for an address by
Transportation Safety Board of Canada
at the Canadian Marine Pilots' Association
September 01, 2005
It's a pleasure to be here on behalf of the Transportation Safety Board of Canada.
We know a ship is at greatest risk when it arrives or departs from port. The same is true for a speaker who must use her opening and closing remarks to capture and sustain an audience's attention.
But what about the journey . . . the main body of my speech? This I promise to navigate with an old adage in mind: Always be shorter than anybody dared to hope.1
I can't embark, however, before I say a few words about today's host: the Canadian Marine Pilots' Association.
We appreciate the complex challenges faced by your members: coping with larger ships and smaller crews; mastering the rapid introduction of new technologies and the unique characteristics of each ship . . . just to name a few.
We also value your unwavering commitment to ensure the safe and secure passage of goods and people in Canadian waters. Our economy and environment are all the better for it.
In a 2004 speech, journalist Michael Grey, another of the Congress speakers, described pilots as
an essential safety net to compensate for the often inadequate manning at a time when the demands upon a ship's crew are arguably highest.2
We couldn't agree more.
But the greatest testament to your expertise is expressed in numbers, not words.
We've seen a steady decline in occurrences in Canadian waters where a pilot was on board one of the vessels involved. On average, there have been 72 occurrences per year during the past 10 years. That's approximately half the rate as compared with the preceding decade.
It's worth noting that this decline began at the same time that Bridge Resource Management gained greater prominence within the shipping industry in Canada and around the world.
BRM takes the position that a ship's safety is determined by a combination of individual, organizational and regulatory factors. It therefore emphasizes the need for a strong safety culture, which represents the way things are done by the entire crew, not just any one individual.
So too when something goes wrong - there is rarely a single cause.
The truth is that accidents, by their very nature, are a confluence of factors, be they human, technical, procedural, environmental or cultural. And while our investigations rarely find one primary cause . . . communications - or the lack thereof - is most often a thread that runs through marine accidents.
That's why advancing transportation safety demands much more than a focus on quick-fix solutions. Or, for that matter, a comprehensive set of rules and regulations.
Instead, we believe a transportation safety culture is sustained by those who abide by rules but also seek to improve them.
In the world of transportation safety, the success of each and everyone in the marine industry - including the TSB and the CMPA - depends on a mutual commitment and concern for promoting a strong safety culture. Complying with regulations is simply the bare minimum.
To this end, we look to the pilots and their authorities to promote a strong safety culture in the 21st century. And in the true spirit of an investigative body, I'll make some recommendations for your consideration.
But first let me tell you how we contribute to Canada's safety culture.
The TSB is an independent agency. That means we operate at arm's length from other government departments such as Transport Canada.
Our mandate is to advance transportation safety by conducting investigations into selected occurrences.
In all investigations, our focus is straightforward. We examine what happened; why it happened; and how we can help ensure it never happens again.
There were 441 marine accidents reported in 2004, involving 470 vessels. These accidents resulted in serious personal injury or death, or significant damage to property, affecting the safe operations of vessels.
We respond to each of these occurrences, but only fully investigate those that represent the greatest potential to advance transportation safety.
When we find unsafe conditions, we act immediately by communicating with those who can take corrective measures. This means that if you have a direct interest, you often don't have to wait for our draft report.
We also suggest potential remedial action . . . and make safety recommendations.
It's important to highlight a couple of key points about how we do our work.
From a legal perspective, information gathered by the TSB is to be used strictly for safety investigations, and it is not intended for the purpose of litigation.
That's a key premise, because the point is to get quickly to the facts, find out what happened and make recommendations for improvements.
In the same vein, the confidentiality of evidence is protected because we're in the business of pursuing the greater public good, not pointing the finger of blame or demanding reparation.
Witness testimony, for example, is protected by law so that no individual is discouraged from giving a complete and honest account of what happened and why - from their perspective.
Our investigative approach is comprehensive. We look beyond what physically happened to all other factors at play.
This means our safety recommendations consider the broader implications and the larger systemic connections within the transportation system.
For instance, we recognize that smaller bridge teams can impede BRM. The master, a helmsman and a navigating officer should be available for the proper verification of courses and monitoring of the vessel movement during the passage. However, for a number of reasons, that doesn't always happen.
And finally, we need to take the time to go where the evidence leads us. I recognize that some investigations have taken too long and I want to assure you that steps are being taken to address these delays.
However, we also need to get it right and so the TSB will not cut corners, or rush complex processes. This would not enhance safety, nor advance the interests of the transportation industry or the Canadian public.
For some, the TSB may appear to be a "stop and start" organization. We investigate an occurrence, we make our report public and then we wait for the next call.
It's a bit of a simplistic view because the reality is that our investigators are in constant contact with the marine industry. Many of you will have the opportunity to meet with TSB captains Paul van den Berg and Christian Ouellet at this Congress.
And I know that our investigators make a real difference in terms of setting the bar high for safety performance on a national level.
Furthermore, they ensure that issues are identified in the international forum by actively participating at IMO.
But we're keen to have our work contribute to a stronger sense of the "safety continuum" in Canada. That's because the marine industry is far too complex for short-term, band-aid solutions.
And ultimately, we know that our findings bear no value if pilotage authorities fail to act upon the issues that we identify or implement recommendations we make. It's for this reason that we need to strengthen links between your organizations and ours to ensure our safety culture can be improved.
I'm sure that pilots can appreciate this last point. Let me explain.
I've already mentioned the steady decline in Canadian occurrences when pilots have been on board. To be sure, the industry is committed to the best marine pilotage system in the world. Everyone knows that accidents bear too many costs, strain too many resources and affect too many reputations.
Still, we're far from perfect. Accidents do happen, often as a result of a breakdown in communications between the pilot and master or the officer of the watch.
"Communications" is the keyword here. As the Det Norske Veritas' Rules for Pilot Organizations states, "The pilot should try to create good working relationships with the master and (his) bridge team. A positive attitude enhances communication which is vital for effective resource management."
Communication breakdowns are not surprising, when you consider the difficult circumstances faced by bridge teams.
Take a complete stranger, the pilot, and plop him on board with a diverse mix of crew and languages. Then expect this team to work in unison . . . under stressful conditions and often in complex operational situations - and the next assignment is totally different.
In the world of professional sport, it may take a few weeks for a team to "gel together" when a new player is added to the roster. In your business, it has to take a few minutes.
This challenging environment is exacerbated by the passive approach taken by some ships' complements. It's been said that the pilot's arrival can prompt the bridge team to "lapse happily into a collective coma."3
It's time these teams get a wake-up call.
So too for pilots - who may be reluctant to use the ship's complement for varied reasons.
Neither scenario is conducive to creating a climate whereby bridge team members can work effectively together.
As you know, BRM training helps to address these deficiencies, by breaking down barriers between members of the bridge team. We've been encouraged by the fact that Canadian pilotage authorities and pilots have been quick to endorse and participate in BRM training.
We believe that its ability to help bridge teams use all available resources, exchange vital information, and improve decision-making processes has contributed to the downward trend in pilot-related occurrences.
However, training is not an end in itself. Like any education, it's what you do with it.
And the fact is that we've investigated enough occurrences to know that some pilots, and ships' officers, do not put their knowledge into practice.
While this, like all other factors, is not the "primary" cause, it certainly is a thread running through marine occurrences - and it presents a risk.
For instance, some of our investigations show that the elements of BRM - such as effective communication and distribution of workload based on individual expertise - were not put into practice by BRM-trained pilots, resulting in a number of pilot-related occurrences.
In one, the ship's master was acting as the officer of the watch and was therefore responsible for navigation. However, he was doing administrative tasks for some of the time the vessel was navigating in the confined waters.
The master was not actively sharing the conning position with the pilot nor was he actively involved in the navigation of the vessel. Clearly, the environment on the bridge was not conducive to promoting good communications or a shared mental model.
Keeping a close watch on the movement of a vessel is key to safe navigation in confined waters.
That's why it's essential that each member of the bridge team clearly understands his role and ensures that all information relating to the conduct of the vessel is conveyed to other team members.
Risk will remain until BRM permeates the operational front.
The challenge, then, is to build a bridge between training and real world application. To this end, we believe that pilots must traverse between ongoing classroom experiences and work cultures that reinforce BRM practices.
Establishing a safety management code for each ship is a step in the right direction. So too is mandatory BRM training and refresher courses, as well as the requirements to keep abreast of changing technologies.
But it's not going to get any easier to promote a strong safety culture on the bridge. As W.A. O'Neil, the former Secretary General of the International Maritime Organization, pointed out:
There [is a] trend towards greater cultural and ethnic diversity among ships' crews and even towards the employment of seafarers on a short-term casual basis. These trends carry with them clear implications for pilots, for whom interaction with shipboard staff is vital.
This leads us to consider if language and communication will increasingly become a challenge for pilots and crews.
And if widening cultural gaps will impede the bridge team from working in a cohesive manner.
There are other challenges looming on the horizon. With proper training, new technologies such as electronic charting and automatic identification systems offer pilots powerful tools to enhance the safe and secure passage of people and goods.
One risk, however, is an overreliance on such technologies. Make no mistake; they are no substitute for the skills of the pilot and bridge team. But, in an environment where communication is encouraged, members of the bridge team may question pilot decisions that contradict the data presented by these instruments. Needless to say, this could be divisive.
These are just some unique challenges against a backdrop of continuous change in the marine industry, including the evolution of ships themselves.
Promoting a strong safety culture will require all crew members - including pilots - to learn . . . unlearn . . . and relearn . . . a wide range of matters from technology to teamwork.
In this new world, adaptability and flexibility will be the hallmarks of success.
If there are any sacred cows, my advice is to put them out to pasture.
To this point, I've discussed the downward trend in occurrences with pilots on board, and suggested that this positive outcome has coincided with the widespread adoption of BRM training.
Yet, training in itself will not mitigate risk. Our investigations have revealed that some basic BRM principles have been underutilized resulting in unnecessary risk involving
- vessel progress not being closely monitored;
- minimal communication between bridge personnel; and
- bridge teams not functioning in a cohesive manner.
Risk is compounded by the industry's evolution: ship design is changing; crews are increasingly minimized and diverse; and technology is redefining work functions, to name a few.
The confluence of factors presents pilots with both opportunities and challenges. In one sense, our job at the TSB is to help the marine industry identify the risks and advance transportation safety.
But we are only one small piece of the puzzle. It's down to all of us, including marine pilots, to ensure the safe and secure passage of goods and people.
This will demand establishing a bridge between training and real world applications . . . to ensure that lessons learned in the classroom and elsewhere are optimized on the ship.
To this end, we have 5 recommendations for the CMPA. I would ask that you
- stay current with TSB investigations, their key findings and safety recommendations and encourage your members to do the same;
- maintain an open dialogue with like-minded organizations including the IMPA, TSB and IMO and engage them in enhancing your own efforts;
- constantly improve your practices and remember that regulatory compliance is the bare minimum;
- identify and support opportunities for pilots to learn, unlearn and relearn; and
- promote safety through your programs.
All of this to say: risk never sleeps. So we can never rest when it comes to promoting a safety culture.
I'm confident that you're up to the task. Pilots have played a central role in the safe and secure passage of goods and people for centuries.
And while we are in the midst of a sea of change, a ship's success will always be reliant on the skills and expertise of the people on board - none more so than the marine pilot.
I want to thank you for your ongoing efforts and look forward to your future contributions in advancing transportation safety.
I hope that you will have an excellent Congress.
1. Lord Reading, on speechmaking
2. Speech delivered at 2004 International Maritime Pilots' Association Istanbul 2004 Congress
3. Michael Grey, ibid.
- 30 -
- Date modified: