Last year, I was inbound to a port-that-will-remain-nameless, with the local pilot at the conn. As we maneuvered up a winding channel, the channel curved to port, yet the pilot ordered starboard rudder as we approached the next turn.
Our 3rd officer, who had been onboard for over two months already and well-drilled in bridge resource management theory piped up and said, “Mr. Pilot – the channel goes to port, why are you using starboard rudder?” The pilot responded by glancing at the rudder angle indicator and out the window. He then turned and told the helmsman, “Midships,” followed shortly by, “Port 20.”
The pilot then turned, smiled at the 3rd officer, and said, “Thanks.”
The 3rd officer had effectively implemented the first step of the PACE model for “graded assertiveness.” Originating in the medical field, graded assertiveness and the PACE (Probe-Alert-Challenge-Emergency) model were necessary to overcome the power dynamic between nurses and doctors. Much like the power dynamic between the pilot and the 3rd officer, the power dynamic between doctors and nurses is such that nurses are frequently hesitant to question a doctor, even when a patient is at risk of harm.
Probe – “Mr. Pilot – the channel goes to port, why are you using starboard rudder?”
Alert – “ Mr. Pilot – the channel goes to port. We will ground if we continue to turn to starboard.
Challenge – “Mr. Pilot – we will ground if we turn to starboard. I recommend turning to port immediately.
Emergency – “Hard to port!” (or other appropriate order)
Despite the experience and knowledge of maritime pilots, captains and officers on vessels, they are not infallible. The bridge team (including the helmsman, lookout, cadet, deck officers and captain) are all there to assist in error trapping. Unfortunately, sometimes this safety net fails entirely, such as in the “heavy contact” of CMA CGM Centaurus with the berth (and gantry cranes!) in Jebel Ali in May 2017.
The report from the UK Marine Accident Investigation Board (MAIB) detailed the failures in bridge resource management that contributed to this incident. The vessel’s parent company, CMA CGM, issued guidance to their fleet shortly after that included the instruction, “Once pilot decision looks unsafe to you, challenge and be ready to take over command.” At some point in the maneuver to the berth, utilizing the PACE model might have avoided or mitigated this incident.
The Five Step Assertive Statement Process
The PACE model is effective in acute situations where immediate actions need to be taken to correct the situation, such as the rudder order or speed directed by the pilot. When a concern needs to be raised in a less immediate situation, a less aggressive, but equally effective method is the Five Step Assertive Statement Process.
The Five Step Assertive Statement Process comes out of the aviation industry. Leading the transportation industry in human factors studies, the aviation industry had multiple serious incidents where a problem had been identified by the co-pilot or first officer. Yet, these concerns had not been properly communicated to or been ignored by the pilot due to the power dynamic between pilot and co-pilot. Much like the aviation industry, the maritime industry has its fair share of egos, where the senior officers or advisors (marine pilots) feel themselves to be above reproach (or questioning!).
The five steps are :
Start with the person’s formal title (i.e. Captain / Mr. Pilot). Starting with anything else can diminish the importance of the message.
State, “I have a concern.” This is a trigger statement. In the aviation industry, by policy, this is statement that requires the captain acknowledge and consider the concerns of the crew member. Shipping companies might consider adding such a policy to their safety management system (SMS).
State your concern and provide details.
Suggest an alternate plan.
Seek permission to implement the alternate plan.
In practice, this statement might sound something like :
“Captain, I have a concern. There appears to be a crack between 1 port bunker tank and 3 port water ballast tank. The level on 1 port has gone down while 3 port has gone up with no ballast or fuel transfer operations taking place. I recommend we treat 3 port ballast tank as contaminated and do not discharge it as planned in the next port. Does that sound like a plan?
In reality, neither of these systems will be effective without buy-in from all parties. There are plenty of captains, chief engineers, pilots and other senior officers still out there that will reprimand a subordinate for questioning their decisions. There are probably an equal number of junior officers and ratings who are unwilling to voice their concerns due to lack of training or prior negative responses. The combination of these two groups often prevents adequate communication which then becomes a casual factor in incident investigations.
The solution? A strong first step is the institution of a “just culture” within an organization and on its vessels. A just culture provides the safe space within which concerns and safety issues can be discussed without fear of repercussions. The implementation of such a culture requires policies first, followed by actions that support those policies. Additionally, policies and training that support the concept of graded assertiveness at all levels is critical. If junior officers and ratings are never encouraged to voice their concerns, will they? Even worse, what about the captain that won’t question the pilot when he is concerned? What can YOU improve on your vessel?