The Costa Concordia had more than 4,200 passengers and crew on board when it slammed into a reef Friday off the tiny Tuscan island of Giglio after Capt. Francesco Schettino made an unauthorized maneuver from the ship's programmed course — allegedly to show off the luxury liner to the island's residents. Adam Smallman, editor of shipping magazine Lloyd's List, tells NBC News that the Costa Concordia took a "pretty much identical" route past Giglio Island in August last year to the one Friday that led to the sinking of the ship. He said the route taken in August, based on satellite tracking, was "authorized by the company and the coast guard." "Our assessment of the route this vessel took (in August) is it must have come perilously close, and I mean possibly within touching distance of the rock that it hit this time ... which the company is saying is wholly unauthorized in terms of its proximity to the island," Smallman said.
Doesn’t that sound like a classic example of Reason’s Swiss Cheese Model? Leaders (and operators) had taken shortcuts in the past, but (unknowingly) had narrowly avoided an accident. So, in an example of Normalized Deviance, they continued this risky practice until one day the holes all lined up (resulting in literally a 160-foot hole in the side of the Costa Concordia).
This one is interesting:
Schettino, whose actions during the disaster have come under intense scrutiny as details of his role on the night of the disaster emerge, appeared before a judge in Grosseto, Tuscany, where he was questioned for three hours. Schettino's lawyer, Bruno Leporatti, said urine and hair samples have been taken from Schettino, apparently to determine if he might have consumed alcohol or used drugs before the accident. Martino Pellegrino, a crew-member on Costa Concordia, described Schettino as "authoritarian," "stubborn" and "egocentric," in an interview with Italian newspaper La Republica on Tuesday." Schettino likes to be in control of the ship's wheel," he told the newspaper.
When I read those last two sentences I immediately thought about Dutch researcher Geert Hofstede’s concept of Power Distance – the extent to which the less powerful expect and accept that power is distributed unequally. The strong authority gradients that grow out of a perceived power distance environment will lead subordinates to be hesitant to share information, cross-check colleagues or speak up when concerned about a problem. I wonder how many other members of the ship’s crew were uncomfortable with the ship’s dangerously close course to Giglio Island? Were there some that tried to speak up, or wanted to, but didn’t because of Captain Schettino’s authoritative personality?
Finally, in the aftermath of the grounding there were some obvious gaps in the ship’s disaster preparedness posture. Check out these quotes from Joe Ryan, a passenger from Louisville, KY:
Ryan said the group put on life jackets and headed for safety without any type of evacuation plan from the crew. "No one ever told us to get on a boat," Ryan said. "We stood at the room until the ship was so far slanted that you could barely walk. Finally, we just decided we had to go to see where we needed to go." He said they made it off the ship and into a hotel in Italy. It was until then, he said he saw the severity of the crash unfolding on the internet. "We didn't even know there was a gash in the boat," he said. "All we knew until the news told us otherwise was what they told us on the boat, which was there was an electrical problem that was being taken care of."
In our diagnostic assessment of healthcare organizations, we evaluate how safety is governed and managed using 40 different elements taken from how High Reliability Organizations operate. Mr. Ryan’s comments made me think of two of those elements and how they were implemented (or not) at Costa Cruise Lines: Emergency Plans (OS6) and Consequence Confinement (OL8). HRO’s have well-defined and understood emergency plans in place that are operationally tested and effectively communicated to all members of the organization. They practice these plans on a regular basis because they know the possibility of events is so rare that when one does occur, team members won’t have time to think about what needs to be done – they just have to do it. In terms of Consequence Confinement, when a problem or event is identified, leaders ensure action is taken on the spot to prevent the impact from growing in order to minimize the spread of impact to other areas.
As the details of the Costa Concordia tragedy continue to come out and the body count rises, I’m hopeful there will be a full investigation of the individual and system failures that caused this tragedy. In the interim, we as healthcare leaders can hopefully take away some valuable lessons-learned as we lead for high reliability in our organizations:
- Do we as leaders set clear expectations relative to quality and safety, do we hold staff accountable for meeting those expectations, and do we get out to the sharp end on a regular basis to influence members of our organization while looking for signs of normalized deviance?
- Do we have a non-collaborative work culture that promotes hierarchies and authoritative personalities that foster a high Power Distance work environment? Are people afraid to crosscheck one another or speak up when they perceive an unsafe situation? What are we doing to flatten the hierarchy and reduce Power Distance in our organization?
- Are senior and operational leaders able to articulate strategies to address emergency plans while containing the consequences of problems? Do we practice or drill for those rare emergencies on a regular basis?
