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April 2012www.sname.org/sname/mt rough hundreds of accident investi- gations conducted by the NTSB since those words were spoken, the message has been reinforced time and time again. In no mode can this need for corporate?and organiza- tional?commitment to safety be seen more starkly than in the marine sector, where the widespread adoption of safety management systems (SMS) across the marine industry has awakened a growing interest in estab- lishing healthy safety cultures. But while an SMS provides a detailed roadmap along which safety managers may focus their e orts, the concept of a safety culture is far more amorphous. How can a safety cul- ture be de ned in such a way that a marine industry organization might best begin pur- suing the goal? e United States Nuclear Regulatory Commission o ered a succinct and rele- vant de nition of safety culture in a 2011 policy statement: Safety culture is the core values and behaviors resulting from a collective commitment by leaders and individuals to emphasize safety over com- peting goals to ensure protection of people and the environment.? Put another way, safety culture is a set of established atti- tudes, values, beliefs, norms, and practices where safety is revered, promoted, and treated as an overriding priority. It begins at the top of, and permeates throughout, an organization. However, Dr. James Reason, a leading gure in organizational accident analysis, o ers a word of warning in Managing the Risks of Organizational Accidents for those who believe themselves ahead of the curve in their commitment to safety: [I]t is worth pointing out that if you are convinced that your organization has a good safety cul- ture, you are almost certainly mistaken?? He goes on to state that a safety culture is something that is striven for, but rarely attained? [and] the process is more impor- tant than the product.? In short, it is the journey that is important. What does the journey along the course to safety culture look like? L. Lautman and P. Gallimore, in Boeing Airliner , exam- ined attributes of world class airlines, but their ndings could be applied to any organization. e course to safety culture has four main components: r Management commitment and emphasis r Standardization and discipline r Training r Data collection and quality con- trol program As we explore these elements, we will learn how the lack of these aspects has been evident in marine accidents investigated by the NTSB. Management commitment and emphasis It has been stated that the safety behaviors and attitudes of individuals are in uenced by their perceptions and expectations about safety in their work environment, and that they pattern their safety behaviors to meet demonstrated priorities of organizational leaders, regardless of stated policies. When an organizations leaders fail to prioritize safety, however?whether overtly through the issuance of conflicting directives to employees, or indirectly through a failure to enforce safety procedures?a powerful message is sent to employees that safety is not a priority. Alaska Ranger accident On March 23, 2008, the U.S. sh processing vessel Alaska Ranger sank in the Bering Sea 120 nautical miles west of Dutch Harbor, Alaska. e vessel was owned by Fishing Company of Alaska, Inc. (FCOA), head- quartered in Seattle, Washington. Of the 47 people onboard, 5 died in the accident. e NTSB determined that the probable cause of the sinking of the Alaska Ranger was uncontrolled, progressive ooding due to a lack of internal watertight integrity and to a breach of the hulls watertight envelope, likely caused by a physical rudder loss. Contributing to the loss of life was the vessels movement astern, which likely accelerated the flooding and caused the liferafts to swing out of reach of many crewmembers. As part of its investigation of this accident, NTSB investigators inter- viewed numerous employees of FCOA, the vessels owner, to learn more about its operations and commitment to safety. The evidence and testimony uncovered led to serious questions about the com- panys safety culture. The fishmaster on the vessel?one of the ve fatalities?worked for North Paci c Resources, a subsidiary of the sh buyer, and was not an employee of FCOA. The shmasters job was to direct the vessel to shing sites and oversee quality control of the sh products, which were intended for the Japanese market. Despite this limited and speci c role, however, several survi- vors of the sinking told the Marine Board that the shmaster actually ran the vessel. For example, the previous master of the ship had engaged in a heated argument with the shmaster mere days before the accident voyage regarding the speed with which the vessel was being operated in icy sea conditions. According to one wit- ness, the shmaster had actually sped up the vessel through the ice to make bet- ter time to port, while the master was not present on the bridge. The master chal- lenged the safety of this action as well as the shmasters very authority to direct the vessel. Following the argument and the ves- sels arrival into port, the master promptly packed his gear and permanently left the Alaska Ranger , remarking to one crew member that he was going to leave the boat before the company could re him. As one How can a safety culture be de ned in such a way that a marine industry organization might best begin pursuing the goal?