Complexity ≠ Safety + Efficiency
Introduction
Complexity is a much discussed issue nowadays. Whether it is about financial markets being
too complex and difficult to regulate, about a form being too complex or about
a major incident that resulted from a complex organisation complexity gets a
bad press.
The complexity and interconnectedness of the financial
markets is highlighted as a major cause of the credit crunch. The report into the space shuttle Columbia’s
crash highlighted complexity of the NASA organisation as being a significant
issue.
While it is difficult to pretend that the shipping industry
is a complex as either of the above examples it should be clear that for a
relatively simple and historic task i.e. the transportation of goods by sea the
degree of complexity is probably more than it needs to be.
This paper will explain what complexity is and how it
relates to the marine industry
Complexity for beginners
It is worth taking a look at what complexity is
A Dictionary definition is:-
1.
Composed of many interconnected parts
2.
Characterised by a very complicated or very
involved arrangement of parts units etc
3.
So complicated or intricate as to be hard to
understand
The figure below
defines the terms simplicity, complicated and complex in a more scientific
context. The critical point in these
definitions is the ability of people to understand what is going in a
system. It is about perception to some
degree and providing the individual with the right tools and context can
improve understanding.
The other important point is about change in the
system. If you are often surprised by
the results of changes you make to your organisation then you are face to face
with complexity or at least a complicated system that has not been
modelled.
A great deal of research is being done on complex adaptive
systems. The examples that are often
considered are such things as insect swarms, traffic movement and once more
financial markets. The research has
shown that complex adaptive systems have a number of features.
The figure below
shows the generally accepted features of a complex adaptive system and how the
system behaves.
It is important to not try to force fit the shipping
industry into the bullet points. Indeed
one report into the Columbia tragedy blamed bulleted presentations for hiding
the real messages that presenters were trying to give.
It would be hard to define the shipping industry as
competing for scarce resources in the way that insects do to feed but it can be
said that the scarce resource the industry is competing for at present is
revenue. Within the shipping company the
scarce resource may well be time. That
competition for scarce resources can result in decisions that are not in the
best interest of the business or industry.
It’s clear the system is open because the shipping industry
in its role connecting countries together by moving cargo is influenced by
virtually everything that happens whether it is economic downturn, energy
prices, terrorism, and environmental concerns.
The shipping industry is not an island.
There are a large number of interacting ‘agents’. These ‘agents’ can be people or
organisations. Large number? Try to count the number of bodies that
influence the ship operation and the number of people within them. Within the owners ‘system’ he needs to think
about the people in his organisation both ashore and afloat who are influenced
by their history, who remember things that happened in the past and things that
you tell them now. The ability to adapt
to improve performance should be a valuable asset. However great care needs to be taken as to
how define ‘performance’. If you have
defined a narrow goal and provided a large incentive to reach that goal then it
should not be a surprise when you meet that goal. You should also not be surprised by the
unintended consequences of reaching that goal as with rogue traders who lose
large sums of money or manipulate markets etc..
It does seem sometimes that organisations are alive but I
struggle with comparing the shipping industry with financial markets which do
seem to have their own mind despite the number of pundits who claim to be able
to predict the outcomes.
That the behaviour of a shipping organisation is emergent
(i.e. is produced by the system not by a guiding hand) and sometimes surprising
is more easy to understand. The classic
example is when you consider an organisations safety culture. This is especially the case with an
organisation which has a very low accident rate. An organisation achieves that low accident
rate when it has built a large number of effective physical and process
barriers to prevent accidents and those that are left are mainly in the domain
of people and their behaviour. Accident
rates emerge from the culture and it is often surprising to find how that
culture has developed and how your actions have affected it.
I would also struggle with the lack of an invisible
hand. Most shipping organisations are
relatively predictable until they reach the point of overload at which point
managing the workload may dominate over the organisations goals.
Organised then suddenly disorganised is more
recognisable. An organisation may go
along happily with all the systems, KPI’s etc. telling its executive that all is
well and then suddenly a major incident, event, problem appears leaving that
view in tatters.
What are the features of a complex shipping company?
The features of a complex shipping company are as follows:-
•
Periods of steady running followed by sudden
unanticipated mishaps/disasters
•
High executive workload on management (rather
than leadership) issues. Large numbers of meetings on process issues and
failures.
•
High and growing cost from countering complexity
(pedalling faster)
•
Difficult to predict what will happen when
changes are made
•
Disconnection between ship and office
•
Reduced ship performance as goals etc become
confused and staff focus on just following the rules rather than using their
experience and knowledge
•
Difficult to analyse problems because there are
too many ‘pieces’ of the problem that may conflict
•
Difficult to draw the correct conclusions from
investigations and find solutions
If you recognise even some of the above then you are
probably already dealing with the problems of complexity.
The Workload Issue
There is a general
understanding that the workload on board vessel has reached or exceeded the
ability of those on board to absorb it.
The figure attempts to illustrate the growth in workload and
hence complexity over time. The figure
illustrates the increase in both procedures and compliance requirements at the
same time as the capacity to absorb is reduced.
The capacity to absorb is not just a function of the number
of people aboard but is a function of the quality of the system, training,
competence and the allocation of work within the vessel amongst other
things.
As the capacity exceeds the workload you end up with:-
Corner Cutting. Where procedures are not fully followed
to save time. The decision as to what to
follow is taken aboard and is based on managing workload as well as the
individuals perceptions of the organisations and their own goals.
Box Ticking Culture. Where check-lists and documents are
completed without the underlying checks being completed. This can create the illusion of compliance
and steady state running until an incident occurs.
Before I am accused of slandering those who run our ships the
occasions when people wilfully and deliberately ignore the procedures and
compliance requirements are mercifully few.
The problem lies more with lack of trust in procedures either because
they are poorly written or impractical. Conflicting messaging on what the
organisations goals are can also weaken the confidence in procedures. With this background a number of reasons for
not complying with procedures and checks can be found (from a book called Efficiency
Thoroughness Trade Off by Erik Hollnagel.):-
·
It looks fine
·
It is not really important
·
Its normally OK
·
It’s good enough for now
·
It will be checked later(or was checked earlier)
by someone else
·
There is no time to do it now
·
Etc......
The graph shows the evolution of workload over time. Each company will be different in how it evolves
but my view is that the period of clarity existed in the late 90’s where a
combination of strong competence combined with the development of ISM created
the right environment. I believe some
companies may have retained that clarity while others have created more process
and more confusion.
Distortion is a special case where either incentives or
threatened punishments result in goals that are not those of the organisation
dominating.
As we go from clarity to confusion the risk increases and
this may be one reason behind the increase in incidents in the tanker sector (Many
other reasons are possible)
What causes complexity in shipping?
We have covered the increased in workload and confusion
caused by large numbers of procedures.
This creates a difficult in understand what the goals are and what is
important. In a simple world the
workload would be less of an issue and would only be limited by the physical ability
to ‘do’.
When we think back to the various definitions:-
1.
Composed of many interconnected parts
2.
Characterised by a very complicated or very
involved arrangement of parts units etc.
3.
So complicated or intricate as to be hard to
understand
Anything that affects the interconnected arrangements or
affects the perception of it will causes complexity. The perception issue is important. If you have a framework to fit things into
then it is possible to deal with more complexity. Issues that cause complexity in shipping
are:-
Lack of clarity/Conflict in goals and strategy/Conflicting messages from
Leadership
The framework is
important. It is the executive’s role to
provide direction, leadership and management.
If there is no clarity in the
organisations direction then there is no framework to work within.
The figure illustrates this from the point of view of those
onboard. Important point. Complexity as viewed by those onboard is what
is important. The shore organisation
should be able to cope with more complexity while preventing that complexity
from reaching those aboard.
Conflicting messages from leadership is an important one. Anyone who has managed in the email/internet
era will know that it is not what you say in carefully thought out
presentations that causes problems, is off the cuff remarks which ‘go viral’
and are received as the message ‘This is what they really want’.
Reward and Punishment
This was mentioned earlier.
If people are motivated by large rewards or by avoiding punishment then
their understanding of the goals will be changed. If the goal is to reduce accidents and
people get a reward for not having accidents while being punished for not
following procedures then you need to expect that reporting will be
affected. This is not to say reward and
punishment are not appropriate but within boundaries.
Confusing Organisation Structure/Conflicting Accountabilities
Complex organisation structures increase the number of
interactions and the number of potentially conflicting messages. Conflicting accountabilities make decision
making difficult and means endless means to resolve issues. Such structures spend many hours creating
elegant compromises with inelegant results.
Conflicting Messages in Procedures
Procedures take time to update. If an organisation change, cost cutting drive
or other change is introduced without the procedures reflecting the change then
confusion results
Process becomes the end not the means
Process and management systems exist to deliver a
result. Over time and with monitoring of
systems and audits the belief can arise that the organisation exists to serve
the system not the other way round. This
is the ‘2001’ scenario where in the cult film the computer took over the
spaceship.
This also leads to the law of diminishing returns. Where early process wins added a lot of value
with little effort, later changes give limited or no improvement at greater
cost so that ‘continuous improvement’ can be satisfied.
Inappropriate Application of Cross Industry Learning
The shipping industry should learn from itself as well as
from the wider world. The problem arises
when either fads are introduced or a shipping company as part of a larger
conglomerate is forced to apply learning after incidents elsewhere. This may add complexity without adding value.
Drawing the Wrong Conclusions
Most are aware of Murphy’s
Law ‘What can go wrong will go wrong’.
Its less well know corollary is ‘What should go wrong doesn't and we
draw the wrong conclusions’.
The figure based on the excellent book ‘The Art of Action’
by Stephen Bungay illustrates the point.
When analysing management or operational problems it is
often possible to draw the wrong conclusions and makes things worse. The alignment and effects gap shown in the
figure illustrate this.
Using process for everything
Process is one tool that can be used and it is tempting to
use it for all problems when training, competence, and leadership may be the
right answer. Using process for the
wrong things will result in unwieldy organisations and structures.