Joakim Enström, The Swedish Club and Captain Hans Hederström, Marine consultant have written a piece noting that Kristine Vedal Størkersen’s doctoral research, “Bureaucracy overload calling for audit implosion: A sociological study of how the International Safety Management Code affects Norwegian coastal transport” (NTNU, 2018), added an important loss-prevention perspective. Her work examined how the International Safety Management (ISM) Code influenced safety-related decisions when it came to authorities, company management and seafarers and why well‑intended systems could drift towards bureaucracy, which was in competition with safety.
From purpose to paperwork: how drift begins:
The ISM Code is designed as a functional framework: companies are expected to build systems that fit their operations, and audits verify that the system is complied with. In “Bureaucracy overload”, Størkersen called for an audit implosion. She showed how, over time, this can subtly shift what organizations prioritize
Audits were not bad, but incentives emerged when verification relied heavily on documentation. Under internal control regimes, regulators and auditors often assessed systems based on what was on paper, which could encourage organizations to produce more procedures and evidence than operations required. Over time, the objectives of safety could be overshadowed by the mechanics of proving safety.
The writers said that the “4Ps” framework explains why this matters. If philosophy sets intent, policies translate it into decision boundaries, and procedures provide guidance, then practice is where the system is tested under real constraints. When paperwork grows faster than operational usefulness, the link between procedures and practice weakens, and the gap between “work as imagined” and “work as done” becomes a risk space.
Over‑proceduralisation: when adding rules is easier than removing them
One of the most persistent dynamics in safety management is the steady accumulation of procedures. New requirements and lessons learned rarely replace old material; they are layered on top. Størkersen’s broader research programme described how organizations could develop a rapidly expanding internal rulebook, with more protocols, more documentation and more “safety management”, even though the original intention behind functional regulation would have been flexibility and practicality.
Three mechanisms were found to drive internal overregulation:
- work auditability,
- managerial insecurity and liability, and
- audit practices.
Together, these mechanisms helped to explain why “more procedures” became the default response. Standardized work was easier to verify, defend, and compare, even when it was less workable at sea.
The writers noted that, in some companies, masters received new or updated procedures from shore-based management without having been involved in their design. This could lead to procedures being treated with scepticism and open distrust, especially when the rules were far removed from the situations operators must deal with.
Procedures could then be perceived as a way of “shifting responsibility” from shore to ship, rather than as useful operational instructions.
In many fleets, the writers asserted, procedures that looked complete and defensible, in fact did not fit the operational context. This was not always because a procedure was “wrong”, but was because it was written for auditability, standardization and completeness, rather than for peak workload, time pressure, limited manning and the complexity of real decision-making.
Størkersen’s thesis describes this as a situation in which the ISM Code’s core intent could be wiped out because of demands for documentation and verification. Box-ticking took over from real safety guarantees.
In the 4Ps language, this is what happened when procedures started to dominate practice, rather than support it. Crews either hesitated because they could not see how the written instruction allied with the real situation, or they adapted quietly to make the job possible. While this kept operations moving, it also widened the gap between what was controlled and what was merely recorded.
A particularly operational finding in Størkersen’s work was how administrative load could concentrate on specific roles. In coastal operations, officers often became translators between a generic system and a specific situation. They interpreted requirements, adapted procedures, and carried a substantial share of documentation and follow‑up work so that the operation could function smoothly.
While this “translation” work could create value, it also had a cost. Størkersen argued that heavy documentation burdens could reduce concentration and situational awareness for those managing the operation, and that this could contribute to accident pathways in high-workload settings. In other words, the compliance load was not just an administrative concern; it could become an operational risk factor when it competes with attention and rest.
The 4Ps framework says that, when practice was pressured, people relied on philosophy and policy to make sound decisions under uncertainty. If the system was sending mixed signals – “safety first” in philosophy, but “avoid remarks” in the lived incentives – then the decision space onboard became less clear. Judgement became harder to exercise with confidence.
“Audit” had become a word that, to some degree, was now loaded with fear. It would be preferable to reframe audits as “Continuous Improvement Opportunities”. The person conducting the improvement (audit) would then help the crew get things right and focus on learning rather than on non-conformities.
Loss prevention should not be about choosing between procedures and judgement. It should be about ensuring procedures support judgement.
Størkersen’s conclusion was deliberately provocative: the industry may need an “audit implosion”, not an end to audits, but a rebalancing away from auditability as the organizing principle. The aim would be to restore a focus on practical risk control rather than documentation verification.
The 4Ps show that coherence matters. When philosophy, policies, procedures and practice reinforce each other, organizations reduce confusion, increase confidence to act, and strengthen safety margins in the moments that matter most.
1. Enström, J. & Hederström, H. (2025). “From Philosophy to Practice – The 4Ps.” The Swedish Club.
2. Størkersen, K. V. (2018). Bureaucracy overload calling for audit implosion: A sociological study of how the International Safety Management Code affects Norwegian coastal transport. PhD thesis, Norwegian University of Science and Technology (NTNU).
3. Størkersen, K., Thorvaldsen, T., Kongsvik, T., & Dekker, S. (2020). How deregulation can become overregulation: An empirical study into the growth of internal bureaucracy when governments take a step back. Safety Science, 128, 104772.