Risk borders, boundaries, and bridges

Learning from Others’ Mistakes – Part 9: Ruby Princess

The Report of the Special Commission of Inquiry into the Ruby Princess (320 pp) offers numerous governance lessons for non-profit organisations as well as its target audiences in government. Notable among these is the heightened risk faced when multiple agencies and governance systems are involved.

With the 20:20 clarity that only hindsight offers, the Ruby Princess Inquiry has shone a light on coordination and communication issues underlying numerous serious failures which led to 22 deaths and over 900 COVID-19 infections connected to disembarkation of passengers from the Ruby Princess on 19 March 2020.

Few will have time to read the full report, but even limiting your focus to the Introduction and Key Findings (about 30 pp) will offer many insights for directors and managers of non-profit organisations working in partnership or joint venture arrangements with other entities. Much media coverage of the Inquiry has already offered analysis and commentary, and I don’t propose to rehearse that here. Instead, I will hone in on one central issue that we might all need to consider – coordination.

Who knew what, when did they know it, and what should they have known?

The complexity of roles, responsibilities and relationships involved in the Ruby Princess disembarkation was evidently a risk factor in its own right. As illustrated in the header image above, the list of key players is long*. They represented Federal and State departments and agencies in health, maritime matters, and law enforcement, along with private business organisations.

Each of these organisations, agencies, and work units has its own governance systems and risk management measures, and alongside these, coordination and communication arrangements within and beyond their organisational ‘borders‘. As revealed by the Inquiry, when questions were asked about who knew what, when did they know it, and what should they have known, issues regarding decision making processes, and how those decisions were promulgated to all relevant parties became the focus of attention.

No simple Venn diagram could adequately explain the numerous points of intersection and overlap between the complex cast of players involved in the Ruby Princess COVID-19 outbreak. The tangle of ‘crossed lines’ of communication and coordination illustrated below only hints at the multitude of potential ‘trigger points’ for system failure in this case. Hopefully your third party relationships are less complex, and therefore amenable to simpler coordination and communication mechanisms.

When multiple risk governance systems are in play, roles and responsibilities are easily ‘blurred’, thus creating ‘governance risk’

Similar communication and coordination issues involving multiple government and private organisations have already been highlighted in Victoria’s COVID-19 Hotel Quarantine Inquiry, which is still in train.

Lessons for non-profit organisations

Recognising the heightened risk associated with multi-party service arrangements, it would be prudent for non-profit organisations to increase the risk rating assigned to these activities. Enhanced preventive controls and response measures in shared risk management plans, involving all partners and participants in such service mechanisms, are required. Jointly reflecting on the question “What could go wrong?” in defining scopes, compliance activities, training, work flows, resourcing, communications, and lines of authority (chains of command) is a highly recommended preventive measure before implementing any partnership. alliance, joint venture, or ‘scheme of arrangement’.

While the roles and responsibilities of each party in a shared responsibility situation (the boundaries) need to be clear, so too do the communication and decision making mechanisms that will be employed as circumstances change. These ‘bridges‘ must be built in advance to allow rapid and effective response.

The speed with which various key players were expected to respond to rapidly changing circumstances was another risk factor in the Ruby Princess case. There was little opportunity for joint workshops or white-boarding shared and detailed risk analyses. Consequently, some decisions were made in haste, others were not made when they might have been, and some decisions that were made, were not communicated to all relevant parties in a timely and effective way.

Learning from others’ mistakes is the least painful way of avoiding adverse outcomes. There are lessons for all of us in the report of the Ruby Princess Inquiry, whether or not our non-profit organisations are involved in public health activities.

See also:


*In addition to the public at large, the illustrations above do not include the following stakeholders, each of whom was also involved in some way in the events being examined by the Inquiry:

State and Federal Ministers
Prime Minister
State Premiers
NSW Ambulance Service
Taxi and Ride Share Services
Rail and Bus Services
City of Sydney
Interstate Authorities
International Authorities

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