Who should lead organisational change?

In January 2015 the car carrier Hoegh Osaka capsized after leaving Southampton.  The report about what happened was published today, 17th March.

HoeghOsaka 16x9As far as I can see there is not one conclusion or recommendation or action taken that can be attributed to the company management. If one doesn’t understand Human Factors (HF) or Crew Resource Management (CRM) or whatever else you want to call it, you would think that the only place that can do anything to prevent this occurring again is onboard the vessels.  In the report it even states that one of the actions taken by the ship management company has been to issue an advisory notice to all of its masters and crews, including for “the Masters and crew to not come under any ‘perceived commercial pressure”.   Surely this is the wrong way around?  What can Masters and crew do, to not come under any perceived pressure?

It should be “the company should not put the Masters and crew under any ‘commercial pressure’ that might be perceived as such”.

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