Lloyd's List: A world beyond blame
Michael Grey - Monday 10 May 2010
We know now that a human element dimension is a necessary part of regulation and the development of rules and procedures, and that its proper consideration will make ships more habitable, efficient and safer.
ONCE, we had simple human error, which greatly facilitated our requirement to establish fault and attribute blame. It was clearly the master, who was the chief decision maker, who put the ship ashore after he had made an error in his dead reckoning. It was he who had failed to shorten sail before the squall struck and drove the ship to its doom, or pressed on into the fog and the iceberg it shrouded.
If there was a senior survivor, so much the better; he could be peremptorily dismissed by his employer, and his certificate suspended or otherwise dealt with by the authorities.
As a system it might have appeared harsh, but in its efforts to satisfy some pretty basic and unpleasant human traits, it revolved around the need to blame somebody else in order to demonstrate decisiveness and keep our own noses clean. It was also hopelessly ineffective as it did nothing to establish causation. In fact, as a system, it was only useful as a deterrent, much resembling public executions, which did little to prevent crime and really just showed the law flexing its muscles while providing some cheap entertainment.
The effort to look beyond the glib and inadequate explanation of human error is, at least in the maritime world, really quite a recent phenomenon. But at least we are trying, in attempting to broaden the human dimension into the various aspects of the human element, which only the terminally ignorant would now dismiss as insignificant. Through the good offices of initiatives like the International Maritime Human Element Bulletin Alert! along with valuable work at the International Maritime Organization and various casualty investigation agencies, among which the UK’s Marine Accident Investigation Branch shines like a beacon, we know that the human element matters. It is lurking behind virtually every marine accident, incident or near miss.
We know now that a human element dimension is a necessary part of regulation and the development of rules and procedures, and that its proper consideration will make ships more habitable, efficient and safer. Why has it taken us so long to wake up to its importance? The answer is that we are human, and human nature points us to the course that is easiest. It was much easier to deal with the technology, the nuts and bolts and steel thicknesses, the equipment specifications and things we could measure. Human error sort of tripped off the tongue, didn’t it? Why should we look any further? But thank goodness somebody did.
Thanks to those aforesaid agencies, we now recognise the importance of the human element and its contribution, but do we really understand enough about it? People are indeed quite complicated, and understanding the way we behave is central to any greater comprehension of this important subject. So a large bouquet to the UK Maritime & Coastguard Agency for grasping the nettle and producing The Human Element — A Guide to Human Behaviour in the Shipping Industry, which was published just over a week ago.
The guide emerged from the regular meetings of the MCA’s Human Element Advisory Group, which has been effective in bringing together people from all around the industry to think and talk about these issues. In this group, members have been exposed to thinking from other industries on a number of occasions, which really does help to widen perspectives, and in many respects has encouraged members to consider the contribution of behaviour in any study of why something happened. This guide, which seeks to help us understand better concepts such as risk and judgement, decision-making, complacency, the contribution of our cultures, communication and how we are affected by stress and tiredness, is a really worthwhile project.
It is written by organisational psychologists Dik Gregory and Paul Shanahan, who have experience in the defence, railway and air traffic control sectors and has been supported by BP Shipping, Teekay Marine Services and the Standard P&I Club. It is readable and from a maritime point of view, completely authentic, proving the authors have dug deep into this curious industry, its organisations and people. It is designed for masters and crews, owners and managers, designers and buyers, regulators and investigators, and all of these groups can take something useful away from its pages.
It is a guide that attempts to answer a lot of questions. How do we assess situations that confront us? What stimulates our decision-making process? Why do we take risks and what affects our judgement? What processes lead to mistakes? It also uses a number of case studies from maritime casualties and incidents that illustrate the practicalities of the concepts that the authors are introducing.
How do we make sense of what is going on around us? The authors point to an accident in the River Trent in which those in charge of three ships all made different sense of the same situation, with expensive results. A case of mistaken identity, with the master of one ship agreeing a course of action with a ship other than that he thought he was talking to, might be dismissed as an error. But the authors probe this chain of events, and demonstrate that a whole range of different factors, from personal needs to past experience and current practicalities were in play during this decision-making process, described as “inappropriate sense-making”, which led to a collision. The now notorious case of the cruiseship Royal Majesty , which grounded on a bank 17 miles off its planned course, further illustrates this problem of people seeing what they want to see, rather than the reality.
Similarly, we cannot eliminate risk from shipping. Ships have to go to sea, and they are fundamentally hazardous places, but people, by understanding risk better, can become better attuned to it. A valuable lesson provided is that equipment, designed to reduce risk, can have the opposite effect, whether it is seat belts or airbags encouraging us to drive faster, or the perceived safety from clever kit that makes us forget about the risks that were once in the forefront of our minds. There is a grim reminder of this from the fatal running down of the coaster Ash by the tanker Aquamarine , when the watchkeeper was lulled into a false sense of security by the track control system. Reduced sensitivity to risk can come from a variety of different sources, and the authors are insistent that risk elimination is not the answer, but people need to be given the means to become more accurately aware of it. Lessons here for both operators and for designers and equipment buyers, who need to understand how one’s appreciation of risk might be affected by the new kit being offered.
There are interesting sections on decision making, and the trade-off between efficiency and thoroughness, an area where perception may differ from reality or where inappropriate organisational pressures may intrude, especially in an era where time is regarded as crucial. It offers some of the answers as to why people break rules, and how an organisational culture can influence decision making, for good or ill.
This leads inexorably into the reasons why we make mistakes, and what can be done to stop mistakes developing into full-blown catastrophes. The authors suggest that skill-based, rule-based and knowledge-based activities are areas where we make mistakes and that inadequate rest or high stress levels, training and experience and inadequate communications are personal contributors to these. Organisational inadequacies also contribute, through time pressures, inadequate design, or staffing, along with an inadequate safety culture. The frightful example of the Scandinavian Star , where both personal and organisational inadequacies contributed to the loss of 158 people, is cited as a classic case. The authors also introduce readers to the important concept of accountability, and the need to protect organisations from things that happen, through the use of experience, foresight, systems thinking and expertise. The importance of a company developing a “just culture” which will promote communication, and change attitudes, is emphasised.
THE influence of fatigue and stress are seen to deserve a section all on their own, perhaps unsurprisingly bearing in mind the MCA’s championship of these important issues and its frustration at failing to accelerate international action to deal with something that we know causes serious accidents. The guide notes that there are many things that can be done to address fatigue, but also realistically points out that many parts of the shipping industry need to co-operate. How counter-productive is it that port inspections require the attention of fatigued ships’ crews? But who thinks about this as the inspections are scheduled? It also asks whether boardrooms which dictate that crews observe prescribed hours of rest and work provide them with operational and crewing policies that enable these rules to be kept. If not, the term is a “policy mismatch”.
The book, which is designed to be dipped into as much as something to read cover to cover in one session, also has important sections on learning and developing, working with others in an industry where teamwork is vital in so many different levels, communication with others and working with human behaviour. Peter Cardy, retiring head of the MCA, describes the book as “a building block for effective people policies”. Teekay Marine Services president Graham Westgarth says the guide reveals the complex challenges of human behaviour, and that it is needed by all sides of the industry. BP Shipping’s vice-president, HSSE Martin Shaw says the book is about the interaction of people with ships, and will help people and organisations recognise their own limitations.
I believe that it will make people who read it think rather more about their actions and behaviour, and that it will be seen as an important step away from simplistic ideas about error and blame.
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