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The Human Element in shipping Commodore David Squire, CBE, FNI Editor Alert! The International Maritime Human Element Bulletin Slide 2 Slide 3 Slide 4 Slide 5 Slide 6 The Human Element Slide 7 An alternative to the term Human Factors to avoid ambiguity and aid comprehension (CAP 719 - Fundamental Human Factors Concepts, Chapter 1, Art 1.4) Human and organizational influences on marine safety and maritime system performance (US Coastguard Prevention Through People website (http://www.uscg.mil/hq/g-m/nmc/ptp/) Slide 8 The Human Element A human act under the influence of predominant factors (MSC 82/15/6 - SMS Self Assessment - A Key To Human Element Management (The Russian Federation)) Predominant factors: Those factors that have the greatest impact on persons Slide 9 The Human Element Embraces anything that influences the interaction between a human and any other human, system or machine aboard ship Slide 10 Has been with us since time immemorial Systems have changed: Increased electronic technology Maintaining the competitive edge Reduced running costs Reduced manning scales Cheaper & multi-national crews Differing interpretations of international guidelines Inconsistent standards in lifestyle, training & education The Human Element Slide 11 The norms of past experience amongst the seafaring population are not immediately transferable to computer based control systems & other new technologies Competition in shipping services has reduced manning levels so that back up may not be available in critical situations Ships are operating to tighter schedules & to more critical tolerances The Human Element Slide 12 Ships are becoming more integrated into transport chains, thus the consequences of failure are greater Growing international public pressure to protect the marine environment The majority of crews are employed from supplier countries having different cultures & languages & differing attitudes towards education and training The Human Element Slide 13 Shipyards/equipment manufacturers optimising production methods separately - do not always develop integrated, operator- focused systems Ships trials do not adequately test all ship systems International regulation lags behind the operational needs of modern ship systems Ship types getting larger - consequences of single failure more significant The Human Element Slide 14 The perfect ship? A compromise between: what is needed to satisfy the regulations what is absolutely necessary to fulfil the operational role what is affordable what the design team perceive to be acceptable to the generic seafarer Must be fit for purpose Slide 15 Slide 16 Slide 17 The over-reliance of the watchkeeping officers on the automated features of the Integrated Bridge System The failure of the Company to ensure that its officers were adequately trained in the automated features of the Integrated Bridge System and in the implications of this automation for Bridge Resource Management Deficiencies in the design and implementation of the Integrated Bridge System, and in the procedures for its operation Slide 18 Slide 19 The chief engineer did not communicate the gravity of the generator problem to the master The ships safety management system checklists were of a general form and would not have provided any guidance or advice which would have been of assistance Although the ships safety management system provided for periodic training for such emergency situations, this scenario had last been practiced more than ten months prior to the incident Slide 20 Slide 21 The incident was causedby the poor interpersonal relationship that developed between the pilot and the master Communication between members of the bridge team was conducted in a language unfamiliar to the pilot The investigation was hindered by the lack of information from the VDR which had not been backed up immediately after the grounding (highlighting a deficiency in crew training) Company procedures were not followed with respect to the keeping of bridge records Slide 22 Slide 23 Charterers directed that no changes be made to layout of operating compartment Operating compartment was poorly designed and equipped and did not comply with the High Speed Craft Code. Further deficiencies included: poor instrumentation layout, light pollution from the passenger cabin, faulty instrumentation and control station window demisting difficulties Slide 24 Slide 25 Lack of commitment & inadequate allocation of resources by the ship management company OOW fatigued and drunk on watch No lookout employed Bridge watch alarm inactive (didnt know how to use it) Poor quality of spoken english Excessive working hours of Master & mate Slide 26 Slide 27 STCW 95 in respect of bridge watchkeeping poorly applied Too few watchkeepers on the bridge, excessively heavy work loads, poor organization on board and insufficient crew numbers all lead to inefficient watchkeeping, partial or even non-existent processing of nautical information and reduced situational awareness Call for better qualifications, better organization on board, increasing crew numbers and stricter control of safety management and full compliance with international conventions Slide 28 Slide 29 Ships engineers were unable to correctly diagnose the reason for the engine faults Did not have sufficiently good knowledge of the main engine control system or specific system engineering training to successfully diagnose faults The generic training undertaken by marine engineers during courses leading to professional qualifications, may be insufficient on its own to equip engineers to operate, maintain and successfully diagnose and repair faults on fully integrated, complex engine systems The proliferation of and problems with the identification of alarms Slide 30 Slide 31 Failed to make a programmed course alteration while in automatic steering Mate/master did not notice change in system mode No proper training in the use of Integrated Bridge Systems Deficiencies in the ergonomics of the bridge design Poor situational awareness Routinisation Slide 32 Over-reliance on automation Inadequate design & implementation of systems & in operating procedures Generalisation of safety management system checklists Poor maintenance Poor communication Slide 33 Inadequate onboard continuation safety training Disregard for rules & regulations Regulatory, design/construction & training deficiencies Inadequate training in operation, maintenance & fault finding of technically complex, and multi- discipline systems Slide 34 Failures in effectiveness & spirit of application of shore & onboard ISM procedures Minimum manning Use of lookout Effects of fatigue & alcohol The proliferation & identification of alarms Slide 35 Poor contingency planning for safety-critical situations on board Inadequacies in procedures covering the dissemination of information Routinisation and complacency Slide 36 It makes sense That a ship should be designed and built with the user and the operational task in mind, taking into account the environmental conditions that it is likely to encounter during its working life That experienced crew should stand by during the build to ensure that the ship and its systems are ultimately fit for purpose, and that the crew should be familiar with their ship well before it leaves the builders yard Slide 37 That the ship should be sufficiently manned to ensure its safe operation For crew members to be competent to operate the ship and its systems, in accordance with the requirements of international conventions and industry guidelines For those who are involved in the design, build, regulation and management of ships and their systems, to have an understanding of the ways of the sea It makes sense Slide 38 To ensure that handbooks and operating instructions take into account the different nationalities, languages and cultures of seafarers, and that they are set out in a clear and simple manner, are not technically complicated and are easily understood That seafarers are able to communicate effectively in the execution of their duties and that their knowledge of the English language is sufficient to be able to communicate safety messages both internally and externally It makes sense Slide 39 To invest in quality not only through compliance with international conventions but also through self-regulation and voluntary commitment to industry standards and codes of practice To invest in people by encouraging the highest standards of education and training and a common spirit of professionalism in the industry; and by providing the seafarer with a safe, happy and healthy working and living environment, and fair terms of employment It makes sense Slide 40 To keep the human element under review throughout the lifecycle of any ship to take account of changes in its role, its operating pattern, system updates, improved technology and new regulation For all responsible stakeholders to work together to ensure that ultimately the master and his crew have the right tools in place, and are properly trained, to ensure the safe conduct of the ship, and the safe and timely delivery of its cargo It makes sense Slide 41 Its common sense! Slide 42 http://www.he-alert.org