Human Element

by: G Sachdeva 1 30th April 2014
HUMAN ELEMENT
WHY DO THINGS GO WRONG?
SOME NUMBERS TO THINK ABOUT.

4 Major Incidents occurred EVERY TWO DAYS due to Human Errors during 2008.

40 - Ships collided, grounded or suffered explosions EVERY THREE DAYS from 2000 to 2005.

$ 4,000,000 - WAS THE VALUE OF CLAIM EVERY DAY from 2000 to 2010

$ 400,000,000 THE VALUE OF CLAIMS PAID OUT BY underwriters in 2008.

$ 4,000,000,000 was the cost of claim for Exxon Valdez.

$ 40,000,000,000 EXPECTED LOSS FOR BP FROM SPILL IN THE US GULF.

$ 400,000,000,000,000 Estimated Market Value of ExxonMobil in 2012.

HUMAN ELEMENT
WHY DO THINGS GO WRONG?
30th April 2014 by: G Sachdeva 3

The EIGHT traits of human element?
1. Make
sense of
things
2. Take
risks
3. Make
decisions
4. Get
tired and
stressed
5. Learn
and
develop
6. Work
with
others
7. Make
mistakes
8.
Communicate
with others

HUMANS

Human Traits
What is obvious to you, might not be same to the others.

What you see and understand, is what you expect to see.

Situations are constantly unfolding, you must share with colleagues.
Making mistakes and recovering from them is a fundamental human strength

Without error there is no learning. Potentially harmful mistakes must be prevented or
minimised.

Both individual competence and organisational culture are important for this.
1. Make
sense of
things

4. Make
mistakes
3.
Make
decisions
People make decisions differently to how they think they make decisions.

Decision making is different when you are learning as compared to when you are an expert.

Experience does not make you an expert, but to be an expert you must be experienced.

2.
Take
Risks
Everybody takes risk at some time or the other and this is inescapable.

Human perception of risk is quite different from the probability with which events occur.

We have to ensure that our perception of risk maps well into the world with which we interact.
.

Human Traits
People learn all the time.. It is important to learn the right thing at the right time.

People aspire to learn and the organisation should manage this to enhance safety and profitability.

In the absence of good management, these aspirations may dominate or be ignored bad outcome.

Fatigue and Stress have their causes and consequences.

We must always know how to avoid fatigue and stress

Workload can be managed with experience even when the job demands are high
6. Learn
and
develop
5.
Get tired
&
stressed
7. Work
with
others
Sometimes we work alone, at other times we work as a team member

Key problem is to have people skills as well as technical task skills

Things go wrong when these two skills are absent..
8.
Communic
ate with
others
Successful communication involves clear transmission, is only part of the story

Even with clear transmission, both parties were interpreting different meanings

Responsibility of the listener as well as the person sending the message should be understood.

.

Human Traits
What is obvious to you, might not be same to
the others.

What you see and understand, is what you
expect to see.

Situations are constantly unfolding, you must
share with colleagues.
1. Make
sense of
things

Human Traits

We make sense of things which support
our goals, plans and activities.

We see what we expect to see.

Each persons sense making is unique based on their physiology,
self culture, experience, social and intellectual needs.

Each person interprets the same situation differently.

We make sense of things based on
1.Our personal needs
2.Our self concept
3.Our past experience
4.The goals we share with others
5.Our current practicalities.

1. Make
sense
of
things

Human Traits

1 - Our personal needs

We have huge amounts of information.
Our mind filters these based on the needs
The most basic filter concerns our survival.
We get hungry, thirsty and tired. These demand attention.
When ignored these needs dominate our behaviour.

A more advanced filter deals with the need to find acceptance by
social groups we value, such as family, friends and colleagues.

Yet another advanced filter is concerned with recognition by our
peers for our personal achievements.

The most advanced filter looks at how the world can contribute to
our own growth and development for personal fulfillment.
1. Make
sense
of
things

Human Traits

2 - Our self-concept

Each of us know who we are and what we
are like. Our sense of personal identity is
developed through contact with friends, family, workmates,
managers and our cross cultural colleagues.

How we make sense of the same situation depends on our sense of
self whether we want to listen what we are told to, or, to follow
instructions, or to negotiate with authority etc. and this influences
our approach to team working.

Sometimes we may overload ourselves, in order to comply with what
we believe is expected of us, due to our own self-esteem. This could
cause to making incorrect sense of things by ignoring the big picture
and concentrating on a narrow focus to our self esteem.

1. Make
sense
of
things

Human Traits

3 - Our past experience

The conclusions and reflections from past
Experience shape how we make sense of
present situation.

The past experience may consists of beliefs, mental models, rules,
procedures and stories which we apply to the present environment
to make it meaningful. The more experience we have, the more we
apply the past to the present, even this it is only a projection and
may not be the best in the present situation.

Failure to appreciate this sometimes results in serious incidents
such as grounding, collisions etc.

We also confuse experience with expertise. Experience may result in
wrong conclusions, over confidence, complacency and risk taking.
1. Make
sense
of
things

Human Traits

4 Our shared goals

If we share a common goal, agree on a
joint goal and refine our understanding,
We can make better sense of things.

Goal sharing can be helped by training in teamwork and
understanding of each others roles, capabilities and limitations.

Where goals are different, problems occur. For eg: when Safety
considerations are given a lower priority over Commercial matters
and is seen to conflict with profit making.

When one perspective is allowed to dominate the other common
goals cease to exist. If situation is allowed to continue failure
occurs. For eg: if Regulators dominate Ship owners, there is room
for failure due conflict of interests.

1. Make
sense
of
things

Human Traits

5 Our need to be practical

As we have limited time always, we
process tasks based on incomplete
Information. We go for a working level
of understanding rather than dig deep to get all the facts.

An example of this is the modern Bridge technology and computers.
ECDIS, ARPA, RADAR, UMS, Computers, OWS, ODME, PMS etc are
all examples of technology advances which are complex and we
settle for the bare working knowledge.

In times of Crisis, we need simplicity of equipment to get the job
done practically and as best possible.
1. Make
sense
of
things

Human Traits
How big is SENSE MAKING problem?
Inappropriate sense making is a costly problem in terms of lost profits,
fines, injuries, investigations, legal costs, insurance costs,
environment damages or sheer human misery.
As per Lloyds Register, an average of 182 ships were
lost EVERY YEAR between 1995 and 2007.
This amounts to 160 Mill GRT lost.

When does SENSE MAKING get out of control?
1. Too many procedures, rules, regulations and technologies. These
are well intended, but land up doing the opposite.
2. Every incident leads to investigations & new recommendations to
plug the loop holes these are over-prescriptive & complicated.
3. Bigger rule books and more gadgets increase uncertainty,
ambiguity and complexity.
4. Automation leads to over-reliance on machines and lack of inter-
personal relations. Confusion reigns, when this fails
5. Insufficient attention to Team Work and Training, communication
skills and cross culture tolerances.
1. Make
sense
of
things

Human Traits

SOME DOs

Ask your people perhaps
they know or observe
something you missed.

If you observe an unsafe
behaviour go for the root
cause and ask the 5
WHYs, which is turn will
help you understand
more.

Get the team work
training, to understand
what motivates your team
and how they interpret
your messages.

1.
Make
sense of
things

SOME DONTS

Dont assume other people
think and understand like you
do. They have different
backgrounds and pressures
and see differently.

Dont ignore the hierarchy of
others needs physiological,
safety, social, self respect and
self development.

Dont under-estimate the
power of your feelings,
personal circumstances,
current pressures and past
experiences. They decide how
you react next.

Human Traits
No matter how good is our sense making,
we can never match the complexity of the world.

The assumptions we make and the things we do attract an element of RISK.

RISK refers to the chance that our sense-making will be inadequate to deal safely and
effectively.

OUR PERCEPTION OF RISK HAS LITTLE TO DO WITH ACTUAL PROBABILITY

The THREE main factors that influence our sense of risk are

1. The amount of control we think we have PERCEIVED CONTROL

2. The amount of value something has for us PERCEIVED VALUE

3. The extent to which things are familiar to us PERCEIVED FAMILIARITY

2.
Take
Risks

Human Traits
1. PERCEIVED CONTROL

The more control WE BELIEVE we have, the less risk WE BELIEVE we are taking.
Shore staff believe the risk of ship incidents is TWICE of that believed by Crew.

Overconfidence, skills or knowledge missing, Stress or fatigue lead to wrong beliefs.

People with well developed skills and highly pertinent assessment have a better
control over any situation.

Example of flipping a coin 8 times

What is the probability of the following sequence?
1 HHTHTTHT
2 HHHHTTTT
3 - TTTTTTTT

What is the probability of the 9
th
flip coming out TAIL?

2.
Take
Risks

Human Traits
2 PERCEIVED VALUE

The more an action appears to support a goal that
WE BELIEVE is important or highly desirable,
the LESS RISKY it will appear to be.

e:g: 1) Entering into a port beyond the point of no return to pick up pilot.
2) Leaving berth hastily in foggy condition to arrive at the next port earlier.

An action can also appear to be high value if it is the easiest way to achieve the goal.

e:g: We routinely take short cuts in flogging reports / checklists to satisfy the company
requirements for Hot-work, tank entry or Bunkering etc.

2.
Take
Risks

Human Traits
3 PERCEIVED FAMILIARITY

THE MORE FAMILIAR AN ACTION IS,
THE LESS RISKY IT WILL APPEAR TO BE

This is also known as COMPLACENCY which is known to be a major
contributor to most accidents. Like HUMAN ERROR, complacency
is an effect rather than a cause.

If our surroundings are familiar, we feel safer and more comfortable
and less prone to examine the risks on the job.

E:g: Pilotage in Singapore traits done it a 100 times
What can go wrong now? ZOEY

2.
Take
Risks

Human Traits
HOW TO GET BETTER AWARE OF RISKS?

Understand that RISK CANNOT BE TOTALLY ELIMINATED.

People NEED RISKS to provide excitement and avoid boredom.

It is not the Risk elimination that we seek,
it is the AWARENESS of Risk in their OWN BEHAVIOUR
and the BEHAVIOUR OF THEIR COLLEAGUES.

This awareness can be raised by
training in human perception
of Risk and the factors that influence it.

2.
Take
Risks

Human Traits
SOME DOS

Do be suspicious if things seem
under control and on track,
familiar, comfortable, quiet and
safe. You might be missing
something.

Do try to train yourself and your
team for HUMAN PERCEPTION
OF RISK. It will avert the
development of Complacency.

Do try to maintain your fall back
measures when faced with new
and sophisticated equipment.
Going back to basic
seamanship might get you out
of trouble should these
complex instruments fail.

SOME DONTS

Do Not confuse qualification with
experience. People cannot
become aware of equipment
risks by just studying the
books. They need to experience
these first hand, and mentored,
monitored by other colleagues.
If people are promoted without
enough experience, they will
under-estimate the risks they
take and expose all toe great
dangers and costs.

DO NOT confuse a persons rank
with his status of information.
The higher the rank, the greater
the responsibility but they have
to ensure that those with
relevant knowledge are heard.
2.
Take
Risks

Human Traits
HOW DO PEOPLE MAKE DECISIONS?

To make a rational decision, you must
Have complete information about alternatives
Be able to distinguish between alternatives
Use comprehensive criteria
Have the time to do all this.

In practical situation, this does not happen as
TIME IS ALWAYS LIMITED and
INFORMATION IS NEVER COMPLETE.

Peoples decisions are a trade-off between
available information (thoroughness)
and
the time available (efficiency)
3.
Make
decisions

Human Traits
EFFICIENCY vs THOROUGHNESS

Efficiency increases when people spend less time and effort in thinking
and more time in action.
When this is reversed, thoroughness increases as the cost of efficiency.

For an organisation If Safety and Quality are very important then
thoroughness is favoured.
If production targets and outputs are emphasised, then efficiency if
favoured at the cost of safety.

Every decision made is a compromise between Efficiency and
Thoroughness.

Thoroughness is produced by training, mentoring, on-the-job briefing and
experience over time.

If organisational expectations are too demanding and the staff are not
thoroughly trained, this will lead to unnecessary risk taking with drastic
consequences.

3.
Make
decisions

Human Traits
10 RULES WHICH GOVERN OUR WORKPLACE BEHAVIOUR

1. It looks fine or it is not really important. (If it aint broke, dont fix it)
2. Its normally OK or much quicker this way (done it million times)

3. It is good enough for now (it is better than average expectations)
4. It was checked earlier and we will recheck it later (dangerous)

5. There is no time or no one to do it now so do not worry (false hope)
6. I do not remember how to do it and do not have the time (see manual)

7. We must get this done in time no time for procedures (dangerous)
8. It looks like something we know. (assumption convenient for next step)

9. If you do not tell anyone, I wont either (lets ssshhh, we took shortcuts)
10. I am not an expert so will let you handle it (dont want responsibility)

3.
Make
decisions

Human Traits
Why do people break rules?

At work, people are immersed in organisational culture which favours
efficiency . When rules are knowingly broken, it is to improve the teams
efficiency. Rule breaking is a major cause of accidents.

The violations arise due to following
1. Trying to solve a pressing problem with limited knowledge instead of
stopping and seeking advice.
2. Trying to take a short-cut or work-around. Soon these become the
norm as these are seen as efficient measures. When things go wrong,
the short-cut taker gets disciplined rather than the Policy maker whose
policy might not be practical in the first place.
3. When a supervision is lacking this allows unchecked broken rules,
sets in complacency and allows rule breaking to get worse and
frequent due to no accountability.

3.
Make
decisions

Human Traits
HOW DOES ORGANISATIONAL CULTURE INFLUENCE DECISIONS?

1. Incident reporting policy Most companies have it, but reporting should
not conflict with reputation, bonus etc. Absence of report does not
mean everything is OK. Incident reporting may not increase safety.
2. Management Policy Managers usually favour efficiency to
thoroughness. Non efficiency is noticed fast. If things go well, its all
praise. If they do not then the blame is for lack of thoroughness.
3. Subcontracting Policy Subcontractors are under pressure to perform
but if they report too much they may lose contract as they feel
efficiency is favoured over thoroughness.
4. Cost Policy Most Organisations like to reduce cost by cutting down
unnecessary, but the interpretation may be different. It is often used to
favour efficiency over thoroughness.
5. Policy Integrity Organisations say they want Safety (thoroughness)
but their Policies and performance measures target efficiency.
3.
Make
decisions

Human Traits
Expert decision making

Decision makers are dependent on their training and experience.

Expert decision makers

1. Have an accurate mental picture of what is going on and what can
happen next. Situational Awareness.
Perception, Comprehension and Projection.

2. Are able to arrive at good decisions directly often under time
pressure. Situational Familiarity.
Using past similarity of incident or from stories heard before to
compare the present situation and to project it to the end result.

Novice decision makers must rely on the rule book or look for a mentor
which takes time and they may take decisions based on what makes
most sense in their limited experience background.

3.
Make
decisions

Human Traits
SOME DOS

Do recognise that everyone
in the organisation balances
efficiency with thoroughness.
If people are untrained or
inexperienced and cross the
line, they sacrifice
thoroughness and cause
unsafe situations, risks.

Do support investment in
training and competency
testing, apprenticeship,
mentoring.

Do find ways to motivate and
retain staff following the 10
years to make them experts
in your organisation.

3.
Make
decisions
SOME DONTS

1. Dont send mixed
messages to your staff
asking for safety and
demanding efficiency at
the same time to push
them to take short cuts.
Rule breaking is a
major cause of
accidents.

2. Dont assume that you
can take shortcuts in
getting expertise. It
takes about 10 years of
structures and guided
experience to develop
an expert do not lose
him.

Human Traits
4.
Make
mistakes
Making mistakes is normal for people including experts, but safety
critical mistakes can have serious consequences.

The mistakes we make could be
1. Skill based well practiced, so tend to lose focus or suffer
memory lapse and can lead to mistakes.

2. Rule based where we focus more on procedures and rules or
apply rule incorrectly than use good seamanship and common
sense and make mistakes.

3. Knowledge based where what needs to be done requires
knowledge, but, we make incorrect sense of situation on wrong
information. This is usually a result of insufficient training or
experience or bad communication.


Human Traits
4.
Make
mistakes
2008 A DISASTEROUS YEAR?

US$ 548, 000, 000 PAID IN CLAIMS DURING 2008

135 VESSELS WERE LOST, NEARLY 3 PER WEEK

41 OF THESE WERE DISASTERS (CLAIM $ 18M, IMPACT OVER
$85M)

1600 PEOPLE DIED OR WENT MISSING DUE MARITIME
DISASTERS

150 PEOPLE DIED ON GEN CARGO SHIPS YEARLY FROM 2002-
2008


Human Traits
4.
Make
mistakes
Factors which mostly lead to mistakes

Inadequate rest or high stress level reduces attention,
concentration and slow reaction.
Insufficient training and experience trying to do a job with little
knowledge or failure to understand and prevent a dangerous
situation.
Inadequate Communications It involves clear messaging, empathy,
active listening and understanding cultural norms.
Inadequate time Time pressure where thoroughness is sacrificed
for efficiency
Inadequate design Poor design or over complicated design
increases stress and encourages use of short cuts and mistakes.
Inadequate staffing Less people or people with extended contracts
tend to cause stress, de-motivation, low morale and overload others.
Inadequate Safety culture MOST IMPORTANT Commitment from
Senior management ashore, investment in training, making the right
policies and procedures and overseeing implementation onboard.


Human Traits
4.
Make
mistakes
Mistakes are PREDICTABLE and
could be traced down to
CAUSE & EFFECT

Here the primary cause, secondary cause and root cause is identified
and fixed. Safety specialists perform risk assessment and rectify
flaws in work procedures.
Efficiency usually wins (economic considerations)
Behaviour drifts towards danger (also known as Complacency)
Mistakes are invisible till a disaster strikes (just a decision before)
Accidents keep happening anyway (Organisational culture).

The Cause & Effect analysis is mostly historical based on what
happened. In live situation as every incident can be traced down to
differing circumstances, this usually becomes additional bureaucracy.


Human Traits
These could happen UNPREDICTABLY from
behavior of complex systems

This is a new view how mistakes are made. The world today is a complex
system of interacting, circular relationships.

1. Humans Create Safety Humans do not cause errors, but the gaps in
any system are corrected by humans if they are given freedom to cope
with unexpected, as no system can be made fully tight.
2. Organisations are actually organic Safety emerges continuously from
overall behaviour of an organisations components, including its people.
A good safety record promotes Complacency and allows risks to grow
unseen. Political or economical forces can shift organisations shift away
from safety.
3. Organisations create the bahaviour they get Operating within
commercial, political, regulatory framework, they tend to drift away from
what is actually beneficial for the organisation.
4. Protecting organisations from things that happen Rules and
procedures design to limit system variability may avert accidents to a
point but they also prevent beneficial novel behaviour.

4.
Make
mistakes

Human Traits
4.
Make
mistakes
SUCCESSFUL ORGANISATIONS HAVE FEWER
ACCIDENTS BECAUSE

Expertise is developed, retained and exploited.
to achieve greater efficiency, people in organisation identify failure
and develop alternate strategies creating minimal safety margins.
Expertise and ability to read complex situations and project into future
plays a crucial role in their assessment.

Organisation pay attention to their fault lines
The real risk to safety is often in interfaces between different parts
of organisation such as charterers, builders, crew, managers etc. Good
organisations analyse near misses and accidents for interface faults.

Decision making is based on system thinking
Look for faults in the systems which include PSC, Flag, regulators,
Designers, Charterers, managers and the crew. Not just rules.


Human Traits
4.
Make
mistakes
WHO IS ACCOUNTABLE AND WHAT CAN BE DONE?

It is normal to make mistakes.

Wider organisation factors are critical in shaping our behaviour.

The industry has now shifted from Blame Culture to Just Culture.

Principles of Just Culture which apply to EVERYONE.

Human error is inevitable and organisations policies, processes
and interfaces must be continually monitored and improved to
accommodate these errors.

Individuals should be accountable for their actions if they
knowingly violate safety procedures and policies.


Human Traits
4.
Make
mistakes
SOME DOS

Do recognise that mistake
making is part of normal
human behaviour and is
generated in part by
organisational systems.

Do look for any downside of
cost-oriented changes in your
organisation. These will
sacrifice thoroughness for
efficiency, which leads to more
mistakes and less inclination
to catch them.

Adopt and implement a JUST
culture. It needs transparency
at ALL levels and open and
honest incident reporting. It
will improve safety which
transforms in profit taking.

SOME DONTS

Dont be misled by the
power of hindsight. It is
useful to investigators but
not as much when actions
unfold.

Dont imagine that there
will ever be a rule for every
eventuality. Behaviour
emerges from complex
interactions between
people and systems. It is
not completely predictable.

Human Traits
People learn all the time.. It is important to learn the right thing at the right time.

People aspire to learn and the organisation should manage this to enhance safety and profitability.

In the absence of good management, these aspirations may dominate or be ignored bad outcome.

Fatigue and Stress have their causes and consequences.

We must always know how to avoid fatigue and stress

Workload can be managed with experience even when the job demands are high
6. Learn
and
develop
5.
Get tired
&
stressed
7. Work
with
others
Sometimes we work alone, at other times we work as a team member

Key problem is to have people skills as well as technical task skills

Things go wrong when these two skills are absent..
8.
Communic
ate with
others
Successful communication involves clear transmission, is only part of the story

Even with clear transmission, both parties were interpreting different meanings

Responsibility of the listener as well as the person sending the message should be understood.

.

Human Traits
5. Get
tired &
stressed
REMEMBERING THE EXXON VALDEZ DISASTER

In March 1989, Exxon Valdez struck Bligh Reef off Alaska and spilt
11 Million US Gallons of Crude oil into the sea.

The slick covered almost 11 thousand square miles of ocean and
killed thousand of sea creatures. The local fishing collapsed and
many residents committed suicide. Billions of Dollars were spent on
cleanup and compensation.

At the time of accident, the 25 year old 3
rd
mate and an able seaman
were on bridge. Both had not been given the mandatory 6 hours rest
before their 12 hour duty.

The Companys manning policy did not consider the increase in
workload caused by reduced manning.

Human Traits
WHAT CAUSES FATIGUE?
Workload The harder people work, the sooner they need time to recover.
Workload is influenced by design of tools, equipment, procedures, and expertise
gained through training and experience.

Sleep debt This builds up if people do not get enough sleep of the right sort and
causes people to misread situations, overlook key information and fall asleep even
when this would put them and others to extreme risk.

Perceived risk If people are stimulated by their sense of risk, they can stay awake
and alert longer. If doing tedious or boring jobs then they feel tired sooner. People
increase their exposure to risk to stimulate themselves.

Diet heavier means with carbohydrates encourage drowsiness whereas lighter
protein meals induce wake-fullness.

Fitness & Movement Overweight and non- exercising people feel fatigued earlier.

Time of day People live by natural daily rhythms. They are least alert during early
hours of the morning and most alert before mid-day.

Environment - Environment with poor lights, noise, vibration, temperature and
motion cause fatigue. Some aromas such as lemon encourage alertness.

5. Get
tired &
stressed

Human Traits
5. Get
tired &
stressed
CASE STUDY GENERAL CARGO VESSEL ANTARI

In June 2008, Ch Officer began his 6 hour watch on Bridge on passage from Corpach to Ghent.
As vessel headed south at 11 knots with the west coast of Kintyre peninsula on the port side, the
next course change off Mull of Kintyre would be 11 miles away. The Ch Off excused the AB who
had done the cargo watch earlier and was needed for deck maintenance as was now alone on the
Bridge after taking over from the Master who had done the earlier 6 hour shift.

With both wheelhouse doors closed, clear, moonless night. Calm sea and slight westerly winds,
the Ch Officer settled in the Pilot Chair next to the ECDIS on the Stbd side, to rest a bit. The watch
keeping alarm had been switched off earlier, not to disturb the others. He was soon asleep and
woke up after the ship had run aground three hours later.

The Ch Officer had not shown any outward signs of fatigue even though he was involved with
cargo watch the previous night. The Master know that he had slept between 0230 to 0600 hrs the
previous night. Antari had made 21 port calls within last 2 months and every port call required
both Master and Ch Officer to be involved. Audits and Statutory Inspections had also taken place
along with other Port visitors. Both Master and Ch Officer had been doing 6 on 6 off for some
time and a TIME BOMB was ticking in terms of SLEEP DEBT. Not having a second person on
bridge made matters worse.
AS PER MAIB, 82% GROUNDINGS THAT TAKE PLACE
BETWEEN 0000 TO 0600 HRS ARE DUE TO FATUGUE.

Human Traits
5. Get
tired &
stressed
SIGNS OF FATIGUE

External Signs: Vacant stare with sunken, bloodshot eyes, Eye strain, sore or heavy eyes,
dim or blurred vision, Droning or humming in the ears, Paleness of Skin, Slurred speech,
Headaches, Feeling colder than others in the room, Faintness or dizziness, lack of Energy,
drowsiness, Unstable posture / swaying, dropping chin, nodding head, loss of muscular strength,
stiffness, cramps, loss of manual dexterity, difficulty in making fine movements.

Operational Signs:
Degraded mental performance confusion, poor concentration, narrowed perception,
forgetfulness. Leads to poor response to changing situations.
Diminished personal Safety Reduced self and situation awareness, leading to apathy, less
attention to personal hygiene, neglect of normal safety precautions and more risk taking.
Impaired leadership Take longer or make poorer decisions. Fatigue makes people accept
irrational, erroneous or illegal orders or ignore good ones.
Worsening Team Performance decreased interaction with crew and degraded communication
due to lower sensitivity to other peoples needs and aims. Moody, loss of humour, irritable,
argumentative, socially withdrawn all which affects crew relationship.
Decreased Morale Fatigue decreases satisfaction, motivation and interest in team efforts.
Pessimism increases, people thing of the worst scenario, reject group and take offence easily.
Odd Behaviour People may talk gibberish, neglect routine tasks, have stupid accidents and
suffer hallucinations.
24 hours without sleep is same as 25% over the UK drink-drive limit


Human Traits
5. Get
tired &
stressed
THE 5 STAGES OF SLEEP

1. Dropping off: Transition stage between wakefulness and light
sleep. This stage which is short lived and 5% of your sleep feels
like falling off a cliff as muscles suddenly relax.
2. Light sleep: Accounts for about 50% of the sleep.
3. Deep Sleep: Progressively deeper sleep where physical and
mental recovery takes place. The amount of deep sleep depends
on the fatigue experienced before sleep and harder to get up,
longer to be fully alert. Disturbance such as loud noise, takes
you back to light sleep.
4. Deep Sleep: Same as above.
5. REM Sleep: This is the dream stage when muscle and spinal
reflexes are maximally suppressed. This stage is critical for
mental stability. Lack of REM sleep results in irritability, poor
judgment and hallucinations. If sleep deprived then REM sleep
occurs on the second night after first night of deep sleep.

Human Traits
5. Get
tired &
stressed
HOW TO AVOID FATIGUE

STICK TO THE RULES: Everyone needs to stick to the work / rest hour regime
without fudging records (this offers false security and is often discovered after an
incident with disastrous consequences). After Antari grounding investigation, it was
found that shipstaff had pre-recorded their work / rest hours irrespective of whether
they were working or asleep.

STICK TO THE SPIRIT OF THE RULES: People at all levels of the company and ship
must facilitate, support and implement existing work / rest hour regimes. Lip Service
does not improve safety. The Organisation culture is important here.

FOLLOW A FATIGUE MANAGEMENT PLAN: THE SHIPOWNER / MANAGER
ENSURES: that the ISM Code is clearly communicated, joining crews are adequately
rested, proper hand-over is done on crew change, voyage lengths and leave periods
are OK, god use of time in port is given for administrative functions and Language
barriers, social, cultural and religious isolation is overcome. THE MASTER
ENSURES: Owners policies are implemented, Crew loneliness, boredom, higher
workload is met, adequate shore leave, onboard recreation and family contact is
maintained, effective work/rest arrangements and napping opportunities are
provided.


Human Traits
WORK REST HOURS RULES

Mandated by Article 5 of ILO 180:
Maxm hours of work shall not exceed
14 hours in any 24 hr period
72 hours in any seven day period.
Minimum hours of rest shall not be less than
10 hours in any 24 hour period

Hours of rest may be divided into no more than 2 periods of which one shall be at least 6 hours.
Interval between two consecutive rest period should not be more than 14 hours.

Little more flexibility exists in STCW 1978 Section VIII/I

Other facts:
66% seafarers work 4 weeks off / 4 weeks on.
50% seafarers work 12 hours on 12 hours off
25% seafarers work 6 hours on / 6 hours off.
200% percent is the probability of an incident in 12 hour shift as compares to 8 hour shift.
40% seafarers think they are in danger to themselves and colleagues due to their working hours
50% reduction in incidents can be achieved by small naps.
Most seafarers think that fatigue can be reduced by lesser paperwork and more staff.

Get
tired &
stressed

Human Traits
WORK REST HOURS RULES

Mandated by Article 5 of ILO 180:
Maxm hours of work shall not exceed
14 hours in any 24 hr period
Minimum hours of rest shall not be less than
10 hours in any 24 hour period

Hours of rest may be divided into no more than 2 periods of which one shall be at least 6 hours.
Interval between two consecutive rest period should not be more than 14 hours.

Little more flexibility exists in STCW 1978 Section VIII/I

Other facts:
66% seafarers work 4 weeks off / 4 weeks on.
50% seafarers work 12 hours on 12 hours off
25% seafarers work 6 hours on / 6 hours off.
200% percent is the probability of an incident in 12 hour shift as compares to 8 hour shift.
40% seafarers think they are in danger to themselves and colleagues due to their working hours
50% reduction in incidents can be achieved by small naps.
Most seafarers think that fatigue can be reduced by lesser paperwork and more staff.

5. Get
tired &
stressed

Human Traits
6. Learn
and
develop
People are always learning. We are doing it right now.
We learn by aspiring, copying, comparing, interpreting and
practicing. As we learn, we change into different people with newer
capabilities.

The Organisations have to make sure that with the right guidance,
they learn the right things. When organisations invest in training,
they take control of their own future.

Learning depends on the learner and should be within grasp,
interesting, rewarding and direct the learner to new levels of
performance and achievement.


Human Traits
6. Learn
and
develop
What is the difference between EDUCATION and TRAINING

The aims of both are different.

Education widens and extends peoples horizons. It brings a
universe of opportunities.

Training focuses on response and behaviour to achieve
performance standard. It concentrates on a narrow band of a
constrained section.

Both demand a large increase in a persons mental and behavioral
repertoires.


Human Traits
FORMAL vs INFORMAL learning

Formal learning comes with effective principles. In the absence,
most learners learn from colleagues, take shortcuts and learn
informally which can lead to unsafe behaviours which may
manifest only after an injury or an incident has taken place.

People form attitudes about their organisations and the industry.
Whatever they learn, they transmit to others, which maintains an
overall culture of the organisation.

PEOPLE ARE OUR GREATEST ASSET, is true where organisations
share their best practices in knowledge, skills and in attitudes
focuses on organisations goals.

Learning involves deliberate and significant investment of time,
money and effort by individuals and organisations.

6. Learn
and
develop

Human Traits
LEARNING and SENSE MAKING

Whether learning is formal and deliberate or Informal and
automatic, people need to create meaningful mental connection
between what they understand and what they are trying to
understand.

The key difference is in emphasis.
In Sense making, the focus is on applying knowledge, skills and
attitudes from previous learning to current operations.
By doing so, new learning results.
In learning, the focus is in using sense making to acquire new
knowledge, skill and attitude.
By doing so, better sense-making and learning capability results.
6. Learn
and
develop

Human Traits
6. Learn
and
develop
BENEFITS OF TRAINING TO ORGANISATIONS

1. Increased organizational performance
2. Better organizational culture
3. Reduced staffing problems and operational costs.

THE FOUR STEPS FOR EFFECTIVE TRAINING
1. Analyse needs Task identification Gap identification and
solution identification.
2. Design content Learner engagement Knowledge training
Skills training Trainee feedback. Modes used are Hi Fidelity
simulation, CBT, Embedded training, Chalk and Talk etc.
3. Evaluate results Trainee satisfaction Course objectives
Job performance Organisational performance.
4. Go to step 1.


Human Traits
TEN POINT CHECKLIST FOR ORGANISATIONS

1. We know what each of our employee needs to be able to do what is expected in a safe and effective
manner because we have a comprehensive competency network.

2. We know what our employees know because we carry out competency tests in realistic setting within
proven framework.

3. The competency framework we use recognizes that many competencies are interdependent and have to
be considered together e:g: ships and shore operations.

4. The competency framework is connected to our training needs analysis methods and training courses.

5. The training programs we deliver are based on trainees actual needs by reference to their job they need
to do and takes into account their learning styles.

6. Our training is effective because we assess responses to it immediately after each course, again in a few
weeks for retention tests and on the job as part of our regular competency assessments.

7. We collect data on job performance, productivity, turnover, incident rates and bahaviour, which is then
used to evaluate our training programs and strategy.

8. We understand the training power of communicating by story telling and experience sharing, and, we
have created opportunities for doing so in Office and onboard.

9. We understand that good trainers require subject matter expertise and teaching skills, in terms of
structuring, pacing, feedback methods, trainee engagement that accounts for age and skills.

10. Our trainers have access to a full range of training aids and know how to use hi fi simulation, CBT, part-
task training, classroom training, one to one training and refresher training.

6. Learn
and
develop

Human Traits
SOME DOS

DO be aware that people learn all the
time and mostly from colleagues.
Organisations have to ensure they
learn the right stuff by training
everybody.

Do consider SCOPE or TOTS or
SIGGTO for your organisation.
Experience is essential but it is
equally important to learn to do the
right thing in the first place.

Do understand that good trainers
understand how students view the
training and use the material. Having
the best material is not enough.

Do carry out training needs analysis,
training design and outcome
evaluation for all staff as continuous
improvement in organisation. This
leads to better performance, safety
culture and lesser problems.

SOME DONTS

DONT assume that one
training fits all. Different
people need different levels
of support depending on their
level of expertise.

DONT be satisfied with
training evaluation which
stops at training satisfaction.
Dig deeper and check the
course objectives, job
execution and organizational
performance. This also
reassures the organisation
that the expertise needed is
available to the organisation.
6. Learn
and
develop

Human Traits
7. Work
with
others
Working with individuals requires different sets of skills than when
working in teams.

Working with Individuals with their own individual goals requires inter
personal skills.
Working in teams requires people working to support each other to
achieve a common goal. Here effective interaction and teamwork is
needed.

To get the best out of each other, there is a need to assess people, to
confront a difficult and complex issue and to negotiate a disagreement
and difference of opinion.

Human Traits
TEAM SKILLS

Team Leadership
(motivating, directing, coordinating team activities,
developing team members knowledge and skills)

Mutual mentoring
(ability of team members to monitor and guide their
colleagues within a common understanding of goal)

Back-up behaviour
(team members understand each others tasks and work
together to lighten or spread the load)

Adaptability
(Ability of team members to respond to changes in
environment and create better ways to improve
performance)

Team Orientation
(This is the ability of the team members to see themselves
as team members with a common goal and are highly
receptive to each other)

7. Work
with
others
TEAM GLUE

Similar mental models
(The mindset should be similar for a common
understanding and how each contributes to the joint
output and performance)

Mutual Trust
(this is needed so that each team member feels that
their actions, mistakes and misgivings will be
supported and dealt efficiently and constructively with
regard to common overall goal)

Effective communication
(this is to ensure that messages between team
members are delivered and understood completely
and not misinterpreted)

Human Traits
CASE STUDY COSCO BUSAN
On 7
th
Nov 2007 at 0800 hrs. Vessel fully loaded with 900 containers left San Francisco for South Korea in dense fog.
The bow was sometimes not visible due to fog swirls.
The Pilot was 26 years experienced in the Bay. The vessel has an escort tug aft.
The Master, 3
rd
Off and helmsman were on Bridge. All crew were Chinese having joined two weeks earlier. They had
been supervised by the old Ch. Eng., Suptd and Port Captain during the passage.
At 0830 the vessel struck Delta Tower of Bay Bridge.
The impact caused hull breach and spill of 53,000 gallons of fuel oil which damaged 26 miles of shoreline,
closed 27 public beaches, no fishing for over 3 weeks and death to 3000 birds apart from other marine life.
The Direct cost of repair was USD 2,100,000.
The cost of repair to the Bridge was USD 1,500,000.
The vessel owners paid a fine of USD 10,000,000 to US DOJ. The legal costs are unknown.

Findings
The Pilot was on medication and a cocktail of 10 different drugs had clouded his mental ability.
There was ineffective communication between Master and Pilot prior departure and during the accident
The Masters monitoring of Pilots capability was ineffective.
The ship manager failed to adequately train crew.
The USCG failed to adequately respond to the Pilots medical circumstances.
The Far Eastern Crew were submissive and did not challenge the US Pilots expertise, authority and physical condition.
The Crew did not speak English well. The Ships SMS was in English and not enough time to read and understand.
The Crew did not each other well and being new to the Owner did not know Owners expectations well.
No one had received any formal training in Bridge Team Management.
The company overlooked Crews need to deal with Foreign port authorities and pilots and had no plans for training.

THE PILOT, CREW AND THE MANAGEMENT ASHORE FELL SHORT OF
EVERY ASPECT OF EFFECTIVE TEAMWORK.
7. Work
with
others

Human Traits
7. Work
with
others
SOME DOs

DO consider how you can
assess the level of
teamworking in your
organisation.

DO insist on training in
teamworking. It is different
from Technical Skills and
Knowledge.

DO insist on Cultural
difference training.
SOME DONTs

DONT avoid difficult
conversations. These are
necessary and avoiding
these or not facing these
when onboard could lead
to greater
misunderstanding later.

DONT be afraid to stand
up and point out when
anything seems to be
incorrect or going wrong,
even if it means standing
up to an expert, Senior or
Authority.

Human Traits
8.
Communicate
with others

Human communication is the process of influencing a human receiver to
create thought and action that is consistent with, and responsive to, the
senders purpose.

Case Study Pride of Provence

Even when the communication is ample, failure can still result because
Different perspectives of listeners are ignored
There is no common goal and people interpret for the moment without
anticipation or the big picture.

Even with a common knowledge, culture, country effective communication
can fail because each one of us interprets the situation based on our own
ambitions, needs and experiences. To effectively communicate, we must
empathise with the other as much as the message we want to convey.


Human Traits
8.
Communicate
with others
HOW DO YOU DO? National Cultures affect Communication

Power distance A Measure of where the Power is - In LOW power countries like Denmark, Sweden,
US and Germany the subordinates readily approach and contradict their bosses. The consult with one
another often. In HIGH power countries like Panama, India, Philippines and France The people are
more dependent on their bosses and spend less time consulting with one another.

Individualism A Measure of Independence from one another - Individual nationals of USA, UK,
Australia, France, Sweden and Denmark value self-respect and speaking ones mind. Information is
explicit and in the message. Collective nationals of Panama, Pakistan, Philippines and Greece value
harmony and like to protect the groups goals therefore do not put explicit messages.

Masculinity A measure of assertiveness and materiality - Highly Masculine nations like Japan, Italy, UK
and Philippines value material success, progress and competition and see the gulf between facts and
feelings. In contrast the Scandinavian nations and Netherlands value modesty, tenderness, consensus
and caring relationships.

Uncertainty avoidance - A measure of ambiguity tolerance High tolerance nations like Denmark,
Sweden, UK, India, Philippines and the USA are comfortable with unfamiliar risks, innovation and living
by the day. They are less comfortable with excessive rules, displays of emotions and have to learn
precision and punctuality. Low tolerance nations like Greece, Portugal, Japan, France, Spain and
Panama like rules and precision. They are sensitive to anxiety, they need to feel busy and for them time
is money.


8.
Communicate
with others
HOW BIG IS THE COMMUNICATION FAILURE PROBLEM

It is the main feature for 25% of all accidents in UK rail Industry.
It is responsible for over 50% of all accidents with track workers in UK
rail
It is responsible for 25% of all accidents in Australian Aviation Industry.
It is responsible for 30% of all accidents in US general Aviation.
It contributed to the shooting down of Libyan Airliner by Israel in 1973.
It led to shooting down of Iranian Airbus in 1988 by USS Vincennes.
It led to the shooting of two Black Hawk helicopters by UN in 1994
It is often the cause of most friendly shootings in defense establishments
It is the cause of twice as many deaths in US Health sector as skill lack.
It accounts for over 60% of all errors in Operating rooms and ICU in
USA.
It accounted for the torpedoing of my ships chartered to Red Crescent.

AT LEAST 25% OF ALL ACCIDENTS INVOLVE COMMUNICATION FAILURE.
PREVENTING COMMUNICATION FAILURES REQUIRES ACTION AT ALL ORGANISATIONAL LEVELS.

Human Traits

8.
Communicate
with others
PREVENTING COMMUNICATION FAILURE

Lack of Media Skills and Knowledge People may know what, where and how to communicate but may be
physically unable to do due to noisy environment, lack of training or lack of common language fluency.
Address these by proper recruitment and selection policies, procedural training courses, procedure based
manuals and training in Standard Marine Communication phrases (SMCP).

Lack of Task Skills and Knowledge People may not have enough training or skills on the job assigned to
know what to communicate and to whom.
Address these by task training to performance standards and refresher training to prevent skill fade.
Procedure based manuals should be onboard and well understood by all.

Lack of team task skills and knowledge People may not understand the team goals or requirements and to
understand what to anticipate and what is critical.
Best addressed by training such as BRM, tabletop exercises, team building and Seminars.

Lack of social skills and cultural knowledge People may not appreciate how cultural and demographic
differences affect communication understanding or how to overcome personal differences or
incompatibilities.
Address these by personal skills, leadership, cultural awareness, diversity and equality training programs.

Lack of Communication process skills People may not understand their and others 'mental processes
involved in successful communication. This is best addressed by Critical Thinking and leadership training.

Lack of time Fast moving, fast developing, sudden, change conditions or heavy workload distracts people
in sensible and effective communication.
Best addressed by good job design, mentoring, task / team training programs and regular emergency drills.

Human Traits

Human Traits
8.
Communicate
with others
SOME DOS

DO ensure that your
organisation pays full
attention to skills and
knowledge which are the basis
of effective communication.

DO encourage staff to ask and
answer clarifying queries.
People often assume their
situation to be different form
the actual.

DO understand the risk of
communication failure under
heavy workload.

DO understand the enhanced
risk of communication failure
with people who lack the
knowledge. They may miss
vital signs.

SOME DONTS

DONT assume that the message sent has
been received. The importance is not just
the receipt but the understanding and
implementation. The sender has as much
responsibility as the receiver in ensuring
effective communication.

DONT underestimate the power of
communication failure to wreck your
business operations. These account for at
least 25% OF ALL ACCIDENTS.

DONT confuse language with
communication. Communication only takes
place when the receiver makes a decision
or chooses an action to the senders
response.

DONT assume that NO NEWS IS GOOD
NEWS as the sender may be having
difficulty in sending his communication
due to environment, workload, equipment
incorrect assumption, etc.


people
1.
Make
sense

6.
Learn &
develop

2.
Take
risks

3.
Make
decisio
ns

7.
Work
with
others

8.
Comm
unica
te

3.
Make
decisions

5. Get
tired
and
stressed

4.
Make
mistakes

2.
Take
risks

5. Get
tired
and
stressed

5. Get
tired
and
stressed

1.
Make
sense

1.
Make
sense

8.
Comm
unicate

7.
Work
with
others

6.
Learn &
develop

4. Make
mistakes

SUMMARY SHEET

Human Traits
Case Study Collision between Chemical Tanker and Container vessel in Singapore

Chemical Tanker ABC is in the TSS Singapore Straits heading for Pilot boarding
grounds. She is steaming at 9.0 Kts on a steady course. Weather and visibility are
good and 2
nd
Officer is on watch along with an AB and Senior Cadet. The Master
who was on the Bridge earlier has just retired to his room to check emails.
Container Vessel XYZ is departing Singapore, destined for Hongkong and has
slowed to about 6.0 Kts. outside of TSS to drop Pilot. She intends to cross the TSS
after dropping Pilot and steam full speed to Hongkong. Master, Ch Off and AB are
on the Bridge.

8 minutes before the collision took place, the container vessel was spotted. The
Second Officer checked the speed, which was 6 Kts and was confident that the
vessel would cross about 2 cables astern of ABC.
2 minutes before the collision, VTIS Singapore calls ABC advising her of a container
ship crossing the TSS. The 2
nd
Officer responds that he is aware and takes no
further action.

The two vessels collide causing hull damages and Pollution from the vessel XYZ


Human Traits
Case Study Collision between Chemical Tanker and Container vessel in Spore

What went wrong?

1. The ABC 2
nd
Officer believed he was in control of the situation and was
confident that the container vessel, then doing 6 kts would cross TSS clear
astern.
2. The ABC 2
nd
Officer having crossed this channel almost every other week,
believed he was well familiar with the route and another container vessel
crossing her was one of those things you do not worry about.
3. The ABC 2
nd
Officer did not bother to track the other vessel nor requested the
Cadet to assist him or call Master because in his perception there was no Risk.
4. The Master of ABC was very experienced and has been trading in this area for
years, and confident that nothing would go wrong retired to his room.
5. His perception of Risk of leaving the 2nfd Officer in charge was incorrect due to
over-reliance placed on his subordinates.
6. When the collision became imminent, the 2
nd
Officer was confused. This
situation was out of the ordinary and he was not prepared for it. Had he done
nothing, there is a possibility that the ships would have missed each other.
HUMAN ELEMENT
ANY
QUESTIONS..
PLEASE FEEL FREE TO ASK ANY QUESTIONS.

HUMAN ELEMENT
WITH PROPER UNDERSTANDING THINGS WILL NOT GO WRONG

THANK YOU
PLEASE SEND YOUR FEEDBACK TO

sachdeva@greenwave.com.sg

Ph +65 9182 6775

Human Element

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by: G Sachdeva 1 30th April 2014

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