HUMAN ELEMENT
WHY DO THINGS GO WRONG?
16th July 2015
by: G Sachdeva
1
HUMAN ELEMENT
WHY DO THINGS GO WR
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 3 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
30th April 2014
– Estimated Market Value of ExxonMobil in 2012.
by: G Sachdeva
2
HUMAN ELEMENT
16th July 2015
by: G Sachdeva
3
30th April 2015
by: G Sachdeva
4
16th July 2015
by: G Sachdeva
5
Human Traits
1. Make
sense of
things
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.
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.
.
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.
Making mistakes and recovering from them is a fundamental human strength
4. Make
mistakes
Without error there is no learning. Potentially harmful mistakes must be prevented or
minimised.
Both individual competence and organisational culture are important for this.
16th
July 2015
by: G Sachdeva
7
Human Traits
5.
Get tired
&
stressed
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
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.
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.
.
16th July 2015
by: G Sachdeva
8
1. Make
sense of
things
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.
16th July 2015
by: G Sachdeva
9
Human Traits
• We make sense of things which support
our goals, plans and activities.
1. Make
sense
of
things
• We see what we expect to see.
• Each person’s 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.
30th April 2014
by: G Sachdeva
10
Human Traits
1. Make
sense
of
things
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
5.30thInsufficient
attention to Team
Work and Training,
April 2014
by: G Sachdeva
16
Human Traits
SOME DO’s
Ask your people – perhaps
they know or observe
something you missed.
1.
Make
sense of
things
If you observe an unsafe
behaviour – go for the root
cause and ask the 5
WHY’s, which is turn will
help
you
understand
more.
Don’t assume other people
think and understand like you
do.
They
have
different
backgrounds and pressures
and see differently.
Don’t ignore the hierarchy of
others needs – physiological,
safety, social, self respect and
self development.
Don’t
under-estimate
the
power
of
your
feelings,
personal
circumstances,
current pressures and past
experiences. They decide how
you react next.
Get
the
team
work
training, to understand
what motivates your team
and how they interpret
your messages.
30th April 2014
SOME DON’T’S
by: G Sachdeva
17
Human Traits
2.
Take
Risks
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
30th April 2015
by: G Sachdeva
18
Human Traits
2.
Take
Risks
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 9th flip coming out TAIL?
30th April 5014
by: G Sachdeva
19
Human Traits
2.
Take
Risks
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.
30th April 2015
by: G Sachdeva
20
Human Traits
2.
Take
Risks
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
30th April 2015
by: G Sachdeva
21
Human Traits
SOME DO’S
Do be suspicious if things seem
under control and on track,
familiar, comfortable, quiet and
safe. You might be missing
something.
2.
Take
Risks
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.
30th April 2015
SOME DON’T’S
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 person’s 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.
by: G Sachdeva
23
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.
3.
Make
decisions
In practical situation, this does not happen as
TIME IS ALWAYS LIMITED and
INFORMATION IS NEVER COMPLETE.
People’s decisions are a trade-off between
available information (thoroughness)
and
the time available (efficiency)
30th April 2014
by: G Sachdeva
24
Human Traits
3.
Make
decisions
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 at 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.
30th April 2014
by: G Sachdeva
25
Human Traits
3.
Make
decisions
10 RULES WHICH GOVERN OUR WORKPLACE BEHAVIOUR
1. It looks fine or it is not really important. (If it ain’t broke, don’t fix it)
2. It’s 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 won’t either (lets ssshhh, we took shortcuts)
10. I am not an expert so will let you handle it (don’t want responsibility)
30th April 2014
by: G Sachdeva
26
Human Traits
3.
Make
decisions
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.
30th April 2014
by: G Sachdeva
27
Human Traits
3.
Make
decisions
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.
30th April 2014
by: G Sachdeva
28
Human Traits
SOME DO’S
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.
3.
Make
decisions
Do support investment in
training and competency
testing, apprenticeship,
mentoring.
Do find ways to motivate and
retain staff following the 10
30th April 2014
years to make them experts
by: G Sachdeva
SOME DON’T’S
1. Don’t 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. Don’t assume that you
can take shortcuts in
getting expertise. It
takes about 10 years of
structures and guided
experience to develop
30
an expert – do not lose
4.
Make
mistakes
Human Traits
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.
30th April 2014
by: G Sachdeva
31
4.
Make
mistakes
Human Traits
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 20022008
30th April 2014
by: G Sachdeva
32
4.
Make
mistakes
Human Traits
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
30th April 2014
by: G Sachdeva
33
policies and procedures and overseeing implementation onboard.
4.
Make
mistakes
Human Traits
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 apply to EVERYONE (even staff ashore).
•
Human error is inevitable and organisation’s 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.
30th April 2014
by: G Sachdeva
37
Human Traits
4.
SOME DO’S
•
•
•
Make
mistakes
Do recognise that mistake
making is part of normal
human behaviour and is
generated
in
part
by
organisational systems.
•Don’t be misled by the
power of hindsight. It is
useful to investigators but
not as much when actions
unfold.
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.
30th April 2014
SOME DON’T’S
•Don’t 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.
by: G Sachdeva
38
5. Get
tired &
stressed
Human Traits
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 3rd mate and an able seaman
were on bridge. Both had not been given the mandatory 6 hours rest
before their 12 hour duty.
The Company’s manning policy did not consider the increase in
workload caused by reduced manning.
30th April 2014
by: G Sachdeva
40
5. Get
tired &
stressed
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.
30th April 2014
by: G Sachdeva
41
5. Get
tired &
stressed
Human Traits
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.
, 82%
AS PER MAIB
30th April 2014
GROUNDINGS THAT TAKE PLACE
BETWEEN 0000 TO 0600
ARE DUE TO FATUGUE.
by: GHRS
Sachdeva
42
5. Get
tired &
stressed
Human Traits
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.
30th April 2014
by: G Sachdeva
45
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
72 hours in any seven day period.
Minimum hours of rest shall not be less than –
10 hours in any 24 hour period
77 hours in any seven day 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. Causes most accidents.
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.
April 2014
by: Gby
Sachdeva
46
Most30th
seafarers
think that fatigue can be reduced
lesser paperwork and more staff.
6. Learn
and
develop
Human Traits
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.
30th April 2014
by: G Sachdeva
47
6. Learn
and
develop
Human Traits
What is the difference between EDUCATION and TRAINING
The aims of both are different.
Education widens and extends people’s 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.
30th April 2014
by: G Sachdeva
48
Human Traits
SOME DO’S
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.
6. Learn
and
develop
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.
DON’T assume that one
training fits all. Different
people need different levels
of support depending on their
level of expertise.
DON’T 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.
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
30th and
Aprillesser
2014 problems.
SOME DON’TS
by: G Sachdeva
53
7. Work
with
others
Human Traits
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.
30th April 2014
by: G Sachdeva
54
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)
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)
•
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
30thother)
April 2014
by: G Sachdeva
7. Work
with
others
55
7. Work
with
others
Human Traits
CASE STUDY – COSCO BUSAN
7th
On
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, 3rd 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.
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 impact caused hull breach and spill of
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 Master’s monitoring of Pilot’s capability was ineffective.
The ship manager failed to adequately train crew.
The USCG failed to adequately respond to the Pilot’s 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.
30th April 2014
by: G Sachdeva
56
Human Traits
SOME DO’s
DO consider how you can
assess
the
level
of
teamworking
in
your
organisation.
7. Work
with
others
DO insist on training in
teamworking. It is different
from Technical Skills and
Knowledge.
DO
insist
on
difference training.
30th April 2014
SOME DON’Ts
DON’T
avoid
difficult
conversations. These are
necessary and avoiding
these or not facing these
when onboard could lead
to
greater
misunderstanding later.
DON’T 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.
Cultural
by: G Sachdeva
57
8.
Communicate
with others
Human Traits
Human communication is the process of influencing a human receiver to
create thought and action that is consistent with, and responsive to, the
sender’s 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.
30th April 2014
by: G Sachdeva
58
8.
Communicate
with others
Human Traits
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.
30th April 2014
by: G Sachdeva
60
Human Traits
SOME DO’S
•
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
30th April 2014
knowledge. They may miss
8.
Communicate
with others
SOME DON’T’S
• DON’T 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.
•DON’T underestimate the power of
communication failure to wreck your
business operations. These account for
at least 25% OF ALL ACCIDENTS.
•DON’T
confuse
language
with
communication. Communication only
takes place when the receiver makes a
decision or chooses an action to the
senders response.
•DON’T assume that NO NEWS IS GOOD
NEWS as the sender may be having
difficulty in sending his communication
due
to
environment,
workload,
by: G Sachdevaequipment incorrect assumption, etc. 62
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 2nd 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 2nd Officer responds that he is aware and takes no
further action.
The two vessels collide causing hull damages and Pollution from the vessel “XYZ”
30th April 2014
by: G Sachdeva
64
Human Traits
Case Study – Collision between Chemical Tanker and Container vessel in Spore
What went wrong?
1. The “ABC” 2nd 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” 2nd 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” 2nd 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 2nd 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.
30th April 2014
by: G Sachdeva
65
ANY
QUESTIONS…….
30th April 2014FEEL FREE TOby:ASK
G Sachdeva
PLEASE
ANY QUESTIONS.
66
HUMAN ELEMENT
WITH PROPER UNDERSTANDING THINGS
WILL NOT GO WRO
THANK YOU
PLEASE SEND YOUR FE
sachdeva@targets
16th
July 2015
by: G Sachdeva
67
Ph +65 9182 6