Морская индустрия настолько зависит от человеческого фактора, что понимание его и методов работы с людьми, задействованными в индустрии, может трансформировать всю деятельность в этой сфере. Особенно важное значение имеет человеческий фактор в деле обеспечения безопасности мореплавания. Судоходные компании должны начинать работу по совершенствованию культуры безопасности задолго до того, как экипаж взойдет на борт, руководствуясь национальными и международными правовыми стандартами. Особую роль в подборе, подготовке и организации работы судового экипажа играют судовладельцы. Современный молодой руководящий состав и команда гораздо лучше оснащены техникой, так что при наличии соответствующей организации, мотивации и подготовки они могут сделать шаг вперед в развитии морской индустрии. Молодые экипажи и их руководящий состав выглядят более ответственными и способными чем предыдущее поколение. Следует смелее внедрять такие методы работы с людьми, как: сплачивание коллектива, руководство посредством собственного примера, самообучение, например. Большую помощь в организации работы с людьми судовладельцам оказывают ИМО, МФТР (ITF) и Морской институт Великобритании путем разработки стандартов, в частности, укомплектования штатов, регулирования фактора усталости моряков. Расчет на технику и технологию таит в себе значительные риски, и для их уменьшения важно использовать достижения науки о человеческом факторе. Таким образом, очень полезно привлечение к работе экспертов в этой области.
Эти идеи почерпнуты из презентации, представленной на Конференции по образованию, обучению моряков и крюингу в г. Одессе.
Shipping depends on successful voyages – successful for all of the parties involved. The shipowner must make a profit; the cargo must be delivered on time and in good condition; the passengers must go ashore happy and well; our planet is increasingly under threat so the successful voyage must protect and enhance the environment; our crews must be properly compensated and work in conditions that are good for them and for their families. These are shared interests – and even a minor navigational incident will negate them all. Some recent incidents have run up costs in the billions but even a minor incident has the capacitv to wipe out the profits of many voyages, pollute our planet, and cause injury and loss to life and property. Establishing effective defences to navigational incidents will always be good value for money.
Human factors were unheard of when I went to sea 42 years ago – and in many areas, they are equally unheard of or misunderstood today. In that time, I have come to understand the importance of adopting a human factor approach to our industry.
One could argue that we are alreadv well on the road, with Human Element Leadership and Management Training now required under STCW. But in fact, we arc only scratching the surface of what is required. We need to move far beyond the HELM requirements if we want to make a real difference.
Beyond blame
It would be all too easy to add some bullet points listing the latest marine accident reports from around the world. We could look at the errors, shake our heads about too much reliance on teclmologv, place the blame on an individual watch officer or the Master and move on.
As Master Mariners we are used to taking the blame – and perhaps because of that we are also too quick to allocate blame. In all of these instances the real errors and causes lie far bevond the bridge on the dav of the incident. I hope this article will motivate you to consider a far broader picture.
It is generally accepted that some 80% of marine accidents result from human error – although there is a school of thought that the percentage is ultimately closer to 100%. Humans make mistakes. To try to develop a situation where they don’t is to deny nature and is doomed to failure. In the March 2015 Seaways, Dr Nippin Anand wrote Accident Investigations – Learning From the Failure to Learn’. An important conclusion of this treatise is that ‘Human error should be the starting point for a serious investigation not the conclusion’.
Breaking the accident chain
The Swiss Cheese Accident Trajectory model developed by Professor James Reason illustrates how errors do not need to become accidents.
This model illustrates clearly how if we have sufficient defences in place, an accident will only occur when all of those defences fail and the holes align, so that the consequences of the mistake continue until they result in an accident. The key is to ensure we have the defences in place that prevent that inevitable mistake resulting in an incident. If we have established appropriate defences, the failure of any one layer will not be catastrophic.
These defences start long before the crew join the ship, and must be established not only at the operational level on board the ship but deep within the shipping company organisation and within national and international regulators. They cannot be limited to the bridge team, or even to the shore side.
Safety culture – from the top
Our objective must be an effective and comprehensive Safety Management System that provides workable guidance across the entire chain. Today we can only consider this in relation to navigation but there are undoubtedly lessons to be learned across all operational areas.
At the top of the chain is the IMO. The SOLAS and MARPOL conventions alone provide proof of its contribution to safety and security of shipping and the prevention of marine pollution. However, there is an increasing disconnect between the output from IMO and the needs of the mariner. To ensure safe navigation, IMO members and NGOs must focus on the implementation chain of their output and in particular such issues as:
• Construction standards and their impact on navigation and survivability.
• Design standards. The new Human Centred Design guideline will progress this issue but we need to continuously learn from the best of class in other industries.
• Training and its effectiveness in ensuring everyone in the chain is adequately trained for their position. “This must include not just the ship’s crew but the Designated Persons, the ship managers, technical superintendents, port state inspectors, surveyors, charterers and any others who make decisions that impact the ship’s operation.
• Competency and revalidation. We must learn to separate competency assessment from training. There is clear evidence that effective training is best achieved in an atmosphere of learning rather than in a situation where one’s career could be on the line.
• Use of simulators. It is a constant amazement to me how little time is spent on simulators. Good simulation can deliver reallv valuable learning in an increasingly realistic environment.
• Implement clear procedures and requirements informed bv human factors science across the chain.
We can make real progress on this final point if national administrations take a new look at how they implement IMO and other standards. Australia has shown a significant lead in this regard and there is increasing acceptance that thev are on the correct course. We need to say this more loudly and more publicly. If we embrace the science we can make a difference.
The shipowner
To make real change, the human factor revolution must impact deep within the organisation operating the ship (for the purposes of this article, the shipowner). The shipowner, armed with appropriate requirements from the regulators, must develop a clear view of what effective defences look like. I am not for a moment promoting overmanning, over-equipping, and certainly not over-regulating. What I am promoting is knowing w hat we want and providing for that outcome.
Design your ship to deliver for the voyage and for safe navigation. Well positioned equipment, good sightliiies, good living conditions, low noise and vibration and good food are obvious factors in securing this goal.
Manning and recruitment are obviously key factors. Staff must be qualified, motivated, sufficient in number, valued and well treated. It sounds too easy, but these things deliver results. Sadly, these things are still far from a reality in many sectors of the industry.
It is imperative that the shipowner transfers the regulatory training requirements into real effective activity. It is imperative that training deals with real life scenarios on the equipment and in the context that will apply on the ship. We can only do this with input from serving Shipmasters and officers and if we constantly validate our training against what it delivers.
The Designated Person under the ISM Code has a defined responsibility in this regard but the overall management structure has an equally onerous responsibility and duty.
With these measures in place we can redesign our SMS to give truly effective navigation support and guidance.
To achieve this we will need to remove any latent conditions that are increasing navigational risk. If you have a procedure and it is routinely not followed it is dishonest to rely on that procedure as a defence when things go awry. If you consistently allow bad practices to occur you cannot complain when they result in an incident. To identify these conditions we need input from serving Masters, and we need a genuine ‘just culture’ environment that encourages near miss and minor incident reporting. Just culture and no blame approaches are not intended to remove accountability but to ensure that we identity risks before they become incidents. Technology can help in this regard but honest reporting is the real effective tool.
We must mentor our staff ashore and afloat to ensure engagement with the concept of a living SMS. We must audit our actual practices and those of others to ensure we have a dynamic SMS subject to continuous improvement.
On board
Only now do we finally arrive on board the ship, where to date we attributed most of the blame.
The ship and the bridge should by now look very different. The benefits of our regulator}’ and organisational approach should be delivering a motivated and well trained crew. It’s now pay back time. The ship must deliver its part of our human factors revolution.
There is much discussion today in relation to the impact of technology and intuitive versus measured navigation of the vessel. People of my generation tend to complain that ‘voung people’ don’t look out the window enough; similarly younger officers no doubt cannot understand why my generation don’t use modern equipment to its fullest extent. There is a lot of human factor science behind how decisions are made, and particularly how we use our intuitive and reflective decision making processes. We need both, but when stress is invok ed we can start to miss things that we normally notice.
How many incidents have we seen where an officer focused on identifying a missing light or engaged with a difficult collision avoidance situation misses another danger or a course alteration? Our human factors process will ensure a defence for these situations.
There are variations in practice across our industry and we need to learn from the good practice of others. There arc positives in our industry. It is safer and far more environmentally responsible than when I went to sea and I believe young officers today are more capable and responsible than my generation.
We have the officers and crews, we have the equipment and it we have the will we can make a step change.
Putting ideas into practice
Leadership by example, team building, and attention to agreed process, self-knowledge and knowledge of those in your team are essential to a sate and well-run bridge. Let’s consider some practical steps which largely hinge on inclusive behaviour.
Good planning
Safe navigation starts with good planning – which needs to be berth to berth planning – and that means ensuring the plans have been properly reviewed. The entire team must be aware of the plan. This means that any unplanned diversion can be immediately challenged.
I am not advocating ‘redline’ navigation. We hear worrying reports of officers and even Masters who are unwilling to move off a company designated course line for any reason. Good practice includes setting and using safety margins where necessary.
Plans do change but when we need to change, we need to realise we are entering a very high risk situation. That risk increases further where the change is rushed and where we rely on technolog}-. Our defences arc in independent checking. We must discipline ourselves to check and recheck our plans and check, check and check again where we make unplanned changes.
Challenge environment
Thankfully, the days when the Master called you Mister and did a lot of shouting are past. Part of knowing yourself and knowing your team is about encouraging challenge.
It is difficult for a junior officer to challenge the Master during a stressful navigational manoeuvre but that is when we need it the most.
We have discussed intuitive versus reflective decision making and how one of the difficulties with intuitive decision making is that in stress situations it can cause us to over-focus and miss important factors. Our defence is encouraging challenge. With the intuitive approach it is less clear to others when the plan is not being followed and challenge is far more difficult.
The risk of a missed challenge increases w here language and cultural factors are involved. Language is a natural barrier on multinational ships – we must have a clear operational language and stick to it. Cultural factors such as power distance, collectivism and uncertainty avoidance are deeply ingrained and the Master must ensure that thev do not prevent challenge.
We must have effective defences against these issues in place. We must have crystal clear procedures, we must ensure our team are ready to challenge and we must test these defences before we need them and foster and reward good behaviour.
Many practitioners now advise a ‘thinking aloud’ approach. This involves saying what you are about to do and why and saying what you expect the result to be. Developing a thinking aloud habit can be very beneficial in encouraging effective challenge.
Manning and fatigue
Many procedures nowadays define Green, Red and Amber navigational conditions. Each condition requires a progressively greater level of manning and preparedness on the bridge. This creates an effective defence and represents best practice. The difficulty for many ships is where you get the men from.
At the I MO HTW2 sub-committee in November last The Nautical Institute tabled an information paper on manning and fatigue,
highlighting in particular the issue of Master/Mate two w atch systems, which we believe are inherently unsafe. Here, there is no possibility of Green, Red, or Amber manning levels – only a fatigued bridge team coping with whatever circumstance presents.
This is a latent condition that at very least represents a serious risk and is in all likelihood a direct causation for several serious incidents. There was no administration willing to join us in sponsoring the paper; there were no shipowning interests willing to join us in sponsoring the paper; the ITF and the NI stood alone on this one. The paper was ‘noted with appreciation’ and the meeting moved on. We have a long way to go on our human factor road.
Reliance on technology brings new risks. Those risks require new- thought and new techniques to fully mitigate their impact. Human factor science will be significant in mitigating those risks.
I am not a human factor expert but I am and intend to be a human factor champion. І ask you to join me in that campaign.
Based on a presentation given at the Education Training and Crewing conference in Odessa
I would like to recognise some real human factor experts. My own eyes were opened to these issues by Ravi Nijjer, a renowned expert and Nautical Institute member. Antonio Di Lieto has recently published a book on Bridge Resource Management using the Costa Concordia incident to illustrate some key learnings.
Much of this article is grounded in the writings of James Reason, truly one of the fathers of the science of the human factor.
Автор:
Captain Robert McCabe
FNI, President, The Nautical Institute
Seaways. – 2015. – June. – P. 6 – 8.