Building “Error Tolerance” into the Marine Industry
by Capt. Timothy Crowch
www.assm.biz
1. Introduction
Increasingly over recent years, a growing number of organisations, particularly
those operating within complex industries, have been turning toward civil aviation
for assistance in establishing modern, effective safety strategies. The reason for
this is well known, namely, that since the early 1960s, the world of commercial
aviation has invested heavily in safety management and associated training
programmes and is proud to admit that the results are now testimony to the
return on that investment.
However, it was not always this way and we have had our share of “wrong
turnings” and failures along the way. The main benefit, though, from these
negative experiences is that we have learned from our past mistakes and turned
them into positive success stories.
In our world, the 1960s witnessed the introduction of the jet age, which brought
new technologies and demanded new flying skills from our aircrews. It also
brought the beginning of the recording devices that have now become
synonymous with flight safety. With the invention of the first Flight Data Recorder
(FDR) in 1957 by the Australian, Dr. David Warren, followed a few years later by
the Cockpit Voice Recorder (CVR) 1 , we now had the means of recording, at least
then in a rudimentary fashion, some of the aircraft’s behaviour and a little of that
of the crew. Ten years later, two airlines 2 started to analyse sporadically some of
this data to ascertain how their aircraft were indeed being operated away from
base. With time and with the advent of the digital age, these devices became
much more sophisticated and progressed from measuring tens of parameters per
minute to over 1500 per second. The analysis of the acquired data also matched
the sophistication but we were, on the whole, only measuring technical
performance and the crews’ technical skills.
Then on a Sunday afternoon in March 1977, in Tenerife, our worst nightmare
became reality when two Boeing 747s collided on ground in poor visibility caused
by cloud rolling in off the Atlantic and shrouding this high altitude airfield. That
afternoon, our industry killed 583 people – to this day the industry’s worst
disaster. There were a number of contributory causes to this accident but what
broke through the final defence barriers was a misunderstanding in
communication (between the air traffic controller and the crew as well as within
the crew) exacerbated by a very steep authority gradient on the flight deck of the
departing aircraft. The Captain believed that he had received his take-off
1
The original predecessors of the VDR
2
BOAC and Swissair
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clearance; the First Officer was of another opinion and attempted to intervene.
The Captain, rather than clarify the situation, overruled him, applied take-off
thrust and seconds later collided with another 747 that was still taxiing along the
runway as part of the taxiway had been closed for repair.
The realisation hit the industry that we were doing something very wrong and we
had no alternative but to change – we had to change the way we were operating
aircraft in the then modern environment; we could not tolerate creating such
gruesome spectacles for the travelling public. The industry would not survive. We
had been warned of such a possibility some years before but we chose to ignore
those warnings – to our cost. One immediate consequence was that one of the
airlines involved, KLM, launched their “KHUFAC” 3 programme created and led by
Dr. Frank Hawkins, then a Human Factors consultant and pilot with the airline. Its
emphasis was to be solely on the area of human factors or, otherwise referred to
as, “non-technical skills” training.
2. Pro-Active vs. Re-Active Safety Strategies
This was, in essence, the birth of aviation’s cockpit resource management (CRM)
later to be renamed “Crew Resource Management” as it started to encompass
crews and teams outside the cockpit. This philosophy has grown to the point that
we are now teaching a “6th generation” format of the original but the initial
pioneering work performed by Hawkins among others is as valuable to us today
as it was revolutionary then. The training targeted soft skills, interpersonal skills,
which, in the average pilot, had not been honed to the levels of his technical
skills. Here was the identified weakness in our operating system.
In parallel with this new Human Factors approach to training, data analysis was
used to support this, reporting systems were created and introduced; initially
these were anonymous only later to evolve into confidential and even, in some
companies, open systems. The emphasis was finally shifting from “reactive”
safety management to a more “pro-active” approach.
Modern safety management has, at it heart, the anticipation of danger, the
awareness of hazards and their identification. By raising the levels of awareness
of all members of an organisation’s staff to potential danger, we establish another
line of defence in our system. Our culture begins to change to one that protects
an organisation from possible events that have not yet happened.
Reactive safety management conversely is the most ineffective and expensive
form of safety. With this approach we will never prevent the first accident, at best
only the second. This philosophy presupposes that we are prepared to accept the
first accident in every category.
A number of shipping companies are integrating human factors training into their
crew training curricula but unfortunately too few. P & I Clubs and Classification
Societies are together collecting data that indicate that 80-90% of shipping
incidents and accidents can be traced to human error or inadequate team
performance. Despite these figures, crew training is still heavily weighted towards
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KLM Human Factors Awareness Course
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training and retraining of technical and ship handling skills. The human
weaknesses are almost being disregarded, with the result that there are often too
few “error tolerant” procedures in place on complex vessels. As with aviation in
the 1970s, many of the technical weaknesses in our system were improved with
improved technology but it was only when we radically shifted our focus to the
non-technical factors and fully integrated these into our training that we finally
laid the foundations for the safety record, which other industries wish to emulate
today.
The central point of the “pro-active” safety approach is the installation and
effective management of a safety reporting system. Without such a well-
functioning system, management is blind as to what is actually happening within
its fleet. The crews, those in the front line, are the eyes and ears of the company
and it is essential that they are motivated to report all perceived hazards, errors
and incidents to the safety officer. We must not omit to mention that these
systems are also ideal channels for feeding positive suggestions and good ideas
to the policy makers.
In addition to reporting, training is also a major component in ensuring safer
operations. For a pro-active system to work effectively, all ranks of a ship’s crew
ought to be availed of the same training, from the Master through all levels of the
officer team. This is essential as the introduction of a reporting system and a
safety programme (the first is only a component of the second) necessitates the
introduction of a totally new operating culture within the whole organisation.
Fear and reluctance normally predominate at the introduction of such a
programme. It can be wrongly interpreted as just another means by which
management wishes to control or even spy on its employees. Quite the opposite
is the case; a reporting system is finally a tool for the staff, a tool by which they
can effectively improve their working environment. It focuses on the staff and the
programme is driven by the staff. This message is seldom brought across to them
strongly enough, however. Only when all are fully integrated into the programme
will a “unité de doctrine” stand any chance of being established and, only when
that has successfully been achieved, will the system perform as the creators
designed it to and the management expects.
Safety management is another form of change management and we all know how
we inherently tend to resist change. It is unfamiliar, we fear it, we are suspicious
of it and it upsets our comfort zones. This is why it is imperative that safety
awareness and non-technical skills training accompany the introduction of safety
programmes. Such programmes demand a wholly new set of attitudes, behaviour
patterns, methods and styles of communication. This was the experience of the
aviation community and it was not easy. Those who needed the training most at
the start were exactly those who resisted it the most, walking out of what were
then voluntary training courses. However, the critical mass of the change drivers
slowly started to prevail and the former detractors realised that, even without
openly admitting it, they, too, might have something to benefit from the new
culture that was being introduced.
The result in the airline world was a flatter hierarchical structure, more open
communication, enhanced team performance and a phenomenal degree of “error
tolerance” in the entire system. People create safety, no person or system has an
automatic right to it; it has to be earned – every day.
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3. The Way towards “Error Tolerant” Marine Operations
Much has been written in more recent times on the Marine industry leaning
from aviation. Many of the proponents of safer marine operations concede
that the airline industry, though much younger, has overtaken marine. 4
It is, nevertheless, most important that we take time to recognise the
different characteristics of the two complex industries. There are fundamental
differences and it is essential that we are aware of these. However, it serves
us well to concentrate on the multitude of similarities that exist between the
industries and the common denominator is – the human element. We are able
to offer considerable support in this area as the increasing complexity of the
ship’s bridge environment is driving it closer to the aircraft’s flight deck and
the challenges facing the crews produced by systems automation and
integration. The same human weaknesses in the man-machine interface are
manifesting themselves.
Aviation is most fortunate in that the vast majority of research carried out into
human factors in aviation during the 1970s and 1980s was supported by State
Government institutions or universities, which have had generous resources at
their disposal. The knowledge gained, though, is not the exclusive property of
the aviation world alone and may be shared and profited from by other
complex, human controlled industries.
Whereas CRM or non-technical skills training is now mandatory in the airline
business throughout most of the world, it is a long way from being so in the
world of shipping. This is unfortunate because institutions, as mentioned
above, are gathering enough data to prove that the percentage of their
incidents resulting from deficiencies in non-technical skills (NTS) is similar to
that traditionally in aviation, namely 70-80%.
If we take the view that non-technical skills comprise the glue that holds
together the professionals’ technical skills, then the standard of NTS takes on
a new importance. By improving these skills, by raising them to the level of
the technical skills, we are taking a quantum leap towards a pro-active safety
management culture and building effective error tolerance into the marine
system.
Statistics point to the greatest causes of incidents and accidents being poor
communication, loss of situational awareness, poor decision-making, lack of
effective leadership, breakdown in team performance and non-adherence to
procedures and checklists. Nothing here has anything to do with the
individual’s ship handling or technical skills training and yet the training
programme emphasis remains on these technical skills instead of focusing on
these self-evident weaknesses in the operating system.
4
“Seaways” April 2009, The Nautical Institute
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At some time we have all heard the phrase “fail safe”. Simply defined it
means that if a component somewhere fails, the system in question (usually a
machine or the person operating it) will not come to grief. It is possible to
build the same principle into complex environments that are people intensive.
The starting point is to identify what is referred to in accident investigation as
a “single point of failure”. This implies in the complex environment that if the
individual perpetrates an error, either of commission or omission, then the
whole system becomes endangered and runs the severe risk of failing – and
tragically often does. The marine environment is littered with a multitude of
these single points of failure and the industry is fully aware of this. The old
culture of blame and punishment has failed to shore up the defences. Imagine
the consequences if, every time a pilot made a mistake, the result was an
accident. You do not have to look far for the answer – just review our pitiful
statistics of the 1950s and early 1960s and several recent fatal accidents in
Asia.
The more complex the working environment becomes, the greater the
demand for team performance. The complex world no longer tolerates “star
performers” as they have no place. We have all, as fallible humans, become
dependent upon one another. No-one can any longer function as an island, a
law unto him/herself. This intensifies the demand for perfecting skills in
communication, intervention, leadership, followership, judgement, decision-
making, feedback and more. Only by consciously developing new processes
and procedures can we effectively reverse the trends in incidents and
accidents. Attitudes towards different communication styles, to monitoring the
work of colleagues and to intervening in times of uncertainty must change.
However, they can only change and bear fruit in a new, open culture where all
involved are genuinely encouraged to anticipate an event and not await its
arrival. This is known as a “Just Culture” 5 and is a subject for another time. It
is essential to investigate all incidents and casualties thoroughly. It is then
critical, not only that the findings are published and circulated to all parties
but also that any resulting recommendations are acted upon and all possible
lessons learned. In the aviation world this is tragically the part of the safety
process where our reputation stalls and risks coming unravelled. This is a
harsh admission but true. Why? The industry is struggling to survive in its
present form and much-needed resources are being diverted elsewhere.
4. Toward a Safer Future
5
(Reason 1997) A “Just Culture” is an atmosphere of trust in which people are encouraged, even
rewarded, for providing essential safety-related information but in which they are also clear about
where the line must be drawn between acceptable and unacceptable behaviour.
It refers to a way of safety thinking that promotes a questioning attitude, is resistant to complacency,
is committed to excellence and fosters both personal accountability and corporate self-regulation in
safety matters.
A “Just” safety culture is both attitudinal as well as structural as some personal attitudes and
corporate styles can enable or facilitate the unsafe acts and conditions that are the precursors to
incidents and accidents.
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The external market pressures are enormous with the competitive,
environmental and, more recently, security demands being placed upon world
shipping. However, it is worth considering the short- and long-term
perspective. Are all economies and cost-cutting measures truly effective even
if the costs of failure are deducted from another account? Has everyone given
serious thought to the uninsured costs entailed in a marine casualty?
Safety management is a profit centre, not a cost position. It constitutes an
investment in future earnings. No-one budgets for an accident, the costs of
each tragedy are met out of net profit. Safety management is wealth
protection.
The cost of these accidents is increasing. The focus of the media is turning
away from the traditionally sensational aviation accident (there are not
enough of them) to another area that stirs public opinion sooner or later and
carries with it equal quantities of emotion as does an air disaster – the
environment. Where the media leads, litigation is not far behind. Criminalising
accidents is a subject all by itself but it is anathema to a healthy safety
culture. However, ignoring NTS training may, one day, risk being classified as
a breach of duty or even negligence. The world’s legal systems were designed
to deter wrongdoing not to deter human error and accidents. However, recent
high profile cases 6 are proving to us all that the thirst for “justice” and blame
is smudging these divisions to the detriment of safety in all complex
industries.
Pro-active thinking and the heightened need for “error tolerance” in every
aspect of the mindset of the shipping industry are the keys to protecting its
resources and its future image. The perception of the public is predominantly
subjective and highly emotional, facts and statistics are seldom given the
attention they deserve.
Tenerife forced change upon aviation – we had absolutely no alternative.
Change is painful but essential – the professional image of our two industries
hangs upon it. We ignore it at our peril but let it not be forgotten, it is easier
to change in our own time than to delay and have change imposed through
legislation upon us.
6
viz. The Hebie Spirit in South Korea (2007), the GOL air accident in Brazil (2006), the Tuninter air
accident in Italy (2005), the innumerable malpractice suits brought against Health Care professionals
worldwide.
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References:
1. “Just Culture”, Sidney Dekker, pub. Ashgate Publishing Ltd.
2. “Managing the Risks of Organisational Accidents”, James Reason, pub.
Ashgate Publishing Ltd.
3. Aviation Week & Space Technology, McGraw Hill, April 2009
4. “Seaways”, The Nautical Institute, April 2009
5. “Culture at Work in Aviation and Medicine: National, Organizational and
Professional Influences” by Robert L. Helmreich and Ashleigh C.
Merritt, pub. Ashgate Publishing Ltd.
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