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The Role of an Education in the Behavioural Sciences Towards Contributing to a

Safety Culture in the Maritime Industry

Research · November 2015

DOI: 10.13140/RG.2.1.1317.8322

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 WORLD MARITIME UNIVERSITY
Malmö, Sweden

THE ROLE OF AN EDUCATION IN THE BEHAVIOURAL SCIENCES

TOWARDS CONTRIBUTING TO THE SAFETY CULTURE OF THE
MARITIME INDUSTRY

By

CAROLYN A. E. GRAHAM
Jamaica

A dissertation submitted to the World Maritime University in partial fulfilment of

the requirements for the award of the degree of

MASTER OF SCIENCE

In

MARITIME AFFAIRS

(MARITIME EDUCATION AND TRAINING)

2008

© Copyright Carolyn A. E. Graham

ii
 ACKNOWLEDGMENTS

Ingratitude is worse than witchcraft

To my benefactor, Mr. Yohei Sasakawa and the staff at the Ocean Policy Research
Foundation, who saw it fitting to award me with a fellowship to study at the WMU,
thank you.

Thanks to Professor Jens-Uwe Schröder, my supervisor and Michael Ekow Manuel,

for tolerating the barges into your respective offices and the constant questions and
lamentations. Both your comments and direction were insightful and I hope I did
them justice.

To persons within and outside the university community who took the time to answer
questions and discuss with me; to Professor Nakazawa, head of MET specialization,
who took an interest in my progress; to Cecilia Denne in the library who was most
helpful in sourcing and advising on new material that was useful to this work.

To my friends and family home, thanks for the prayers and the encouragement.
Barbara Andrews at work, thank you. Sean Ffrench, Delmares White and Sydney
Innis, special and dear friends, for helping to keep things together in my absence.
Nikki Kea, who was my constant companion on Hotmail Messenger when I was
close to packing my bags to go home, thank you.

Marclene Gail Merchant, Guyana and Nadège Chia Angbo, Côte d` Ivoire, two
school mates and two of the lasting friendships I have developed. Thanks for keeping
me from starving when I was a prisoner at my desk.

Thanks to my host family, Maria and Ed Epstein and their children, for the warmth
and social gatherings that made the distance from home tolerable.

iii
 ABSTRACT

Title of dissertation: The role of an education in the behavioural sciences

towards contributing to the safety culture of the maritime
industry.

Degree: MSc
Developing a safety culture is a prime aim of the maritime industry as spearheaded
by the International Maritime Organization. For several reasons such as number of
accidents and a poor public image, safety culture is seen as a way to move beyond
current levels to optimum safety. However, the human factor poses a challenge to the
achievement of a safety culture and the dissertation argues that this is more so due to
the neglect of a holistic engagement with the behavioural sciences in devising
solutions to the need for non-technical skills.

Through literature review, case studies and interviews, the dissertation explores
safety culture and the factors impacting its development. A number of factors which
shape performance such as fatigue, lack of teamwork and poor situational awareness
were identified as needing attention. The role of MET and the STCW in contributing
to effective training of the seafarers to counter the negatives of the performance
shaping factors was examined. It was found that both needed to be improved. The
relevant aspects of the behavioural sciences were investigated to ascertain their
contribution to creating awareness and understanding of the performance factors.

It was concluded that in order to develop a safety culture there has to be a holistic
approach to the human factor and that the behavioural sciences has a role to play. It
is recommended that with further research, the STCW considers making mandatory,
the training in the relevant aspects of the behavioural sciences that are relevant to the
development of the non-technical skills in the maritime industry.

KEYWORDS: Safety culture, behavioural sciences, human factor, maritime

industry, maritime education and training, STCW convention.

iv
 TABLE OF CONTENTS

Declaration ii

Acknowledgements iii

Abstract iv

Table of contents v

List of tables x

List of figures xi

List of Abbreviations xii

Chapter 1: Introduction: Engaging The Science Of Man 1

1.1 Safety Culture In The Maritime Industry 2

1.2 Human Factor Contribution To Maritime Accidents 4

1.3 Maritime Education And Training 4

1.4 The Behavioural Sciences 5

1.5 Summary/Statement Of The Problem 7

1.6 Objective 7

1.7 Methodology 7
1.71 Cases 8
1.7.2 Literature Review 9
1.7.3 Interviews 9
1.7.4 Other Sources 9

1.8 Theoretical Considerations/Definition Of Concepts 9

1.8.1 Safety Culture 10
1.8.2 Behavioural Sciences 11
1.8.3 Human Factor 11
1.8.4 Other Concepts 12

1.9 Chapter Summary And Conclusion 12

v
Chapter 2: Safer Shipping Demands A Safety Culture 14
2.1 Introduction 14

2.2 What Is Safety Culture? 16

2.2.1 Definition 17
2.2.2 Safety Culture And Safety Climate 20

2.3 Why A Safety Culture For The Maritime Industry? 22

2.3.1 Safety In Shipping 23
2.3.1.1 Can Safety Culture Be Regulated? 25

2.4 Human Factor: A Challenge To Safety Culture? 26

2.5 How Is Safety Culture Achieved? 28

2.5.1 Approaches To Achieving Safety Culture 29
2.5.1.1 Social Engineering 29
2.5.1.2 Evolutionary Model 30
2.5.1.3 Reciprocal Safety Culture Model 31
2.5.1.4 The Convergence Model 32

2.6 Safety And Security 34

2.7 Chapter Summary And Conclusion 36

Chapter 3: Human Performance In Safety-Critical Systems 37

3.1 Introduction 37

3.2 The Safety Critical System 38

3.3 Human Erroneous Acts 40

3.4. Human Performance In Safety-Critical Systems 41

3.4.1 Assessing Performance 44
3.4.2 Nature Of Human Performance 44
3.4.3 Performance Shaping Factors In The Maritime Industry 46

3.5 Reducing Human Erroneous Acts 46

3.6 Chapter Summary And Conclusion 48

Chapter 4: Education And Training Of Seafarers - Part I

The Role Of Training Institutions In Safety Culture 49
4.1 Introduction 49

vi
 4.2 Theories Of Learning 50

4.3 Teaching Methodologies 52

4.3.1 The Use Of Simulators 53

4.4 Context 53

4.5 Content 55
4.5.1 Culture 56
4.5.1.1 Cultural Awareness 57
4.5.2 Communication And Language 58
4.5.3 Leadership And Teamwork 58

4.6 An Amalgamation Of Context And Content 59

4.6.1 School Of Maritime Business Management 59
4.6.2 Warsash Maritime Centre 60

Education And Training Of Seafarers - Part II

STCW 1978 Convention: Human Factor Provisions 61

4.7 The Need For The STCW Convention 61

4.8 First Comprehensive Review 63

4.8.1 Addressing The Human Factor 65

4.9 Current Comprehensive Review: Human Factor 67

4.9.1 Fatigue 67
4.9.2 Bridge Resource Management 68
4.9.3 Communication And Leadership 68
4.9.4 Other Human Factor Considerations 69

4.10 Chapter Summary And Conclusion 70

Chapter 5: The Human Condition: Idiosyncrasies In Action 71

5.1 Introduction 71

5.2 The Behavioural Sciences 72

5.3 Perception And Situational Awareness 74

5.3.1 Complacency And Diffusion Of Responsibility 78
5.3.2 Distraction 79
5.3.3 Violations 80
5.3.3.1 Rules 80
5.3.3.2 Risks 81

vii
 5.4 Teamwork, Leadership And Power 81
5.4.1 Destructive Obedience 83
5.4.2 Teamwork And Group Cohesiveness 84

5.5 Fatigue 86

5.6 Challenges To Engaging The Behavioural Sciences 87

5.7 Summary And Conclusion 88

Chapter 6: Discussion - Part I 90

6.1 Introduction 90

6.2 Safety Culture 91

6.2.1 Maritime Resource Management (MRM) 92

6.3 Human Factor Challenges To Safety Culture 93

6.3.1 Fatigue 93
6.3.2 Teamwork 95
6.3.2.1 Communication 96

6.3.3 Situation Awareness 97

6.4 Met 98

6.5 Behavioural Sciences 98

6.6 Summary Of Part I 99

Discussion Part II: Lessons From Aviation 100

Chapter 7: Conclusion: Beyond A Boundary 103

7.1 Contributions Of The Study 108

7.2 Recommendations 108

7.3 Limitations And Challenges Of Study 109

References 111

Appendices

Appendix 1 Maritime Accident Cases 127

Green Lily – Refrigerated General Cargo Vessel 127

viii
 Dole America – Refrigerated Cargo Vessel 128
Domiat – Bulk Carrier 129
Bow Mariner – Chemical Tanker 130
Attilio Ievoli – Chemical Tanker 131
Supporting Cases 132

Appendix 2 - Responses From Seafarers 134

Appendix 3 – Interview With Training Manager 146

Appendix 4 – Responses From Met Institutions 151

Appendix 5 – Non-Technical Aspects Of The Stcw Code Parts A And B

Geared Towards The Human Factor 153

Appendix 6 – Problem Based Delivery Method Adapted By Dokuz Eylul

University School Of Maritime Business Management,
Kaynaklar Campus In Turkey 157

Appendix 7 – Aspects Of The ABC Approach To Developing Non-Technical

Skills Adapted By Warsash Maritime Centre, Southampton
Institute, UK. 158

Appendix 8 – Maritime Resource Management (MRM) Course Contents 159

Appendix 9 – Crew Resource Management 161

ix
 LIST OF TABLES

Table 1-1 Performance shaping factors identified in maritime accident 8

Table 2-1 Milestones in maritime safety 24

Table 3-1 Accidents involving human error 38

Table 4-1 Types of skills that are taught on the CRM course 60

x
 LIST OF FIGURES

Figure 1-1 Relationship of the behavioural sciences to the three important

areas of a seafarer’s life 6

Figure 2-1 The three legged stool 14

Figure 2-2 The relationship among the three components of the psycho-
socio-technical space 17

Figure 2-3 The iceberg metaphor of safety culture and safety climate 20

Figure 2-4 Headlines to news items 23

Figure 2-5 Hudson’s evolutionary model of safety culture 30

Figure 2-6 Cooper’s reciprocal safety culture model 31

Figure 2-7 Convergence model of safety culture 32

Figure 2-8 Road map to safety culture 33

Figure 3-1 The total system according to Redmill and Rajan 39

Figure 3-2 An accident trajectory passing through the holes and defences
in a system 45

Figure 4-1 IMO guidelines on fatigue: List of human factor items 63

Figure 4-2 Aims of the STCW 1978 first comprehensive revision 64

Figure 5-1 Duck or hare? 74

Figure 5-2 The young woman and the old hag 76

Figure 5-3 Upside down head 88

Figure 7-1 Key concepts and their interrelationship 104

xi
 LIST OF ABBREVIATIONS

ATSB Australian Transport Safety Bureau

BRM Bridge Resource Management

ERM Engine-room Resource Management

FSA Formal Safety Assessment

HRA Human Reliability Assessment

IFSMA International Federation of Shipmasters’ Associations

INSAG International Nuclear Safety Advisory Group

IMO International Maritime Organization

ISM International Management Code for the Safe Operation of Ships and
for Pollution Prevention (International Safety Management Code)

ISPS International Ship and Port Facility Security Code

MAIB Marine Accident Investigation Branch

MARCOM Maritime Communication

MET Maritime Education and Training

MRM Marine Resource Management

NTSB National Transportation Safety Board

METNET Thematic Network on Maritime Education, Training and Mobility of

Seafarers

PSC Port State Control

PSF Performance Shaping Factors

SOLAS International Convention for the Safety of Life at Sea

xii
STCW International Convention on Standards of Training, Certification and
Watchkeeping for Seafarers 1978, as amended.

SMI Swedish Maritime Inspectorate

STW Standards of Training and Watchkeeping Sub-Committee

xiii
A little Learning is a dang'rous Thing;
Drink deep, or taste not the Pierian Spring:
There shallow Draughts intoxicate the Brain,
And drinking largely sobers us again.
Fir'd at first Sight with what the Muse imparts,
In fearless Youth we tempt the Heights of Arts,
While from the bounded Level of our Mind,
Short Views we take, nor see the lengths behind,
But more advanc'd, behold with strange Surprize
New, distant Scenes of endless Science rise!
So pleas'd at first, the towring Alps we try,
Mount o'er the Vales, and seem to tread the Sky;
Th' Eternal Snows appear already past,
And the first Clouds and Mountains seem the last:
But those attain'd, we tremble to survey
The growing Labours of the lengthen'd Way,
Th' increasing Prospect tires our wandering Eyes,
Hills peep o'er Hills, and Alps on Alps arise!

Excerpt from: “An Essay on Criticism” by Alexander Pope

xiv
 CHAPTER 1
INTRODUCTION

ENGAGING THE SCIENCE OF MAN

I have one gnawing concern which embraces the whole question as to why
intelligent, well trained, highly-skilled and experienced professional seafarers
make critical mistakes despite the advances in technology which have been
designed to make them more efficient and, by inference safer in the way they
operate. It is extremely important that we should get to the root of this
question so that we can introduce corrective measures. [author’s emphasis]
(O’Neil, 2001).

At the turn of the 21st century when reflections are taking place as to the past and
paths for the future, the maritime industry found itself at a cross roads of safety
measures that were not bearing the expected fruits. The concern articulates a
burgeoning realization that something more was needed in the industry to stem the
number of accidents which were inimical to the International Maritime
Organization’s (IMO) goal of safer ships and cleaner oceans. The more that was
needed turned the spotlight onto the human factor and that something has been
translated into the establishment of a safety culture. This concern remains relevant
as the industry seeks to understand and devise solutions to the role of the human
factor in accidents (Barnett, 2005; Pekcan, et. al., 2005; IMO 2006a, 2007a, 2008). It
is the subject of this dissertation that the behavioural sciences can assist in getting to
the root of the question by offering insights into the human condition and suggesting
areas for education and training.

This chapter introduces the subject of this dissertation by presenting an overview of

the issues to be explored such as the human factor challenges as regards the
establishment of a safety culture; behavioural factors that shape performance; a
review of the maritime education and training regulatory regime and possible areas

1
within the behavioural sciences which may be incorporated to develop personal skills
and abilities to contribute to safety culture as a whole.

The purpose of the opening question was to focus on the need to foreground the
seafarers. Crucial aspects of their lives are not fully addressed – “certainly fatigue,
boredom, health …family problems, pressure to meet schedules, shipboard living
conditions…can all play a part” (O’Neil, 2001) in the seafarer contributing to
accidents. Indeed fatigue, the most studied of those factors, has been implicated in
many accidents (UK P & I Club, 1996; MAIB, 2004; Hetherington et. al., 2006;
Lützhöft, et. al., 2008). However, fatigue is addressed mainly in physiological terms
and the psychological dimensions are neglected (Smith 2007). These human factor
variables are the “softer” non-technical skills, the nature of which needs a multi-
disciplinary approach to solutions that include the behavioural sciences, which are
currently peripheral in the maritime education and training regulatory regime and
applied in an ad hoc way in the industry as a whole.

1.1 SAFETY CULTURE IN THE MARITIME INDUSTRY

Shipping faces negative perceptions as regards its safety and pollution record
(Clayton, 2005; Kristiansen, 2005; Sohmen, 2005;). Although it is said that generally
the total number of accidents are declining (Baker & McCafferty, 2005; Barnett,
2005; Owsley, 2005), a recent article in the ISM Code magazine (Reportism, 2008)
laments the many collisions despite the existence of electronic aids to navigation,
rules, and safety management procedures. Solutions to the problems of safety had
focused primarily on the technological (Schager, 1998; Psaraftis, 2002; Eriksson &
Mejia, 2003), a fact admitted by former secretary general of the IMO (O’Neil, 2002).
The spotlight has now turned on the people leading to increased work in the industry
(Eriksson & Mejia, 2003; Arthur D. Little Ltd. 2004; MAIB, 2004; Barnett, 2005),
and the IMO where Members made submissions regarding understanding the human
factor (IMO, 2003a; IMO, 2003b; IMO 2003c).

2
The International Convention on Standards of Training, Certification and
Watchkeeping for Seafarers (STCW) 1978 and the International Management Code
for the Safe Operation of Ships and for Pollution Prevention (International Safety
Management (ISM) Code), are the two instruments considered to address the human
factor aspect of a safety culture (O’Neil 2001, 2002; Veiga, 2002; IMO, 2003a;
Winbow, 2003; Bhattacharya, 2007; Fuazudeen, 2008). The STCW addresses the
actors at the sharp end, the seafarers, while the ISM Code addresses the actors at the
blunt end, management in the shipping companies. The success of these two
instruments is in question (Pekcan, et. al. 2005; Bhattacharya, 2007; Fuazudeen,
2008) due to lack of global implementation (Veiga, 2002), and a lack of provisions
for relevant aspects of the human factor (Pekcan, et. al., 2005; Barnett, et. al. 2006).

The STCW Convention focuses primarily on the technical competence (Gauw, 1994)
and provisions regarding human and social competence are limited (Pekcan, et. al.,
2005; Barnett, et. al. 2006). There are mixed perceptions regarding the ISM Code as,
while it is viewed positively in some quarters, it is believed that it is most helpful to
those at the middle of the safety continuum rather than those at the poles (Arthur D.
Little Ltd., 2004).

Establishing a safety culture involves deliberate and sustained orchestration (Reason,

1997; Cooper, 2000; Hudson, 2001; Sudhakar, 2005), the cultivation of the correct
mindset and behaviours (Veiga, 2002; IMO, 2003a; Manuel, 2005; Bhattacharya,
2007) and these two safety culture instruments do not make substantial provisions in
this regard. As has been confirmed, technological advancement does not
automatically make operators more efficient, responsible or inculcate any of the
behavioural imperatives necessary to ensure safe operations (Schager, 1998; O’Neil,
2001; Broadbent 2006; Reportism, 2008). Likewise, focus on organizational policies
and procedures without equal focus on the people will not bear much fruit. The
behavioural and attitudinal imperatives are developed through education and training
with the appropriate content (Asyali, et. al., 2003; Barnett, 2005; Barnett, et. al.,

3
2006) and the industry has to be willing to fully engage all aspects of the human
factor which cannot be accomplished without an engagement with the behavioural
sciences – “The human factor, how people function, belongs to the domain of
psychology.” (Schager, 1998, p.63).

1.2 HUMAN FACTOR CONTRIBUTION TO MARITIME ACCIDENTS

Although only one of the sources that contribute to accidents (the others being
technical and organizational), the human factor is seen as the main source in shipping
(UK P & I Club, 1996; IMO, 2001; Baker & McCafferty, 2005; Barnett, 2005;
Owsley, 2005; Hetherington, et. al., 2006). Yet the IMO’s human element strategy
(IMO, 2006a) does not include any provision for education and training, neither
direct reference to welfare or working conditions. It may be extrapolated that areas of
focus in the strategy such as a safety culture, safety management systems,
incorporating ergonomic approaches and more inclusion of human element expertise
in IMO’s deliberations, may eventually lead to a full engagement with the more
complex “human condition,” but as with the experience of the STCW Convention,
what is not explicitly stated is left to wide ranging interpretations (IMO, 1996;
Fuazudeen, 2008). Other areas of neglect which influence safety are welfare and
rights of seafarers. Job satisfaction and positive perceptions of rights may be viewed
as defences against accidents. However, seafarers’ rights have become a contentious
issue in the industry (Gold, 2005; Mukherjee, & Mustafar, 2005; ITF, 2006; Donner,
2008; Zhang, 2008; Mukherjee, n.d.).

1.3 MARITIME EDUCATION AND TRAINING

Maritime education and training (MET) is seen as an important defence in accidents
if training is adequate and relevant (Pekcan, et. al., 2005; Barnett, et. al. 2006). The
STCW convention is the standard bearer for education and training and therefore has
a critical role to play in the quest for a safety culture. It is instructive that an article in
Lloyd’s Ship Manager in 1992, (Seafarers’ training needs…1992), called for a focus
on basic skills and human factors. The discussion introduced the notion of the

4
“seafarer of the future” where it noted that education and training had to be
conscious of the technical as well as the social-psychological dimensions, stressing
the importance of understanding human behaviour. The article also noted that
seafarers were “socially poor” and modern shipboard management required a broader
set of skills. Yet, years later the discussion of providing a more holistic education
remains on the table (Schröder, et. al., 2003; Ho, 2004; Manuel, 2005; Solanki, 2007).
This is the role of MET to respond to the training needs of the industry. A more
holistic approach to education would contribute to empowering the seafarer, making
him more prepared to take on the demands of contemporary shipping as well as
preparing him for roles in the shore-based maritime sector (Schröder, et. al., 2003;
Solanki, 2007). Education in the behavioural sciences also promises to impart
survival skills as regards welfare and health issues. It is believed that this kind of
empowerment could also benefit the industry in terms of recruitment and retention of
seafarers (Solanki, 2007). As such, a long term human resource strategy for the
industry is seen as the prudent course of action (Solanki, 2007; Graveson, 2008).

1.4 THE BEHAVIOURAL SCIENCES

The maritime industry has been engaging the behavioural sciences evidenced by the
proliferation of such concepts as leadership, power distance, fatigue, teamwork,
communication, attitudes, complacency and destructive obedience, to name a few
(Schager, 1998; MARCOM, 1999; MAIB, 2004; Kristiansen, 2005; Manuel, 2005;
Sohmen, 2005; Horck, 2006, 2008a; Kahveci, 2007). The term behavioural sciences,
as used in this dissertation, will be limited to psychology and social psychology as
the concepts of interest stem mainly from these disciplines. Social psychology is seen
as a branch of psychology which stresses the social nature of man as distinguishable
from the individual focus of psychology (Hayes, 1993). The foregone discussion has
revealed human factors as being of importance to the maritime industry’s quest for a
safety culture, noting the need for an engagement with the behavioural sciences as
the area concerned with people.

5
The behavioural sciences have a rich tradition of research and theories that my assist
in explanations and applications of strategies to the human factor challenge to safety
culture. For example, theories and practical applications in perception (Zebrowitz,
1990) that may assist in the area of situational awareness; group dynamics (Brown,
2000) for areas such as team work, leadership and multi-cultural interactions on
board. Figure 1-1 is an illustration of the relationship between the behavioural
sciences and areas of a seafarer’s life. This is not comprehensive but gives an
example of where the behavioural sciences may be useful.

Operational Level
- situational awareness
- team work
- fatigue
- values/attitudes

Professional Level
Behavioural - team work
Sciences - fatigue
- situational awareness
- social competence
- career development
- values/attitudes

Personal Level
- stress
- depression
- values/attitudes
- social competence
- career development

Figure 1-1: Relationship of the behavioural sciences to the three important areas of a seafarer’s life.
Source: Author

6
1.5 SUMMARY/STATEMENT OF THE PROBLEM
The discussion may be summarized as follows:
• There are problems in the maritime industry as regards safety.
• The human factor plays a substantial role in accidents.
• Many aspects of the human factor are behavioural, that is, belonging to the
psychological and/or social-psychological realm.
• The IMO has opened the topic for debate and finding solutions, yet the
regulatory regime is lacking in addressing it holistically.
• Maritime education and training has a role to play in transferring skills and
knowledge that resides within the behavioural sciences so as to enhance the
human factor contribution to a safety culture.

These are the ideas for exploration in the reminder of the dissertation. The
dissertation does not discount the value of the technical approach of the STCW,
neither the work of the IMO in safety. The wish is to point to other areas that may be
of benefit to the industry if such strengths are harnessed. The human factor is
complex and the way to access to any degree such complexities towards
understanding and possible solutions is to engage the science of man. It is against
this background that this dissertation explores what education in the behavioural
sciences can contribute to meeting the challenges towards achieving a safety culture.

1.6 OBJECTIVE
The objective of the dissertation is to identify and explore the human factor
challenges in developing a safety culture and the potential benefits of an education in
the behavioural sciences towards achieving the same.

1.7 METHODOLOGY
The study is exploratory. As such a qualitative approach was taken using maritime
casualty cases and the literature as the main sources of information. A limited
number of interviews and discussions were held with persons from the seafaring

7
profession and MET institutions as well as one professional body. Special focus was
given to the STCW Convention as the regulatory training regime and therefore
extensive use was made of IMO papers.

Arising from background reading, the following research questions were developed:
1. What are the human factor challenges to arriving at a safety culture?
2. What provisions are there in the STCW to address these challenges?
3. What is the role of MET in meeting these challenges?
4. What can education in the behavioural sciences contribute towards
meeting these challenges?

1.7.1 Cases
Accident analyses provide valuable sources of information on human factor
contribution to casualties. As such it was thought that the use of cases would benefit
the research process by substantiating the human factor challenges to safety culture.
Five cases were selected for detailed exploration and five as supporting evidence.
This however did not preclude the mention of other cases where relevant. The
sources of cases were Horck (2006), Sampson (2003) and accident reports of the
Marine Accident Investigation Branch (MAIB) and the internet. Original cases were
read and selected on the basis of the investigators’ analysis of the human factors.
Therefore, accidents reporting fatigue, situational awareness, and teamwork were
selected. These are the factors which shape performance and will be the focus in the
dissertation. Human factor issues were grouped as per Table 1-1.

Table 1-1: Performance shaping factors identified in maritime accidents

PERFORMANCE SHAPING FACTORS
Situational Awareness Teamwork Fatigue
• perception • leadership • health
• complacency • communication • stress
• distraction • destructive obedience • welfare issues
• violations1 • power distance

Source: Author – compiled from accident reports and the literature.

1
Violations are grouped here for convenience.

8
 1.7.2 Literature review
The literature review served a two fold purpose; firstly, for generally guiding the
research process, and secondly, as a source of data. As such the literature will be
referred to throughout the dissertation. The literature was drawn from a number of
sources: peer reviewed journals, books; conference proceedings; research reports;
seminars; periodicals, class handouts and the internet. Sources were selected for
their relevance to the topic and currency of information. This however did not
preclude the use of sources that were dated but the information was relevant. The aim
was to acquire a wide range of information from a variety of sources to achieve as
global a picture as possible on the issues in keeping with the exploratory approach.

1.7.3 Interviews
This took the form of online discussions where questions were sent via email and
responses returned and follow-up discussions, for clarification, took place where
necessary via email. This was necessary as persons were either in another
geographical location or indicated they preferred that method. One personal
interview was done. A visit was made to one professional body, the Swedish Club to
participate in a seminar in Maritime Resource Management (MRM). Discussions
were held with the presenter and participants on the course who were from a popular
cruise line.

1.7.4 Other Sources

Use was made of observations and notes taken on field trips to MET institutions in
Europe as part of the WMU’s curriculum for its students pursuing the MET
specialization.

1.8 THEORETICAL CONSIDERATIONS/DEFINITION OF CONCEPTS

The dissertation explores and utilizes a number of theories as dictated by the four
main concepts under discussion: safety culture, human factor, MET and the
behavioural sciences. Each concept carries its own theoretical perspective(s) as

9
purported by practitioners and detractors alike. This section draws attention to the
theories governing the concepts to be used as well as definitions of concepts to be
introduced by the writer.

1.8.1 Safety Culture

Theories of safety culture surround its nature as an organizational approach to risk
management. It rests on theories of culture and therefore has its foundation in
anthropology (Cox and Flin, 1998; Cooper, 2000). Theories surround for example
components: shared values, attitudes, commitment; management: such as top-down
or bottom-up; its nature: whether it is something the organization is or something the
organization has.

An accompanying concept is safety climate which, by its existence has contributed to

the development of safety culture theories. Climate is seen as being on the surface
and reflects perceptions of safety at a moment in time whereas culture lies below the
surface (Cooper, 2000). The debate is divided on disciplinary lines. From a
management perspective culture is something the organization has (Cooper, 2000;
Reason 1997), meaning it can be orchestrated and is malleable (Reason, 1997). The
contending perspective from the social scientists and academics sees culture as
something the organization is (Cooper, 2000; Reason 1997) as it emerges as a
property from the values, attitudes, and ideologies of all the members of the
organization (Reason, 1997). Approaches to the achievement of safety culture is
influenced by the view one holds and Reason is inclined towards the has theory.
Although it may be rationalized that what an organization has may and does lead to
what it is; and what it is drives what it has, as Reason (1997) comes to acknowledge
at the end of his discussion on safety culture.

The dissertation operates on the premise of the mutual influences between the
concepts but also takes the position that safety culture is something the organization
is, in keeping with its anthropological influences. This position provides the basis for

10
later discussions on the maritime safety regime of rules and regulations as belonging
to the realm of safety climate, what the organization has, which at best fosters a
compliant culture. To achieve a safety culture, the dissertation argues, a holistic
approach engaging the human factor as social-psychological beings has to be among
the strategies, to create what the organization is.

1.8.2 Behavioural sciences

This is a general term used to refer to disciplines concerned with people and their
place and behaviour in the social world, whether as individuals or as groups.
Disciplines such as Sociology, Psychology, Anthropology and branches thereof fall
in the realm of the behavioural sciences. For this dissertation the term behavioural
sciences refers particularly to psychology, but also social psychology as a branch of
psychology. Psychology is concerned with the individual while social psychology is
concerned with social interactions (Hayes, 1993; Brown, 2000). Theories of salience
to this work are cognitive theories such as perception and information processing
explaining issues of situational awareness, and group theories for explanations of
leadership, teamwork, and power etc.

1.8.3 Human factor

The concept human factor is largely an ergonomic term. The term human element is
also used, both terms are taken to mean the same thing for the purposes of this
dissertation. Using Hawkins’ (1993) definition, human factor is about people in their
working and living environment. “It is about their relationship with machines and
equipment, with procedures and with the environment about them. And it is about
their relationship with other people.” (Hawkins’ 1993, p.20). The area of concern for
this dissertation is human factor highlighting the factors that shape performance as
they are discussed in risk management analysis. The dissertation also takes some
liberty and uses the term loosely in general reference to people and related issues.

11
 1.8.4 Other Concepts
The dissertation has coined a number of concepts which are explained below:
• Safety triad – this concept is used to refer to the interrelationship of the
technological, the organizational and the individual factors in safety-critical
systems. Chapter 2.
• Psycho-socio-technical system – this concept refers to the elements of the
safety triad. It is an extension of the socio-technical space to emphasize the
place of the people in safety-critical systems. Chapter 2.
• Idiosyncrasies – this word, meaning a behavioural attribute that is distinctive
and peculiar to an individual,2 is used as a concept in the dissertation to refer
to distinctly human behaviour and disposition such as those lying in the
cognitive domain as peculiarities in perception or those mediated by culture
such as power distance.

1.9 CHAPTER SUMMARY AND CONCLUSION

The chapter introduced the ideas surrounding the main concepts of safety culture,
human factor, MET and behavioural sciences. The basic premise is that safety
culture is seen as a desirable pursuit for the maritime industry to promote safer
operations, improve public image and protect the marine environment. However,
there are human factor challenges that are not solved solely by regulations or
technical means. To devise appropriate solutions, the human factor must be
understood on its terms. The behavioural sciences, as the science of man, have been
underutilized in the maritime industry. It is suggested that a holistic approach is
needed which entail training and education, but the STCW Convention needs to
strengthen its provisions for the non-technical skills.

The remaining chapters develop on the ideas introduced in this chapter. Chapter 2
looks at safety culture in detail highlighting the place and role of the human factor
and emphasizing the need for the behavioural sciences. Chapter 3 examines the

2
Oxford Advanced Learners Dictionary.

12
factors that shape human performance as the source of erroneous acts and the target
of intervention strategies. Chapter 4 is divided into two parts. The first section looks
at MET and its role in developing the non-technical competence. The second section
is a review of the STCW Convention to ascertain its provisions to address the human
factor. Chapter 5 introduces the behavioural sciences vis-à-vis the accident cases and
discusses their potential for contributing to a safety culture. Chapter 6 is an overall
discussion bringing the whole together. It presents the aviation industry’s CRM as an
example of lessons to be learnt for the maritime industry. Chapter 7 concludes the
arguments highlighting the contributions of the study and makes recommendations.

13
 CHAPTER 2
SAFER SHIPPING DEMANDS A SAFETY CULTURE

2.1 INTRODUCTION
The three legged stool – the most important leg is the one that is missing (Patraiko,
2007).

Figure 2-1: The three legged stool

Source: Patraiko (2007)

…while reflecting on the gains which have been made, a look to the future is
also made to determine which areas offer the greatest opportunities for
further advances….it has been recognized that there have been marked
improvements in the casualty records… than was the case a decade ago. The
records also show that there has been a concurrent decline in the amount of
pollution entering the marine environment…These successes have been
achieved mainly through improved standards and an enhanced regulatory
regime… accompanied by the introduction of technologically advanced
navigational systems.
However, it has also been recognized that the one area to which most
accidents have been attributed – namely the human factor – while not being
totally neglected in the past, was in need of greater attention. (O’Neil, 2002,
p.1). [Author’s emphasis]

14
The title for this chapter was adopted from the 2002 World Maritime Day message
by former Secretary General of the IMO, William O’Neil where he unequivocally
declared the need to focus on human behaviour as an intrinsic aspect of any quest
towards a safety culture. It is instructive to note that this focus refers to actors both
at the sharp and blunt ends “… the importance and advantages of creating a genuine
safety culture in the people involved in all components of the shipping industry.”
(O’Neil, 2002, p.1). Leading players in the maritime industry have also
acknowledged the importance of involving the people on ship, ashore and at the ship-
shore interface (Arthur D. Little Ltd., 2004). This is not to suggest that such an
approach is entirely new, but the decade of the 2000s has seen much more focus on
the people as indispensable to the safety goals of the maritime industry (Veiga, 2002).

The focus of this chapter is safety culture and the place of people in defining and
achieving a safety culture. On the one hand, safety culture is an organizational or
industry approach to engender safety in the very being of the organization or the
industry so that nothing is done without thinking safety (INSAG 3 , 1991; Veiga,
2002). On the other hand, humans pose a challenge to this approach if they are not
factored in all aspects; the human factor is the centre (Mathiesen, 1994; Arslan, & Er,
2006). People can be the champions of a safety culture or as equally, its adversary.
So whereas the organization is the embodiment of safety culture, the people are the
drivers, both as individuals and as groups and therefore conscious and deliberate
actions should be taken to “engineer”4 their place in the overall system.

There are many issues being discussed regarding safety culture. Chief among them
are a lack of a common definition, contentions between safety culture and climate
and the lack of consensus on the “cause, the content and consequences of safety
culture” (Cooper, 2000; Guldenmund, 2000; Hale; 2000; Wiegmann, et. al., 2002;
Zhang, et. al. 2002; Manuel, 2007). These discussions will be mentioned so far as

3
International Nuclear Safety Advisory Group
4
As used by Reason (1997) to suggest focused actions at developing.

15
they have implications for the human factor focus of this dissertation and are
explored on the basis of: What is safety culture? Why the need for a safety culture?
How is a safety culture achieved? (looking at a number of models); and whether the
human factor is a challenge to safety culture. A brief discussion on the relationship of
safety culture with security is presented as the two impacts each other and is a
contentious issue within the maritime industry.

2.2 WHAT IS SAFETY CULTURE?

The term safety culture is said to have been introduced in the “Summary report on
the post-accident review meeting on the Chernobyl accident” (INSAG, 1991). The
term was further developed in a follow-up publication “Basic safety principles for
nuclear power plant” (INSAG, 1991) bringing the term into “authoritative” usage
(Reason, 1997; Cox & Flin, 1998). The dangers to life, property and the environment
posed by high risk industries, such as shipping, were contrary to the demands of a
modern society that had evolved beyond basic needs. Corporate society had to
develop a social conscience and therefore the need to engender a safety culture in
their organizations emerged as the sine qua non of responsible corporate operations.

The literature has revealed that safety culture is a complex multi-dimensional, multi-
disciplinary concept which, for high risk industries, involves the dimensions of the
psycho-socio-technical. Figure 2-2 is borrowed from Hollnagel (1998), to
demonstrate the relationship among the three components of the system which this
dissertation refers to as the safety triad. The term socio-technical has its foundation
in ergonomics and is used in the literature, particularly in discussing the environment
as created by the organizational and the technical aspects of the system. The addition
of the psychological dimension, seeks to make obvious the need to focus on the
people as feeling, sensing beings who should be understood within their domain as
well as within an overall socio-technical system.

16
 Figure 2-2: The relationship among the three components of the psycho-socio-technical space.
Source: Hollnagel ,1998.

In the safety triad, man represents the people as individuals or groups within the
system both at the blunt and sharp ends. The organization provides the social
environment in terms of policies, rules and procedures, creating the socio-cultural
milieu within which people meet each other and the technology. The technology
provides the machinery (hardware and software) where man interfaces as an operator,
or a monitor, depending on the nature of the technology. Actions at the sharp end are
influenced by all actors within the system although they have significant implications
for those in the immediate environment as the “inheritors” (Reason, 1997) of the
actions of the others, but also as creators of their own actions. These three
dimensions form the safety triad that has to operate in harmony if the quest for a
safety culture is to become a reality.

2.2.1 Definition
Definitions of safety culture encompass its organizational genesis as well as the place
of people in its realization. As such, its definitions have impacted methodologies to
measure, assess and ultimately manage safety culture (Cooper, 2000; Guldenmund,
2000; Hale, 2000; Zhang, et. al. 2002; Human Engineering, 2005). However, one of
the criticisms is the lack of a common definition (Cooper, 2000; Hale, 2000;

17
Wiegmann, et. al., 2002; Zhang, et. al. 2002). What may be arguably the first attempt
at a definition of safety culture was by INSAG (1991, p.1) as “…that assembly of
characteristics and attitudes in organizations and individuals which establishes that,
as an overriding priority, nuclear plant safety issues receive the attention warranted
by their significance.” As explained by INSAG, the aim was to reflect the attitudinal
and structural composition of safety culture relating to the individual and the
organizational respectively, and that the appropriate perceptions and actions were
comparable with the importance of the concept (INSAG, 1991).

Since then, many other definitions have emerged as the concept gained currency
which provide evidence that safety culture is not easily articulated (Cooper, 2000;
Guldenmund, 2000; Hale, 2000; Human Engineering, 2005; Bhattacharya, 2007;
Manuel, 2005, 2007). Turner’s definition, as quoted by Cooper (2000) attempts to
account for the organizational, the technical and the human factors – “the set of
beliefs, norms, attitudes, roles and social and technical practices that are concerned
with minimising the exposure of employees, managers, customers and members of
the public to conditions considered dangerous or injurious.”

The definition that is arguably most widely used (HSL, 2002), and seemed to have
gained favour in the maritime industry, as echoed by the ISM Code, is the UK’s
Health and Safety Commission’s definition:
The safety culture of an organization is the product of individual and group
values, attitudes, competencies and patterns of behaviour that determine the
commitment to, and style and proficiency of, an organization’s health and
safety programmes. Organizations with a positive safety culture are
characterized by communications founded on mutual trust, by shared
perceptions of the importance of safety, and by confidence in the efficacy of
preventive measures.” (As quoted in Reason, 1997, p. 194).

18
This definition seeks to capture the human aspects both as individuals and groups
which are necessary to culminate in a desirable outcome of safety consciousness for
the organization, through commitment.

Despite the criticism of lack of a common definition, there are common elements that
have been identified which give direction to the concept as a whole. In their review
of the safety culture literature Zhang et. al. (2002, pp.2-3) identified a number of
common elements as to what constitutes safety culture:
• Safety culture is a concept defined at group level or higher, which refers to
the shared values among all the group or organization members.
• Safety culture is concerned with formal safety issues in an organization, and
closely related to, but not restricted to, the management and supervisory
systems.
• Safety culture emphasizes the contribution from everyone at every level of an
organization.
• The safety culture of an organization has an impact on its members’
behaviour at work.
• Safety culture is usually reflected in the contingency between reward system
and safety performance.
• Safety culture is reflected in an organization’s willingness to develop and
learn from errors, incidents, and accidents.
• Safety culture is relatively enduring, stable and resistant to change.

These points of convergence suggest that there is some agreement as to what the
contents of safety culture are. Perhaps the approach is to focus on the elements of
salience as was done by the Human Engineering (2005) when faced with the task of
developing as safety culture tool kit following two rail accidents.

19
 2.2.2 Safety Culture and Safety Climate
A brief exploration of safety culture versus safety climate is necessary as this is
another area of contention associated with definition, measurement and management.
The distinction between the two concepts has been an ongoing debate (Cox & Flin,
1998; Guldenmund, 2000; HSL, 2002; Wiegmann, et. al., 2002; Zhang, et. al., 2002:
Ek, 2006; Manuel, 2007). Safety culture and climate were at times used
interchangeably (Cox & Flin, 1998); the general preference however is to separate
both concepts. The debate between the concepts may have arisen because, as Cox
and Flin (1998) explained, both terms developed in parallel but have distinct
etymologies arising from separate theoretical roots. They noted that earlier ideas of
climate had a social psychological background and was used later on for the
measurable characteristics of organization, therefore the use of quantitative
measurement tools such as questionnaires. Safety climate is seen as a “snapshot”
(Glendon & Stanton, 2000; Wiegmann, et. al., 2002; Sudhakar, 2005) reflecting the
perceptions of the employees in an organization at a particular point in time
(Guldenmund, 2000; HSL, 2002; Zhang, et. al. 2002). Figure 2-3 is the iceberg
metaphor used to demonstrate the distinction between the concepts (Manuel, 2007).

Figure 2-3: The iceberg metaphor of safety culture and safety climate
Source: Safety Culture Bulletin 2002 as quoted in Manuel, 2007

20
Culture has its roots in anthropology (Cox & Flin, 1998; Ek, 2006). The emphasis on
culture initially “…was on uncovering deeper organizational values, underlying
assumptions and symbolism associated with artefacts 5 , rituals, norms and rites of
passage” (Cox & Flin, 1998 p. 191). This perspective has informed subsequent
approaches to safety culture as seen in the definitions discussed. Culture is pervasive
(Zhang, et. al. 2002) lying at a deeper level than climate, “below the iceberg”
(Manuel, 2007); its measures are therefore qualitative (Cox & Flin, 1998).

The dissertation takes the position of Mearns, et al. (1998) who believe that
theoretical distinctions should be drawn and empirical investigations should be clear
on which concept is being measured. Such distinction is helpful because, whereas
climate may be indicative of the underlying conditions and hence culture (Wiegmann,
2002), people’s “real” attitudes and perceptions are not easily captured through
“snapshot” quantitative methods, for a number of reasons – fear, job security etc.
Climate indicators need validation to be interpreted in a cultural framework (Glendon
& Stanton, 2000).

This writer sees the usefulness of climate as a desirable stage in the progression
towards a safety culture (Guldenmund, 2000). Mathiesen (1994) identified three
types of culture in the maritime industry: evasive, compliant and safety culture, to
which Sudhaker (2005) has added uninformed culture. These are explained in
Section 2.5.1.4 (Figure 2-8). Climate measures may be valuable for diagnosing an
organization’s state of compliance and therefore becomes a useful audit tool. Having
a climate may be the final step in a “have to” (compliant) culture and steps may be
taken to move to a “want to” (safety) culture. Climate may be achieved through rules,
regulations and compliance with safety systems which is helpful towards a safety
culture. This distinction is necessary to reflect the complexity of the main element,
the people, who may present a desirable picture for a “snapshot” yet disguising the
picture below the surface - safety culture is “a way of life” (Veiga, 2002).

5
Language, technology, products etc. (Ek, 2006)

21
2.3 WHY A SAFETY CULTURE FOR THE MARITIME INDUSTRY?
The fervent engagement with safety culture in the literature, across high risk
industries such as aviation, nuclear and transportation, compels one to coin the
maxim safety is a virtue. Safety culture emerged as an organizational approach to
understanding and managing health and safety issues at work (Cox & Flin, 1998;
Cooper, 2000; Batteau, 2001; Zhang, et. al., 2002; Ek, 2005; Wiegmann, et.al. 2007).
For the maritime industry, human factor is said to be the major contributor to
accidents. A review of major6 accident databases by Baker and McCafferty (2005,
p.70) reveal that management practices, failures of situation awareness and risk
taking/risk tolerance account for 25% of accidents. Also 80 to 85% of accidents were
either directly initiated by human error or were associated with human error. It is
believed that a safety culture will contribute towards a reduction in such figures.
Although cautioned by Cox and Flin (1998) that expectations of safety culture may
be overinflated, it is nonetheless a desirable goal for the maritime industry as there is
no denying the need to protect life, property and the environment which is the
promise of a safety culture if it is realized.

Safety remains one of the fundamental objectives of the IMO, but an “over-riding”
challenge is “how [to] improve global maritime safety still further?” (Mitropoulos,
2004). The IMO’s efforts at promoting a safety culture are evidenced by the
development of the ISM Code and the STCW convention (Veiga, 2002; Manuel,
2005; Bhattacharya, 2007; Fuazudeen, 2008), but good intentions do not make
sensational headlines. Shipping has a poor image which makes a safety culture even
more urgent. Figure 2-4 are a few headlines which demonstrate the public’s attitude
towards shipping. Additionally, names such as the Torrey Canyon, Amoco Cadiz,
Exxon Valdez and the Prestige have gone down in infamy for causing extensive
environmental damages. Likewise, when the vessels’ management contravene the

6
United States Coast Guard, Marine Accident Investigation Board (UK), Transport Safety Board
(Canada), Australian Transportation Safety Board, The Nautical Institute’s Marine Accident
Reporting Scheme (MARS), The Det Norske Veritas Worldwide Offshore Accident Database
(WOAD)

22
rules and regulations, as in the case of the Herald of Free Enterprise, and the Erika,
or the Exxon Valdez where the master was said to be under the influence of alcohol,
the public demand for “heads” increases.

Prestige captain on Chirac hits at Cancer fears over oil

$3m bail 'gangsters of sea' spill
MADRID, Spain (CNN) -- PARIS, France (CNN) -- Volunteers who helped
The Greek captain of the President Jacques Chirac clean oil spilt by the
sunken oil tanker Prestige has blamed the "gangsters of tanker, Erika, which broke
left a Spanish jail after nearly the sea" for the millions of oil up off north-west France in
three months following the pellets that are beginning to December, have been told
posting of a $3 million bond. they could be at risk from
float onto France's beaches.
http://edition.cnn.com/2003/W
http://edition.cnn.com/2003/W cancer.
ORLD/europe/02/07/prestige.c
ORLD/europe/01/03/prestige.c http://news.bbc.co.uk/2/hi/eu
aptain/index.html
hirac/index.html rope/677180.stm

Human error led to the sinking of the ”Bow Mariner”

The final report by the US Coast Guard on the explosion and sinking of the 1982-built,
chemical/product tanker ”Bow Mariner” on February 28 last year in the Atlantic, is grim
reading and bears witness of human error and inadequate operational management.
http://www.shipgaz.com/magazine/issues/2006/02/0206_article.php

Figure 2-4: headlines to news items.

Source: various sources online as per websites.

In addition to the corporate need, many other issues of health and safety, welfare and
rights of the seafarers also hinge on the development of a safety culture. According
to Broadbent (2006, p.1), “optimal safety cultures typically provide the necessary
support for employees to strive beyond minimal efforts.” It is said that morale in the
industry is low and seafarers’ welfare, health and safety are neglected (Stevenson,
2002; Nielsen & Panayides, 2005; ITF, 2006; Kahveci, 2007). A safety culture
therefore offers many promises of safer, cleaner oceans, protection of the
environment and a more people-caring industry.

2.3.1 Safety in Shipping

Of all the high risk industries, the maritime industry has had the longest history of
establishing a safety regime. This can be traced to ancient laws governing various
aspects such as construction, use of ships and cargo carriage. These laws were
mainly to protect property and commercial interests, rather than for safety as a

23
virtue7. Other more substantial laws were developed overtime throughout antiquity
and into modern society (Zhang, 2008)8.

For modern society, the establishment of a safety regime through rules and
regulations had been tumultuous arising from excessive loss of lives in the British
merchant navy and resistance to the establishment of laws to govern safe shipping
(Veiga, 2002; Jones, 2006). Although these were national laws, they ultimately had
influence of international proportions due to Britain’s position and impact in
maritime history and as a colonial power where it bequeathed its laws to its colonies.
Table 2-1 provides a listing of international efforts at regulating maritime safety. The
approach to safety has been reactionary to major accidents, such as the Titanic,
Herald of Free Enterprise, Estonia etc., with strong technical components and
neglect of the non-technical skills.

Table 2-1: Milestones in maritime safety

Year Initiative or regulation

1914 • Safety of Life at Sea (SOLAS): Ship design and lifesaving equipment

1929 • First international conference to consider hull subdivision regulations

1948 • The International Maritime (Consultative) Organization (IMO) is set up as

a United Nations agency

1966 • Load Line Convention: Maximum loading and hull strength

• Rules of the road
• The International Association of Classification Societies (IACS):
Harmonization of classification rules and regulations
1969 • Tonnage Convention
1972 • International Convention on the International Regulations for Preventing
Collisions at Sea (COLREG)
1973 • Marine Pollution Convention (MARPOL 73)
1974 • IMO resolution on probabilistic analysis of hull subdivision
1978 • International Convention on Standards of Training, Certification and
Watchkeeping for Seafarers (STCW 78)
1979 • International Convention on Maritime Search and Rescue (SAR)
1988 • The Global Maritime Distress and Safety System (GMDSS)
Source: Kristiansen, 2005 p. 10

7
See for example, Code of Hammurabi, paragraphs 234-240
8
For example The Rhodian Sea Code, 7th or 8th Century; The Rôles of Oléron, 13th Century; The Judgements of
the Damme, 13th Century; The Rules of Wisby, 13th Century; The Black Book of the Admiralty, 14th Century;
The Ordonnance de la Marine, 1681; and the British Merchant Shipping Act, 1850.

24
 2.3.1.1 Can safety culture be regulated?
“…Although the behaviour of individuals may be influenced by a set of rules, it is
their attitude to the rules that really determines the culture. Do they comply because
they want to, or because they have to?” (O’Neil, 2002 p.1).

The safety regime of the maritime industry rests on international conventions and
regulations (Psaraftis, 2002; Veiga, 2002). It is the position of this dissertation that
the regulatory regime (eg. ISM and STCW) and the enforcement regime through port
state control (PSC) facilitate compliance at best, but more is needed to develop a
safety culture (Mathiesen, 1994; Broadbent, 2006; Bhattacharya, 2007). This is not
an indictment on the regulatory regime, its success lies in effective implementation in
the right environment that would allow the founding principles to flourish. 9 This
environment has to be “engineered” as Reason (1997) puts it. For example, in the
United States it was discovered that regulations do not instil desirable attitudes for
voluntary compliance as regards road traffic (Foss, 2007). Compliance was achieved
with sustained and deliberate actions, including enforcement. The international
nature of shipping necessitates voluntary compliance, and this is more challenging
with substandard shipping. It is recognized in the ISM Code that “In matters of safety
and pollution prevention it is the commitment, competence, attitudes and motivation
of individuals at all levels that determines the end result.” (IMO, 2002, p.5).
Internalized values, manifesting themselves through appropriate attitudes and
behaviours are the hallmark of a safety culture (Guldenmund, 2000; Cooper, 2000).
Safety culture for Manuel (2005) is associated with ethics. On their own, rules and
regulations do not make people ethical, except they are mediated by affect (Nichols,
2002), which requires deliberate actions.

The existence of sub-standard shipping (Mathiesen, 1994; Lang, 2001; Arthur D.

Little Ltd., 2004; ITF, 2006) is evidence that not all players in the industry are ethical

9
Bhattacharya (2007) in his study on the influence of the ISM Code on safety culture, demonstrates
that its principles are defeated by autocratic environments that engender fear.

25
hence there is a role for the regulators to fill the gap where there is not the
organizational consciousness or will to develop a safety culture. To circumvent the
organizational deficiencies, the dissertation sees a possible solution in targeting the
education of the seafarers to instil the desirable values and attitudes that will be
tapped regardless of employer (Manuel, 2005). Regulations and enforcement
strategies are features of a compliant culture where the necessary actions are taken to
avoid the consequences (Mathiesen, 1994; Manuel, 2005; Foss, 2007). A safety
culture goes beyond to an advanced stage (Bhattacharya, 2007) of thinking and doing
safety. Safety systems may be robust but they are insufficient if they are merely
applied mechanically (Hudson, 2001; INSAG, 1991), or if they are founded on
wrong principles (Foss, 2007). Safety systems “… need an effective safety culture to
flourish” (Hudson, 2001, p.3).

2.4 HUMAN FACTOR: A CHALLENGE TO SAFETY CULTURE?

Accidents are usually the starting point to question an organization’s safety culture or
lack thereof (eg. Chernobyl, Herald of Free Enterprise) (Glendon & Stanton, 2000;
Ek, 2006). It has been said throughout the literature that the human factor contributes
to a large percentage of accidents. Although it is realized that such figures lie in the
complex interrelationship of technological, organizational, individual and group
factors (Perrow, 1999; Ek, 2006), the operators at the sharp end are usually the focus
of an accident for the maritime industry.

In looking at causal factors, Kristiansen (2005) identified from an analysis of 419

groundings, that core causal factors involve “soft” problems of work conditions,
human performance and neglect. Neglect is sub-divided into “failure in watch
performance” and “individual human conditions.” Others have identified such causes
as communication, language and cultural diversity (MARCOM, 1991; Hetherington,
et. al., 2006; Horck, 2006), teamwork, stress and health issues (Stevenson, 2002;
Hetherington, et. al., 2006). These factors may be aligned with Kristiansen’s “human
conditions.” The most dominant contributory factor has been identified as lack of

26
situation awareness and fatigue (MAIB, 2004; Baker & McCafferty, 2005; Barnett,
2005; Hetherington, et. al., 2006; Owsley, 2005). Barnett (2005) and UK P & I Club
(1996) have also found violations as another common factor in accidents, possibly
stemming from attitudes to risk (and some amount of male machismo - ego)10

As a contributory factor to accident, Kristiansen’s (2005) “human conditions” could

also been seen in terms of neglect of seafarers’ welfare that may affect job
satisfaction which is important in developing a safety culture. According to the UK’s
submission to the IMO (2003a), job satisfaction is one of the key indicators of a
safety culture, a lack of which can thwart any safety strategy as management is
viewed with mistrust and suspicion. Poor welfare may also lead to depression and
isolation (Kahveci, 2007; Thomas, 2003) affecting mental health and performance.
The UK P & I Club (1996) acknowledges the role of “states of mind” in accidents.

Addressing the root of factors that shape performance, which many see as lying in
the organization (Reason, 1997; Dekker, 2006), is not disputed, but the human
condition is complex and its influence should not be denied (Foss, 2007). As
Broadbent (2006, p.1) sees it “safety [culture] requires people to adopt a set of habits
and ways of thinking that are often difficult and unnatural (eg. reporting one’s own
mistakes…),” “it is human nature to cover things up. There is a fear of criticism and
reprisal from the company” (Arthur D. Little Ltd. 2004, p.63). Solutions to such
primal responses lie in education of the individual to impact the relevant attitudes
and behaviour formation.

Further, the maritime industry has unique challenges that necessitate an engagement
with the sharp end, at the same time it attempts solutions directed at the organization.
These challenges include sub-standard shipping, an open register regime which

10
In investigating the Bow Mariner casualty, the investigator had an interview with the Chief Officer
of the sister ship, the Bow Transporter, regarding operational procedures as outlined in manuals the
investigator noted “…the Chief Officer of the Bow Transporter scoffed at suggestions that the Cargo
and Ballast Operations Manual was governing stating that his ’30 years of chemical tanker
experience’ was all he needed to perform his job.

27
spreads the company’s responsibilities across organizations and countries; it is
sometimes difficult to identify a company, more so to police its operations;
management is outsourced, seafarers are on relatively short term contracts and
therefore time to instil company’s values and attitudes, if these exist, is not sufficient.
Challenges such as these make the development of a safety culture difficult as it must
be admitted that not all owners are interested. In brief, those at the sharp end are left
to learn by trial and error many aspects of the human-human interface. For example
the Crimson Mars grounding where it was reported that the pilot had a “one-on-one”
communication with the helmsman to put him at ease so he could offer challenge if
any orders given appeared “stupid” but this made the situation more tense, and was
interpreted as an “inappropriate joke” by the others on the bridge. Therefore,
intervention at the level of maritime education and training is recommended (Arthur
D. Little Ltd. 2004; Sudhakar, 2005; Manuel 2005, 2007; Horck, 2006, 2008), where
the lessons are learnt to create mental models of appropriate responses before they
are needed.

2.5 HOW IS SAFETY CULTURE ACHIEVED?

Commitment of the people at all levels to the safety goals and principles has been a
consistent theme throughout the literature. As said before, safety culture is an
organizational response to risks. Yet individual actions cannot be separated, although
writers such as Reason (1997) thinks from an organizational perspective on the
premise that one cannot change the human condition, but one can change the
conditions under which people work. At times the conditions are right, but humans in
all our complexities also pose a risk (Foss, 2007). For INSAG (1991), safety culture
operates in a framework where management and policy provide the direction and
individuals provide the appropriate responses to those policies. An individual
approach is also evident where maritime education is discussed as one of the
strategies towards a safety culture (Manuel, 2005, 2007; Sudhakar, 2005). Manuel,
(2005) offers an alternative definition for culture:- “The cultivating or development
(of the mind, faculties, emotions) - improvement or refinement by education and

28
training – the result of such refinement.” – which may be adapted for the purposes of
this dissertation to suggest an educational approach as one of the strategies to
achieving a safety culture. Such a definition of safety culture may be:- The
cultivating or development (of the mind, faculties, emotions) of the safety imperatives
within the individual through appropriate education and training.

2.5.1 Approaches to Achieving Safety Culture

2.5.1.1 Social Engineering
Reason (1997) sees the development of safety culture as “social engineering,” where
deliberate actions are taken by the organization to instil safety in all aspects of its
operations. An organization with a safety culture possesses the following
characteristics (Reason, 1997, pp. 195-196):
• an informed culture – continuously collects data regarding the “many entities
that may penetrate its barriers” and uses these constructively to ward off
complacency. The organization must not forget to be afraid.
• a reporting culture – the people at the sharp end are willing to report their
errors and near-misses without fear of punishment.
• a just culture – an atmosphere of trust where people are encouraged when
behaviours are appropriate and contribute to safety, and they are also aware
of unacceptable behaviours.
• a flexible culture – adaptability to changing demands, as such power and
authority does not interfere with the safe procedures. Control of a hazardous
situation passes to the person with the knowledge on the spot and reverts
when the situation is returned to normal.
• and a learning culture – where lessons are taken from the system and a
willingness to make major reforms if these are needed.
For Reason, safety culture equals an informed culture and the others are seen as
subcomponents. These must be “engineered” through deliberate actions on the part
of the organization.

29
 2.5.1.2 Evolutionary Model
Hudson, (2001) stresses the development of solid individual and organizational
safety management skills that have to be cultivated: “skills have to be developed, and
require practice; they do not suddenly appear just because you read the manual” (p.6).
Writing from an aviation perspective, Hudson (2001) combines Reason and Westrum
to develop this approach. Reason’s categories have been summarized into the
following:
• A safety culture is informed at all levels
• A safety culture exhibits trust by all parties
• A safety culture is adaptable to changes in conditions
• A safety culture worries
Figure 2-5 is the adapted Westrum’s model which shows the movement with
increasing trust and “informedness”, from a pathological stage to the highest level of
a generative stage which is the place of safety culture. The rationale for an
evolutionary model is that it gives direction, where the organization is going (Hudson,
2001). The development of good safety management skills which is learnt and
practiced is the mainstay of this approach.

Figure 2-5: Hudson’s evolutionary model of safety cultures

Source: Hudson (2001)

30
Both the social engineering and evolutionary models involve the development of
skills, attitudes, mutual respect for members in the organization, they involve
flexibility, willingness to change, commitment, and learning. Both Hudson (2001)
and Reason (1997) admit that safety culture is not necessarily an easy pursuit but it is
a desirable pursuit.

2.5.1.3 Reciprocal Safety Culture Model

Cooper (2000) proposed a goal making model whereby safety culture is seen as a
super-ordinate goal. This model is an adaptation of Bandura’s model of reciprocal
determinism. Cooper (2000 p.116) believed “the creation or enhancement of a safety
culture is dependent upon the deliberate manipulation of various organisational
characteristics thought to impact upon safety management practices”, hence a theory
of action. Each characteristic is viewed as a sub-goal, the antecedents, leading to a
safety culture, the behaviour and consequences which are the goal-achievements.
The model (Figure 2-6) emphasises the “reciprocal relationship” among the
behavioural, situational and psychological and therefore sees a holistic engagement
to successfully arrive at a safety culture as imperative.

Figure 2-6: Cooper’s Reciprocal safety culture model

Source: Cooper (2000)

31
 2.5.1.4 The Convergence Model
Sudhakar (2005) proposed a convergence model where the top-down and bottom-up
approaches to safety culture are merged, Figure 2-7. Writing from a maritime
industry perspective, Sudhakar presents his model in the ambit of safety as a risk
management tool. The top-down approach sees safety culture as a sub-set of
organizational culture and the bottom-up approach sees safety culture as learned
behaviour. Safety culture existing in the industry takes four possible forms as
outlined by the road map to safety culture (Figure 2-8) (Sudhakar, 2005). It is
therefore suggesting that to move from an uninformed culture to a safety culture the
“interactive relationship” (Cooper, 2000) among the stakeholders must be
“engineered” (Reason, 1997), which is also a reciprocal relationship of another kind,
but necessary to achieve the goal of a safety culture.

Figure 2-7: Convergence Model

Source: Sudhakar (2005).

32
 UNINFORMED EVASION CULTURE COMPLIANCE SAFETY CULTURE
CULTURE CULTURE

Symptoms Symptoms symptoms symptoms

-gaps in knowledge and -perfunctory approach -focus on compliance -safety awareness visible
skills needed for safe -focus on paperwork -conversant with rules throughout
operations -appearances are most -flawless records -collective approach
-poor emergency important -safe practices a routine -proactive risk
preparedness -inadequate training -extensive checklists identification
-lack of training -poor emergency -inability to deal with -high degrees of
-absence of exercises response unforeseen emergencies preparedness
-cohesive team

Culturally driven beliefs Culturally driven beliefs Behaviour pattern Behaviour pattern

.fatalism .excessive safety is .discipline .clarity of objectives

.safety measures “bookish” .obedience to rules .positive group
increased accident risk .’smart’ operations .clear role definition dynamics
.no matter what you do, involve cutting corners .pride in doing things .professionalism
accidents will still occur .the chief objective is right .sure support
not to get into trouble .group commitment .confident in
with authorities .clean record matters emergencies
most
Figure 2-8: A Road Map to Safety Culture
Source: Sudhakar (2005).

The models demonstrate that safety culture rests on the people. Reason (1997) and
Cooper (2000) presented general organizational models, with Reason presenting
from a managerial/leadership perspective, while Cooper’s model is based on a more
social psychological view. Hudson wrote from an aviation perspective, presenting an
organizational psychology model and Sudhakar’s model is an organizational/
educational model. What these models offer are differing perspectives on addressing
the human factor that may be adopted according to the nature of the organization or
the industry within which one is operating. The point of convergence for the models
is that achieving a safety culture arises from deliberate efforts at engineering
(Reason), cultivating (Hudson), developing by deliberate manipulation (Cooper) and
fostering linkages (Sudhakar); they stress the need for a holistic approach to the
human factor in safety culture predicated on behaviour modification. Therefore to
reiterate the adapted definition of safety culture: The cultivating or development (of
the mind, faculties, emotions) of the safety imperatives within the individual through
appropriate education and training.

33
2.6 SAFETY AND SECURITY
Any discussion of safety in shipping necessitates, at the very least, a mention of
security as it impacts the seafarer’s performance. A quote from Benjamin Franklin
“The way to be safe is never to be secure” (quoted in Schröder, et. al.) sums up the
tensions between the concepts.

In Jamaica (my home country) it has become standard procedure in certain parts to
construct homes with burglar bars as a means of access control due to crime
problems. These ensure security but present direct threats to safety in the event of
dangers such as fires. Persons have been known to die in fires because they could
not leave the house as the keys to the burglar bars could not be found (possibly a case
of panic), or they lie unconscious from smoke inhalation and nobody could get in…
secure, but not safe.

The IMO’s commitment to security is firmly embedded in the amended motto of

“safer, secure, efficient shipping on cleaner seas.” The maritime industry’s security
regime has been adequately documented by a number of researchers in the area
(Mejia, 2007; Mensah, 2005). The most recent addition to the security regime, the
International Ship and Port Facility Security (ISPS) Code, has given rise to tensions
between safety and security. The background and rationale for the implementation
of the ISPS Code are well known (Franson, 2005; Wright 2006). Safety and security
have been at logger heads since the implementation of the Code. At the very
minimum, it has added to the administrative responsibilities aboard, hence increased
workload (Schröder et.al. 2006; ITF, 2006) amidst concerns of fatigue and lack of
situational awareness (Barnett, 2005; Hetherington, et. al. 2006) which are
implicated in weakening the system’s defences against accidents.

Additionally, seafarers’ right to shore leave has become a contentious issue since the
increased attempts at security (ITF campaigns…2004; Mukherjee & Mustafar, 2005;
Grey, 2006; ITF, 2006). Lack of shore leave exacerbates health issues, particularly

34
mental health such as stress, isolation and boredom, (Kahveci, 2007) and compounds
the possible negative effects on performance (Schröder, et. al. 2006). Issues of
conflicts of interest (Schröder, et. al. 2006), and overall mistrust in the industry
surrounding perceptions of unfair treatment at ports (ITF campaigns…2004; ITF,
2006; Joshi, 2004; Grey, 2006) have impacted on an amicable union between safety
and security. An attempt at addressing possible conflicts is found in provisions of the
ISPS Code section 11.11 (IMO, 2003d), where it is the duty of the company security
officer (CSO) to ensure consistency between security and safety requirements.
Additionally, Regulation 8 of Chapter XI-2 of the International Convention for the
Safety of Life at Sea (SOLAS) 1974, gives the master power to prioritize safety over
security where such conflicts arise during operations, but such jurisdiction does not
go beyond the guard rails of the ship and may of the issues are with border personnel
(ITF campaigns…2004; Joshi, 2004; Grey, 2006; A question of balance, 2007).

The relationship between safety and security does not have to be acrimonious as both
are affected by similar complexities and human idiosyncrasies. Harmonization is
necessary to reduce the tensions and increase the scope for cooperation (Schröder, et.
al. 2006; A question of balance, 2007). Despite the separation of security and safety
in maritime studies (Mejia, 2007), there are grounds to subsume security under an
overall safety regime, as vulnerabilities to security threats also compromise safety. It
would therefore be useful to strike a balance and engage the human factor issues for
both safety and security simultaneously so there is not a reinvention of the wheel
when it is discovered that more is needed to ensure persons not only comply with
security measures but internalize them as well, as is the current challenge with safety.
The term security culture has already been mentioned in the human element strategy,
MSC/MEPC 7/Circ. 4 (IMO, 2006b).

35
2.7 CHAPTER SUMMARY AND CONCLUSION
A number of issues were looked at in this chapter. It was ascertained that although
the genesis of safety culture is organizational, it places great emphasis on the people
as their responses and attitudes towards safety culture is key to its realization. It was
shown that there are many definitions for safety culture but there are points of
convergence which gives guidance in identifying workable approaches to achieving a
safety culture. Culture and climate are differentiated on the basis of compliance
versus an advanced response to safety. Although climate may be an indication of
culture, it measures perceptions at a particular moment in time whereas culture is
more pervasive. This distinction has implications for the maritime industry’s safety
regime. The chapter makes a distinction between the maritime industry’s safety
approaches which, while being robust, does not necessarily engender a safety culture,
and may, at the most achieve a safety climate, as the key ingredient, the people, have
been left out of the loop in a holistic way.

Safety culture is a necessary goal for the maritime industry to stem its accident and
near miss records through addressing the human factor in all aspects of the safety
triad. A number of approaches exist that are useful in guiding the development of a
safety culture but the maritime industry has additional challenges that are unique to
its nature. Challenges such as sub-standard shipping, an open register regime,
differences in the vigilance of PSC regime, make it difficult for this industry, more
than any other industry, to pilot the development of a safety culture. Having safety
systems in place without the commitment of the people at all levels is tantamount to
not having a system. As demonstrated in this chapter, the human factor is essential to
the successful achievement of a safety culture and as Manuel (2005, p.46) puts it “If
the core of a safety culture is human element, then the source of this element, how
they are educated and how they perform is critical.”

36
 CHAPTER 3

HUMAN PERFORMANCE IN SAFETY-CRITICAL SYSTEMS

“To err is human…” Alexander Pope

3.1 INTRODUCTION
Understanding the dynamics of human performance in safety-critical systems is a
crucial aspect of any safety culture agenda. Humans at the sharp and blunt ends are
regarded as the dominant risk factor in safety-critical systems (Baron, 1988; Reason,
1990; Barnett, 2005) and as noted in Chapter 2, is a major challenge to achieving a
safety culture. The root of this challenge lies in the performance shaping factors
(PSFs) as they are the link to erroneous acts and therefore influences safety. It is the
domain of risk management to understand and devise solutions to risks in safety-
critical systems including those pose by humans.

Table 3-1 gives a summary of major accidents that have come to epitomize what can
go wrong in safety-critical systems with devastating consequences. These accidents
have become fodder for the safety culture quest in all high risk industries. These
accidents have also been used to illustrate the point that no major accident is caused
by a single direct action at the sharp end, but organizational factors, management
decisions and designers of equipment and technology are intricately involved
(Watson, 1988; Reason, 1990; Perrow, 1999; Barnett, 2005; Dekker, 2006).

This chapter focuses on the human factor as a source of risks in safety-critical

systems. In so doing it explores the dynamics of human erroneous acts and factors
shaping those performances, an understanding of which is key to risk management,
which involves training and education. Although the dissertation focuses on the
people at the sharp end, it maintains in principle that actions at the blunt end are
extremely critical towards overall effective functioning of safety-critical systems, as
is proven in the literature. As such, actions at the sharp end cannot be discussed in
isolation and as is appropriate for this chapter, the blunt end is incorporated.

37
Table 3-1 Accidents Involving Human Error
INDUSTRY YEAR ACCIDENT CAUSES IDENTIFIED CONSEQUENCES
1979 Three Mile Island operator error, latent failure, No direct deaths but it
Nuclear maintenance error assumed people died
years later from
radiation poisoning
1986 Chernobyl Deliberate, systematic and 31 lives lost. 400 sq.
numerous violations of safety miles contaminated.
procedures by operators, design Increase in risk of
failures cancer deaths over a
wide area of
Scandinavia and
Western Europe
Petrochemical 1984 Union Carbide, Operator error, poor maintenance, 2500 died
Bhopal failed safety systems, design
support problems.
Maritime/Offshore 1988 Piper Alpha Technical and organizational 167 persons died
causes.
1987 Herald of Free Commercial pressures, poor 150 passengers & 38
Enterprise management, operator error, crew died
Space Programme 1986 Challenger Faulty O-ring, Organizational All 7 astronauts died
failure, conflicting goals,
maintenance management
problems.
Railway 1987 King’s Cross Management failures, 31 died

1988 Clapham Junction Technician failed to remove a 35 died 500 injured

wire, bad workmanship, poor
supervision and poor
manangement.
Aviation 1989 Kegworth M1 Air 47 persons died
Crash
Source: Compiled from Watson, 1988; Reason, 1990; Senders & Moray, 1991; Redmill & Rajan, 1997

3.2 THE SAFETY CRITICAL SYSTEM

The term safety-critical system borrowed from Redmill and Rajan (1997) is useful. A
safety-critical system is defined as one which may present a hazard to human life or
well-being, or the environment. Their theory on human factors in safety-critical
systems highlights the central position of humans in such systems, and supports the
concept of the safety triad where the psycho-socio-technical variables interact to
either promote or undermine safety.

Redmill and Rajan (1997), as indicated in Figure 3-1, show a total system and the
place of people within that system. The system has three parts, 1) the equipment
under control (for example a nuclear plant), 2) the control and protection systems

38
which are computer[ized] elements for monitoring, controlling and providing
protection and 3) the humans.

Control Equipment
system(s) under control

Humans

Protection
system

Figure 3-1: The total system according to Redmill and Rajan.

Source: Redmill and Rajan (1997)

Humans in this context include all the people. Applied to the maritime industry, the
diagram would indicate the equipment under control as the ship; the protection
system consisting of elements that are technological/computerized (warning systems,
navigation systems); and organizational systems such as safety management; and the
control systems also entail organizational policies and procedures as well as the
wider regulatory regime, for example conventions and port state control. Humans are
the point of convergence where the various elements meet each other at the apex of
the safety-triad.

The purpose here is to demonstrate that shipping is a safety-critical system and that
humans pervade the entire system and a balanced and holistic approach towards
understanding such dynamics is indisputable. Further, acknowledging the
pervasiveness of humans in safety-critical systems should ensure that risk
management aggressively adopt a variety of approaches to solutions, which is the
shortcoming of the maritime industry. Solutions, particularly for education and
training, do not reflect the human complexities that exist in shipping (Arslan, & Er,
2006; Kristiansen, 2005). Pekcan, et. al. (2005) thus conclude that approaches to the

39
non-technical aspects in the maritime industry are comparatively (with aviation)
immature. Redmill and Rajan (1997, p-7), underscore the importance of the human
factor, their view is still relevant for today and is instructive for the maritime industry:
The human component should be the subject of hazard analysis and careful,
verified design to the same degree as the other components of the system.
That it often is not, is the cause of many otherwise avoidable accidents. …
people have freedom of choice and, while this is a strength …it also renders
their behaviour unpredictable and its analysis more complex and difficult.

This attempt to balance the scales by giving due regard to the role of humans at the
sharp end is not a popular position to take as the prevailing perspectives focus on the
organization (such as Reason, 1997) or take a systems approach (such as Perrow,
1999 and Dekker, 2006). However this dissertation, also sees the need to consider the
human component of safety critical systems as the subject of hazard analysis in their
own right as feeling, sensing beings with their own human mechanisms for action
and/or inaction.

3.3 HUMAN ERRONEOUS ACTS

Human error analysis, is an integral part of human factor theory, discussing the what,
when, where, why and how of errors (Reason, 1990; Senders & Moray, 1991; Perrow,
1999). However, the term human error has proven problematic within safety culture,
as it connotes blame, whereas the situation is usually more complex. To demonstrate:
A man has a protracted argument with his wife. He stamps out of the house to
the nearest bar and drinks four highballs. He then decides to go for a ride. It is
night-time, there is a skim of snow on the ground, and the tyres on our
victim’s car are smooth. In rounding a poorly banked curve at excessive
speed, the right front tyre blows out; the car leaves the road and is demolished.
What was the cause of the accident? The argument? Drinking? Speed? The
weather? The smooth tyres? The blow out? The poorly designed highway?
(Chapanis as quoted in Barnett, 2005, p.132)

40
Any one of the reasons listed above could be taken as the cause depending on the
perspective and motivation of the investigator, as well as how far in retrospect the
analysis of the chain of events goes (Barnett 2005). As such, Hollnagel (1998) sees
attributing a cause for an accident to human error as a judgment in hindsight and is in
itself erroneous. Likewise, Reason (1998) makes a strong case for human erroneous
acts to be seen as consequences rather than causes. In so doing he emphasized the
role of organizational conditions in shaping the performance of the people, and
therefore cautions the human impulse to lay blame on those at the sharp-end. This is
a major step towards fostering a no blame culture, an important sub-component of a
safety culture (Reason 1997; Manuel, 2005). Causes are attributed to failures within
the organization (Watson, 1988; Reason, 1997; Dekker, 2006), or the system as a
whole (Perrow, 1999).

The organizational perspective is one approach to understanding error. Others have

been the technological approach and the human approaches. The technological
paradigm viewed the technology as the source of errors and attempts were made at
improving the technology (Senders & Moray, 1991; Redmill & Rajan, 1997). The
human perspective saw people as the weak link in an otherwise safe system and
attempts were made to design people out of the system (Senders & Moray, 1991;
Dekker, 2006). These polarities, while useful in their own right, have been
detrimental to a holistic approach to risk management. The dissertation is not
proposing a return to the old paradigm of a blame culture but as the human factor is
the least understood of the systems, they are to be brought into the loop, which is the
focus of this work.

3.4. HUMAN PERFORMANCE IN SAFETY-CRITICAL SYSTEMS

Risk management may be to safety culture what a waypoint is to a navigator. Safety
and safety culture must consider risks (O’Neil, 2000; Kristiansen, 2005). It is in the
consideration of risks associated with humans that PSFs arise. Gyles and Salmon
(1978) as quoted in Barnett (2005, p.134) illustrate by what they describe as the

41
frustration that those responsible for safety may feel in the face of an accident when
they thought all defences were in place:
There was no gross negligence, no recklessness or stupidity, no drunkenness
or fatigue, no question of the ship being without enough trained personnel; no
lack of equipment. But there were mistakes. Mistakes of the kind that all men
are liable to make on occasions. Seeing what they expect to see; not seeing
what they should see, failing to recognise a mistake in a colleague, reacting
too late, or not at all, in the face of the unexpected.
Such an understanding of the human capacity to commit erroneous acts, and viewing
humans as a system in its own right, would lead to a full engagement with the human
idiosyncrasies making them an integral part of the risk analysis, without the blame.

Humans have their own built in mechanisms for protection (flight or fight),
restoration (sleep), for information processing as well as mechanisms that are
sometimes seen as inadequacies such as boredom, distraction, loss of concentration,
(Redmill & Rajan, 1997) and susceptibility to fatigue. Although Reason (1990, p.173)
extols an organizational perspective, he acknowledges the role of the human element:
Rather than being the main instigators of an accident, operators tend to be the
inheritors of system defects created by poor design, incorrect installation,
faulty maintenance and bad management decisions. Their part is usually that
of adding the final garnish to a lethal brew whose ingredients have already
been long in the cooking.

The argument is, human actions contribute to accidents; there is merit in addressing
the “garnish,” without which the meal is not appetizing. For the maritime industry,
Baker and McCafferty (2005) have found where seafarers have been direct
instigators of accidents. Reason (1990) also acknowledges that humans commit
violations. These violations he sees as occurring in a social context where rules,
codes of conduct and procedures exist. Violations are described as “…deliberate –
but not necessarily reprehensible – deviations from those practices deemed necessary

42
(by designers, managers and regulatory agencies) to maintain the safe operation of a
potentially hazardous system.” For example, the master of the Attilio Ievoli, of his
own volition, used the west Solent, against company instructions, where the vessel
ran aground. This dissertation refers to these human related threats to systems as
human idiosyncrasies, as explained in the Chapter 1.

Human threats to system failure are said to stem from two sources, erroneous acts
and violations. Rasmussen’s categorization of performance is commonly referred to
in explaining erroneous acts. These types of performance are skilled-based, rule-
based and knowledge-based (Reason, 1990). Skill-based actions are prone to slips
and lapses; rule-based and knowledge-based actions are pone to mistakes. In brief
planning failures are termed mistakes while execution failures are termed slips and
lapses (Reason, 1990).

The sequence of performance is for skill-based actions to precede rule and

knowledge-based actions (Reason, 1990; Redmill & Rajan, 1997). It is subsequent to
an erroneous act at the skill-based level, if such error is detected, that rule and
knowledge based performance is activated (Reason, 1990). However, as Reason
(1990) explains, the nature of man is such that the tendency is for the actor to resort
to rule-based actions (separate from written rules), seeking a pre-determined solution
from his database of cognitive scripts and schemas. These are human mechanisms for
decision making short cuts but may sometimes lead to inaccurate information and
poor decision. It is at this juncture that the behavioural sciences are evident where
concepts such as availability heuristic and confirmation bias surface. The notion is
that stored scripts and schemas are activated to pair with the existing situation to find
solutions. Information that is readily available in memory is used (availability
heuristic) and such information confirms what the person wishes (confirmation bias)
(Zebrowitz, 1990). It is after these mechanisms have failed to satisfactorily resolve
the situation that knowledge based performance is activated (Reason, 1990).

43
 3.4.1 Assessing Performance
Human reliability assessment (HRA) methods have been developed to analyze the
risk posed by humans to systems. Here, factors that shape performance are
investigated. HRA approaches involve three stages of 1) identifying the possible
errors that can occur, 2) determining the likelihood of their occurrence and 3)
improving human reliability by reducing the likelihood of their occurrence (Redmill
& Rajan, 1997).

Hollnagel (1998) noted that at different periods in the development of HRA methods
the focus was altered. Initially such human risk assessment was categorized
according to errors of omission and commission. Such categorization was behaviour
based. Taking their cue from Skinnerian stimulus-response behavioural theory, the
categories proved useful for observable actions. It was however discovered that
account had to be taken of the internalized (endogenous) actions and therefore other
HRA methods focused on human cognition (Hollnagel, 1998). One of the major
premises of the cognitive approaches is that “…any attempt of understanding human
performance must [Author’s emphasis] include the role of human
cognition…particularly in the study of humans at work.” (Hollnagel, 1990, p. 15).

3.4.2. Nature of Human Performance

Reasons (1997) Swiss cheese model (Figure 3-2) of active and latent failures in
organizations may be used to apply a similar analysis to human erroneous acts. This
writer is of the view that similar to the organization, humans have internal
mechanisms that may be seen as active and latent failures. Such mechanisms lie in
the cognitive 11 and behavioural domain. Therefore cognitive heuristics 12 that
manifest themselves in perceptive biases such as confirmation bias may be viewed in
the sense of a latent failure (although it must be said that these are built in
mechanisms that have their usefulness). Active human failures may be seen a as a

11
This use of cognitive refers to mental programming and not the reference to knowledge gained
through education.
12
Mental shortcuts

44
mistake, a slip or a lapse which manifest themselves in observable behaviours. Both
active and latent failures shape performance. The relationship between the two types
of human failures can be seen as failing to act or acting incorrectly as driven by cues
from the cognitive dimension.

Figure 3-2: An accident trajectory passing through the holes and defences in a system
Source: Reason (1997).

The figure shows Reason’s (1997) accident trajectory to which a parallel may be
drawn. Using the Royal Majesty accident as an example, the holes in the system due
to latent conditions can be compared with the human idiosyncrasies such as
confirmation bias. Active failures may be seen as overreliance on automation
(diffusion of responsibility)13, defences in depth can be referred to as knowledge and
skills gained from training. For the Royal Majesty, the accident trajectory was
activated when at the skill based level, an execution failure occurred; that is, course
was not changed. Due to latent conditions the cues to indicate that something was

13
Less vigilance in the presence of others or an automated system. This is discussed further in Chapter
6 on the Behavioural Sciences.

45
wrong were used instead to confirm that the vessel was on the planned route, as the
officers had over-relied on the automated system; as there was no training on the
human biases, these could not be activated as further defences in the system and
therefore the error led to the grounding.

3.4.3 Performance Shaping Factors in the Maritime Industry

A number of factors shaping human performance have been discussed for the
maritime industry. The UK P & I Club (1996) found that deck officer error was the
highest among its main causes of major P & I claims, accounting for 25%. This
justifies a focus on the factors that shape their performance. In a review of the
literature relating to the human factor in the maritime industry, Hetherington et. al.
(2006, p. 403-409) discussed a number of PSFs; those of relevance to this work are
listed below:
• Personnel issues: Fatigue, stress, health and wellbeing
o Non-technical skills: situation awareness, decision-making and
cognitive demands, communication, language and cultural diversity,
teamwork.
Issues of health, stress and welfare will be discussed under fatigue, while issues of
leadership, power, communication and culture will be discussed as a part of
teamwork, situation awareness is discussed separately.

3.5 REDUCING HUMAN ERRONEOUS ACTS

Senders and Moray (1991) suggest a dichotomous taxonomy of erroneous acts that is
suitable for this dissertation as it relates to internal and external influences -
exogenous and endogenous erroneous acts. Exogenous acts are caused by factors
external to the person and endogenous within the person, which is similar to
Reason’s (1990) intrinsic (cognitive biases, attentional limitations) and extrinsic
factors (structural characteristics of the task, context effects) as well as Hollnagel’s
(1998) internal and external view of PSFs. Since the focus is primarily actors at the
sharp end, this taxonomy is useful to distinguish active failures that arise in the social

46
system (exogenous/context) - team-work, leadership, communication - and those that
arise in the individual (endogenous/intrinsic) - perception, cognition. It is said that
most erroneous acts are exogenous in keeping with other writers who foreground the
organization, and the situations in which this is not true are said to result from among
other things, poor quality of training. It stands to reason therefore that education and
training is a strategy to combat such erroneous acts.

Accidents have many causes and it is considered that interrupting the causal linkages
at any point would prevent the error (Senders & Moray, 1991) although there are
opposing views to this notion (Reason, 1997; Dekker, 2006). The rationale is that, for
the maritime industry it is easier to access the seafarers than companies for
regulatory purposes. The training regulatory regime is in place, what is needed is to
strengthen its provisions taking a holistic, systematic and focussed approach to
training that would engage the science of man.

Maritime education and training is a combination of knowledge and skills to ensure

competence in carrying out the on board tasks. Competence currently does not
include human behaviour. A comparison can be made with the aviation industry
where the behavioural sciences are embraced holistically at every level of the pilots
life. Manuel (2005) points out maritime education and training needs to go further to
instil the correct attitudes to ensure that the requisite mindset is present to carry out
tasks with integrity and professionalism. While this is so, the curriculum has to
contain the correct content as well. Such content has been discussed in terms of
communication and cultural awareness (Horck, 2006, 2008a), leadership and
teamwork (Sampson, 2003; Arthur D. Little Ltd., 2004; Pekcan, et. al., 2005), but
content concerning perception and how these affect judgment and decision making
are yet to be discussed in the maritime industry.

47
3.6 CHAPTER SUMMARY AND CONCLUSION
The premise of this dissertation is that safety culture is a desirable goal for the
maritime industry that promises to enhance safety. The human factor is a challenge
to this goal. The challenge lies in the performance on board in areas such as
teamwork, situation awareness and fatigue. PSFs are usually the domain of risk
management. Risk management strategies to address human performance have
utilized the behavioural sciences. It has been shown that human factor theory and the
behavioural sciences are inextricably linked (Reason, 1990; Senders & Moray, 1991;
Redmill & Rajan, 1997; Hollnagel, 1998). This is the missing ingredient in the
training regime. What is needed is a focus on the actors at the sharp end as
psychological beings. Although the IMO Conventions do not preclude individual
Member States developing higher standards, the industry in general and MET, use
such standards of the IMO as a benchmark and look to the regulatory regime for
guidance and cues towards their action. Hetherington et. al. (2006) indicate that the
provisions for the non-technical training in the STCW Convention do not suggest
what the human behaviour skills are, or what is an adequate level of competence.

The importance of education and training to grasp the aetiology of such conditions
and how they come to influence performance will assist in building defences against
their occurrence. It is proposed that the behavioural based training that has been
recommended (IMO, 2003a) to influence attitudes through behaviour, considers such
cognitive human “failings” in its content. Developing the right attitudes necessitates
the inclusion of the right content.

48
 CHAPTER 4
EDUCATION AND TRAINING OF SEAFARERS
PART I

The Role of Training Institutions in Safety Culture

4.1 INTRODUCTION
In this multi-dimensional, multi-disciplinary and flexible environment, aim of
MET is not only [to] give trainees basic technical knowledge to perform pre-
designed, routine and standardized objectives or briefly “training” but also to
improve their critical thinking, decision making and problem-solving skills,
leadership, social intelligence, moral motivation or briefly “education.”
(Asyali, et. al. 2003).

Training and education is seen as one of the critical mitigating strategies for the risks
associated with the human factor (Arthur D. Little Ltd., 2004; Pekcan, et. al., 2005;
Barnett, et. al., 2006). Seafaring has evolved beyond traditional education and
training requirements of a purely technical nature to the need for the “soft” skills
such as leadership, communication, cultural awareness, group dynamics (MARCOM,
1999; Benton, 2006; Horck, 2006, 2008a). As Ho (2004, p.14) rightly says: “what we
need is to develop the Seafarer of the Future who is mature, responsible, well-
rounded, has a fundamental strength of character, is empowered and aware of how
his actions affect the whole.” Such a seafarer is essential to the achievement of a
safety culture. A seafarer of this nature would be empowered to say no to
substandard shipping, would be averse to violations, and would seek to do the right
thing at the right time (Manuel, 2005) displaying the level of professionalism that
would suggest an internalization of such principles. It seems that a few shipping
companies have found a formula, an organizational culture that reinforces as well as
“goes beyond” the formalized training to the development through shipboard life the
“unwritten” rules of professionalism (Lane, 1999; Hernqvist, 2008). But what

49
becomes of the seafarer when he leaves this company, are the skills sufficiently
ingrained to have continuity?

Professionalism is considered as competence by Lane (1999), demonstrating that a

seafarer’s competence goes beyond the technical. But such companies are few. What
is needed is the kind of empowerment that would instil this “professionalism,”
strength of character; it is believed by this writer, as others have indicated (Sampson,
2002; Ho, 2004; Barnett, 2005; Manuel, 2005), that it is through education and
training that such traits are developed and more so, education and training in the
behavioural sciences to augment the technical, and this should be pursued by the
STCW Convention to ensure that the standards are spread globally.

This chapter has two parts. Part I looks at MET and the state of education and
training in the non-technical areas, which the industry now demands. Part II is a
review of the STCW Convention relative to its human factor provisions. The chapter
is predicated on two assumptions that, since MET institutions are fixed then
enforcement of standards are possible. It is also assumed that unlike with people,
compliance may lead to excellence when given no other choice. There are
institutions that go beyond the basic requirements, however to have global
uniformity in standards the STCW has to prescribe these for MET.

4.2 THEORIES OF LEARNING

It is helpful to explore a few theories of learning to substantiate the need to engage
the science of man at the MET level. Theories of learning are divided into basically
two camps, the behavioural and the cognitive. Bigge and Shermis (1992, p.3) define
a learning theory as:
…a systematic, integrated outlook in regard to the nature of the process
whereby people relate to their environments in such a way as to enhance their
ability to use both themselves and their environments more effectively.

50
What is suggested here is that learning is deliberate and orchestrated by those
responsible for the process. A holistic approach, systematically applied based on
notions of how humans absorb information and relate to their environment. Such
deliberate orchestration is the purview of educational institutions.

Learning theories were developed to make the teaching process more effective and
efficient (Bigge and Shermis, 1992). Early approaches viewed learning as “mental
discipline” where the mind had to be exercised, as such, much learning was based on
repetition and recall. Subsequently, theories based on behaviourism and cognition
emerged (Bigge and Shermis, 1992).

The behaviourists saw learning as a “change in observable behaviour” which was

conditioned through stimulus and response (Schellenberg, 1978; Bigge and Shermis
1992; Muirhead, 2008a). The behavioural approach was seen as an improvement on
the early repetition and recall method. The behavioural approach to education has its
roots in the work of B. F. Skinner and his theory of operant conditioning
(Schellenberg, 1978; Bigge and Shermis, 1992; Conway, 1997). It is reflected today
in behaviour modification that has been a popular approach to instil attitudes and
correct behaviour as regards safety and is commonly recommended for use in the
maritime industry (IMO, 2003b; Manuel, 2005; Pekcan, et. al., 2005; Barnett, et. al.
2006). Behaviour modification rests on the ABC process where antecedents,
behaviour and consequences are “engineered” to elicit desired responses.

Dissatisfaction with behaviourism in terms of problem solving and learning

strategies led to the development of the cognitive approach (Bigge and Shermis,
1992; Conway, 1997). The cognitive approach saw learning as a process of “gaining
or changing insights, outlooks, expectations, or thought patterns” (Bigge and Shermis,
1992, p.10), as the learner actively participates in his/her learning. Thus individual
factors such as personality and motivation, as well as social context influence the
learning process (Bigge and Shermis, 1992; Conway, 1997; Muirhead, 2008a). The

51
cognitive approach has its roots in the work of educational psychologists such as
Vygotsky, Piaget and Bruner (Bigge and Shermis, 1992; Conway, 1997).

4.3 TEACHING METHODOLOGIES

Delivery methods developed can be viewed from the behavioural influences to the
cognitive/information processing method known as constructivism (Conway, 1997;
Arends, 2000). The methods used by MET varies and may be seen as directly related
to the philosophy that drives the school. The lecture mode is still a common method
of delivery. It is a passive method (Muirhead, 2008a). However, technology has
impacted the delivery of lectures by introducing the use of multi-media and other
such teaching aids, thus increasing the opportunities for use of a behaviour based
approach. As such the ABC behaviour based model has been incorporated into the
use of simulators as an innovative method at Warsash Maritime Centre (Pekcan, et.
al., 2005; Barnett, 2006). This will be discussed further.

Constructivism utilizes collaborative/cooperative and problem-based learning

(Conway, 2007) providing more opportunities for internalization of learning
objectives. The terms collaborative and cooperative learning are used
interchangeably, and refers to cooperation in the learning process as against
competition where students work together to find solutions to a problem rather than
compete individually for grades. Problem-based learning may involve collaboration
and is geared at the student finding solutions to real problems; as such, this delivery
method is deemed suitable for andragogy (the teaching of adults) as against
pedagogy (teaching of children). The problem based approach has been
recommended for application to the STCW requirements as it is seen as a valuable
and reliable method of achieving learning objective of knowledge, skills and
attitudes (Asyali, et. al. 2003). It was concluded that the competence demanded of
the seafarer will not be gained through traditional teaching methods, therefore Dokuz
Eylul University School of Maritime Business and Management in Turkey, changed
its curriculum to one that utilizes problem based learning (Asyali, et. al. 2003).

52
 4.3.1 The use of simulators
Simulators have become a ubiquitous teaching tool in MET. If their advantages are
harnessed they can be a very effective delivery method combining both behaviour
and cognitive based approaches. The industry has embraced the use of simulators as
evidenced in the STCW Convention Section A-I/12, being mandatory for Radar and
ARPA training. It is debated whether simulators are more efficient than onboard
training and the conclusion is that it is in many regards (Muirhead, 2008b) as
multiple learning objectives may be covered in a shorter time without the risks;
confidence of the cadet is developed; hands-on experience is gained in decision
making and operational procedures in difficult situations, which would be impossible
on board (Muirhead, 2006, 2008c).

The use of simulators has been observed by the writer on field trips to training
institutions in Europe (France, Netherlands). Both approaches were evident. If the
Warsash behavioural approach is used as reference, aspects of the ABC were present
in the use of simulators at these institutions: A-ntecedents were the class room
lectures; B-ehaviour was the practical exercises on the simulators and C-onsequences
were the debrief. Additionally, the fact that the situations required critical thinking
and problem solving by working as a team, introduced the problem-based
approached of the cognitive theory. The writer was however uncertain that these
methods were exploited to their fullest potential. It was clear that the focus was the
technical. On inquiry, at one location, the writer was told that human factor issues
were mentioned in debrief; yet these could have been incorporated in existing
simulation exercises to account for the need of the soft skills.

4.4 CONTEXT
One of the demands of the industry is to address its accident record. This is
predicated on the development of a safety culture. A restructuring of MET to respond
to the contemporary demands of the industry for well-rounded seafarers has been
seen as an imperative (Asyali, et. al., 2003; Kanev, 2003, Asyali, et. al., 2006). The

53
attitude to safety culture varies across institutions. Interviews reveal that such
attitudes range from conscious and deliberate actions to incorporate the “softer”
skills to not having any such programmes. The importance of the non-technical
demands that not just some, but all seafarers become beneficiaries. Training
institutions have their own philosophies and worldview that influences their
approach to such topics. Although dated, Rosengren, & Bassis (1976) provide
valuable research on the social organization of maritime education and training
which illustrates how the different philosophies and national interests drive the MET
curriculum. The system of training is as varied today with universities, colleges and
vocational training and different curriculum, such as those offering dual purpose
training as against the traditional separation of departments (Schröder, et. al. 2003).
MET curriculum is also affected by the realities of economics and politics (Prasad,
2008a).

Manuel (2005) also found that MET may be driven by similar cultures as the
industry ranging from evasive to those with a safety/excellence culture. He noted that
by far those with a compliant culture are greatest in number. However, unlike with
people, compliance in this instance may lead to a culture of excellence as the
mechanisms can be instituted to drive this development. The nature of the global
regime is such that the STCW Convention governs the curriculum so far as the
provisions are mandatory. The provisions for accountability were strengthened in the
1995 amendments, which are to be further strengthened in the current review (IMO,
2008). It is assumed that since MET institutions are fixed then they are easily
identifiable and may be subjected to the regulations to ensure standards are kept.
There are those in the evasive group that may avoid detection, but it is believed that
improvements will at least be made within the compliant group.

An outcome of the METNET programme was that the quality and employability of
seafarers was mainly the task of MET institutions (Schröder, et. al., 2003). A similar
conclusion from a global perspective was arrived at (Kanev, 2003) in looking at the

54
seafarer labour market challenge and implications for MET. The “soft” skills courses
that are the concern of this dissertation would fit into the framework as developed by
Schröder et.al. (2003) for the enrichment of the seafarer. If the seafarer is to see
seafaring as a career path and he is to be prepared adequately for employment ashore,
leadership, teamwork, cultural awareness and other social-psychological skills apply
to all careers. Such courses could become part of the enrichment process (Schröder et.
al. 2003).

4.5 CONTENT
The “soft” skills that shape performance are more and more coming to the fore as
casualty investigations begin to take account of human factors in accidents. The need
for education and training in these areas is also gaining momentum, however the
approach remains ad hoc as topics are introduced as reactive approaches to accidents.

There needs to be an understanding among the regulators of the need for a holistic
approach as evidenced during the deliberations of the current STCW review (IMO,
2008) where a delegation proposed a combination of BRM, Engine-room Resource
Management (ERM), communication and leadership as they all address human
behaviour and human resources; however, this proposal was not supported.
Additionally it was proposed that the requirements for communication, language etc.
should be only for deck and engineer officers. This writer is of the opinion that all
should benefit from such education. It may be made appropriate to the ranks and
function of the seafarer, however all crew members, including ratings need to be
aware of aspects of shipboard life such as the responsibility of leadership, beyond
their perceptions of the one who gives orders; its role and function, and how they
(the ratings) fit into the team in general. Issues such as obedience to authority
(Sampson, 2003) and its destructive nature may be discussed in a course on
leadership and taught in such a way as to develop the ability to “challenge” authority
respectfully. The provision as it is currently stated in the STCW Table A-II/4 “ability
to understand orders…” may be perpetuating power relations that are

55
counterproductive (Sampson, 2003) and the ability to “challenge” that is being
discussed, may not be fostered in such an “order taking” atmosphere. A holistic top-
down and bottom-up approach is prudent.

4.5.1 Culture
Culture affects both context and content. The seafarer is a product of his culture
which influences the attitudes by which he views the world and through which he
operates. This impacts both the operational procedures and the social interaction with
fellow shipmates on board. Cultural differences are a challenge for the safety of
shipping (Dzugan & Renping, 1999; Benton, 2006; Horck, 2006, 2008a). Such
differences lie in the national/ethnic cultures from which people come (Hofstede &
Hofstede, 2005). However, such dimensions are not easily influenced and therefore
the need to incorporate into the curriculum at all levels. As one institution indicated
that courses developed to address safety culture are taught at every level throughout
the seafarer training programme, “from first year step by step” (Appendix 4). This
approach, strengthened by a cognitive and behaviour based delivery method, would
ensure enculturation of the values and principles embedded in such courses and there
is a greater likelihood that seafarers who are so educated and trained would exhibit a
higher level of ethics and professionalism than those who were not exposed in this
way.

Hofstede and Hofstede (2005) is useful in describing some of the impacts of culture.
Culture is seen as mental programming resulting from socialization. Culture is
learned. As such any effort at mitigating cultural influences has to tap into mind (and
hearts) of individuals. Issues of power and authority and leadership, how these are
perceived and the responses to these are culturally based (Hofstede & Hofstede, 2005)
and impact interactions. The concept of power distance which is becoming a
common concept in the maritime industry, is defined as “the extent to which the less
powerful members of institutions and organizations within a country expect and
accept that power is distributed unequally.” (Hofstede & Hofstede, 2005, p.46). The

56
impact however is in its influence on behaviour where expectations and acceptance
manifest themselves in dependence, that is, the subordinates are afraid of disagreeing
with the superior and expect an autocratic style of leadership and decision making.
Hofstede & Hofstede (2005) also noted that counter-dependence is another likely
outcome of power distance, where the subordinate rejects the power but complies in
practice. This may also result in destructive obedience as the subordinate would
comply with any order given.

Whereas Hofstede’s and Hofstede’s view may be debated, it does provide food for
thought with regards to categorizing behaviours on board. It may be that national or
organizational or shipboard culture is operating to foster power distance which has
implications for intervention (an important area to be researched). Power distance is
associated with destructive obedience (Sampson, 2002; 2003) (obeying a wrong
command, or keeping silent due to the authority of the person giving the orders). For
example the Domiat and the Green Lily accidents were possibly due to power
distance where the masters’ decisions were not “challenged” by any of the officers
which led the Domiat to run aground, and which exacerbated the situation for the
Green Lily leading to the death of a rescue operator Appendix I).

4.5.1.1 Cultural Awareness

Cultural awareness is being discussed increasingly as it is seen as a possible factor
affecting shipboard operations. Investigations into casualties such as the Bow
Mariner suggest that stereotypes may have been operating. The senior officers were
Greek. It was reported that the Filipino officers were given almost no responsibility,
and were closely supervised in every task.” Such behaviours reveal lack of trust in
the abilities of the Filipino crew which may have been motivated by stereotypes of
the abilities of Filipinos in general. As such Horck (2006; 2008a) advocates that
MET be proactive as the need for cultural diversity training is evident. Benton (2006)
also agrees with the need to make the study of “cultural difference” a core
component of the curriculum of maritime institutions. The reality of multinational

57
crew demands that for greater cohesion and safety, seafarers must become culturally
literate (Benton, 2006).

4.5.2 Communication and Language

The tradition in the maritime industry has been to discuss communication primarily
as language difficulties arising from multi-nationality onboard, perhaps because this
was easily identified. The solution has been to develop communication phrases to be
used in specific occasions and stressing the importance of a common language giving
rise to Maritime English as an area of study (Benton, 2006). Communication is
however much more than language - grammar and vocabulary - (MARCOM, 1991;
Dzugan & Renping, 1999; Kahveci et. al. 2002; Badawi & Halawa, 2003; Sampson
& Zhao, 2003; Horck, 2006, 2008a) as culture, non-verbal communication, aspects
of social interaction and meaning are critical aspects that would not be solved by
having a common language.

4.5.3 Leadership and Teamwork

The operational imperatives onboard demand teamwork (Østreng, 2001; Asyali, et.al.,
2006); effective teams have good leaders; lack of teamwork and poor leadership have
been cited as contributory causes in a number of accidents, for example Domiat and
Dole America. The organizational structure of a ship is steep in hierarchal traditions
which seemingly give rise to autocratic styles of leadership (Kahveci, et.al. 2002).

Organizations ashore have long moved on to more horizontal structures where

teamwork is encouraged. Whereas it may be necessary to maintain a vertical
structure, “teamship” (Sampson, 2002) must be encouraged and autocracy
discouraged, this is best done through holistic application via education and training.
Recalling that one of the “principles” of safety culture is flexibility (Reason 1997),
the ability to defer authority according to the exigencies of the situation, such
flexibility has to be “cultivated.” Asyali, et.al.(2006 p.9) noted that coordination on
the bridge requires the ability to work together which in turn requires “…people

58
skills such as communication, teamwork, leadership, the ability to learn, and ability
to adapt to changes.” But has been said by others, (Kahveci et. al., 2002; Sampson,
2002; Arthur D. Little Ltd., 2004) “the existence of these necessary skills among
seafarers is questionable” (Asyali, et.al., 2006 p.9). Although speaking specifically to
the issue of destructive obedience and authority Sampson’s (2003, p.7) observations
may be applied generally to the non-technical requirements of seafarers’ competence:
[these] are likely to require considerable training and re-training for masters
[and crew] who may not currently have the skills required…simulators may
assist in this process but to address the problems…requires that the training
policies of companies and indeed maritime training establishments become
more innovative.

4.6 AN AMALGAMATION OF CONTEXT AND CONTENT

Two cases from the industry were selected to demonstrate the possibilities to enrich
the MET experience by impacting both context and content.

4.6.1 School of Maritime Business Management

A conscious decision was made by the Dokuz Eylul University School of Maritime
Business Management, Kaynaklar Campus in Turkey to change the context of
learning by changing from the conventional delivery to the student-focused problem-
based delivery method. This change was in response to the realization of the need to
promote teamwork and less hierarchal structures according to global organizational
trends, and the demands of the maritime industry (Asyali, et. al. 2006). The
education strategy of the institution was stated as:
“…to provide the students with certain proper knowledge, supported by
desired skills and profound attitudes that they will need in their future
professional careers and also give then the ability to respond quickly to
changes in technology, operations, practices and procedures on board. (Asyali,
et. al. 2003)

59
The procedure is to provide students with problem based scenarios similar to what
practitioners would face. The students define the problem and are given guidance,
resources and are left to solve the problem. Learning objectives are embedded in the
scenarios which require an inter-disciplinary approach working in teams. Appendix 6
graphically presents the process. The outcome has been rated as an effective tool for
the requirements of the STCW Convention.

4.6.2 Warsash Maritime Centre

Using the ABC behaviour modification model and adapting the contents of the
aviation industry’s crew resource management (CRM), the Warsash Maritime Centre,
Southampton Institute, developed a programme to address the need for the non-
technical skills in the maritime industry (Table 4-1) (Pekcan, et. al., 2005; Barnett, et.
al. 2006).

Table 4-1 Types of skills that are taught on the CRM course.

SOCIAL SKILLS COGNITIVE SKILLS

Co-operation Situation Awareness
• Open communication • Situation awareness
• Consideration for others • Risk assessment
• Team working
Leadership and Managerial Decision Making
Skills
• Situational leadership • Problem diagnosis
• Assertiveness • Option generation
• Planning and • Option selection
coordinating
Source: Pekcan, et. al. (2005).

The course emphasizes social and cognitive skills while presenting the students with
new ways of thinking and problem solving. The new ways of thinking are said to be
the antecedents to safe behaviour developed in the lectures and the behaviours
practiced and through debrief receive feedback, which are seen as the consequences.
More details are given in Appendix 7.

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 EDUCATION AND TRAINING OF SEAFARERS
PART II

STCW 1978 Convention

Human Factor Provisions

4.7 THE NEED FOR THE STCW CONVENTION

This section looks at the STCW Convention 1978 as amended as one of the four
pillars in the maritime safety regulatory regime.14 The Convention is tasked with
providing minimum mandatory training standards to ensure that seafarers possess
uniformity in competence to carry out their duties safely and efficiently while
protecting the marine environment. The Convention’s effectiveness as regards the
soft skill has been questioned (Pekcan, et. al., 2005; Barnett, et. al., 2006). This
section reviews the Convention, and current comprehensive review to ascertain the
human factor provisions.

The uniformity of training standards became necessary with increased

internationalization of maritime labour. The spirit of the convention is enshrined in
the following principle and embodies the consensus of the parties that education and
training is critical to the pursuit of safety:
THE PARTIES TO THIS CONVENTION,
DESIRING to promote safety of life and property at sea and the protection of
the marine environment by establishing in common agreement international
standards of training, certification and watchkeeping for seafarers…,
CONSIDERING that this end may best be achieved by the conclusion of an
International Convention on Standards of Training, Certification and
Watchkeeping for Seafarers. (IMO, 2001, p.7).

14
The others being SOLAS, MARPOL and the ILO’s Maritime Labour Convention, 2006.

61
In the absence of any standards, the promulgation of STCW 1978 was laudable and
seen as reflecting the highest standards which could be practicably agreed on at the
time (Agbakoba, 1994; IMO, 1996; Fuazudeen, 2008). However, a number of
limitations were discovered overtime (IMO, 1996, Fuazudeen, 2008; Horck, 2008b;
Prasad, 2008b). The most crucial one preventing the achievement of global standards
was having the provision “to the satisfaction of the Administration,” (Dearsley, 1994;
IMO, 1996; Winbow, 1999; Mahapatra, 2007; Fuazudeen, 2008). This resulted in
subjectivity in interpretation and application of the Convention, giving rise to various
standards of education (IMO, 1996; Fuazudeen, 2008; Horck, 2008b; Prasad, 2008b)
and loss of confidence in the Convention; it was decided that the time was right for a
comprehensive review (Dearsley, 1994; IMO, 1996; Mahapatra, 2007; Prasad,
2008b).

Other issues that were discussed included the role of the human factor in casualties
and fatigue. Communication was an occasional agenda item particularly as it
concerned the Sea-speak Manual and the desire to address poor communication
which was also seen as a possible factor in casualties (IMO, 1986a). The IMO has
therefore been discussing non-technical issues as part of the training regime for over
20 years, beginning with a submission by the Republic of Liberia on the dangers of
fatigue (IMO, 1986b). The International Federation of Shipmasters’ Associations
(IFSMA) also submitted a Note (IMO, 1986c) highlighting concerns regarding
fatigue.

Development in the understanding of fatigue was evidenced by the technical,

operational and human (including the psychological) aspects that later entered the
discussions (IMO, 1988, 1991). Recommendations were made that factors
contributing to fatigue should be taken into account in ship design, training and also
revision of the principles of safe manning. The outcome was Annex 4 to the report
to MSC “Recommendations of the Sub-Committee Related to the Role of the Human
Element in Maritime Casualties” (IMO, 1991). These recommendations included

62
communication, training, fatigue, and reporting of unsafe practices. Much emphasis
was placed on fatigue. It is apparent then that fatigue became the first major non-
technical issue to be considered as regards the STCW Convention. IMO Assembly
resolution A. 18/Res. 772 (1993) indicated, among other things, that: “The objective
is to increase awareness of the complexity of fatigue and to encourage all parties
involved in ship operations to take these factors into account when making
operational decisions.” The annex stated explicitly the dangers of fatigue and fatigue
inducing elements situated in the technical, organizational and the human domain.
Those elements in the human domain included multinational crews, which may
introduce language barriers leading to “social, cultural and religious isolation” and
the impact these may have on safety (IMO, 1993). Resolution .772 became part of
the deliberations on the first comprehensive review.

4.8 FIRST COMPREHENSIVE REVIEW

The first joint MSC/MEPC Working Group meeting discussed human factor issues
that were to be taken into consideration when examining system design or
recommended practices or procedures for human factor implications (IMO, 1992) as
shown in Figure 4-1. Items in the call out box are further details presented in the
source document that are direct subject matters of the behavioural sciences.

List of Items to be explored in examining system design or recommended practices or procedures

for human factor implications:-

• Physical capabilities required for effective human performance

• Mental capabilities required for effective human performance
• Minimum required training or experience
• Critical information required for effective human performance
• Associated events (workload)
• Degree of precision required for effective human performance
• Communication skills
• Time critical factors -Information processing
• Procedural considerations -Memory
-Attention
• Design considerations for operation and maintenance -Mental workload
• Any other relevant factor -Fatigue
-Decision-making

Figure 4-1: IMO Guidelines on Fatigue: List of human factor items.

Source: IMO Guidelines on Fatigue

63
This demonstrated a level of awareness within the IMO of the complexity of fatigue
and the involvement of the psychological aspects. However the amendments made to
the Convention were not commensurate with this realization.

Rightly or wrongly, the deliberations on the human factor began on the premise that
“…human error is the major contributing cause of maritime casualties and pollution
incidents…” which became the motivation for the comprehensive approach to
examining and finding solutions to the human factor problem. However the “devil is
in the details,” as Cox and Flin (2000) said of culture. An examination of the
amendments that emerged from these deliberations presents a lesser picture than the
deliberations promised. The aims of the review, as listed by STW 28th, “Outcome of
the 1995 STCW and STCW-F Conferences…” (IMO, 1996) are shown in Figure 4-2.

The main aims of the revision were:

1. to transfer all detailed technical requirements to an associated Code;
2. to clarify the skills and competence required and take account of
modern training methods;
3. to require Administrations to maintain direct control over and endorse
the qualifications of those masters, officers and radio personnel they
authorize to serve on their ships;
4. to make parties to the convention accountable to each other, through
IMO, for their proper implementation of the Convention and the quality
of their training and certification activities: and
5. to have the amendments enter into force for all Parties to the
Convention with the least possible delay.

Figure 4-2: Aims of the STCW 1978 first comprehensive revision

Source: IMO 1996, p.5

The absence of specific reference to the human factor as an aim should not be taken
as trivial as it reflects the minimal attention given to the “soft” skills. The aims as
laid down were achieved: technical competence was addressed (Dearsley, 1994;
Gauw, 1994; Winbow, 1999); quality standard system was introduced (Regulation

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I/8, Section A-I/8); enforcement and accountability were addressed (Regulation I/7),
and the ensuing “white list” of complaint countries could have their systems
examined by any other member state for purposes of recognition of certificates
(Regulation I/10). Qualifications for lecturers and assessors (Regulation I/6, Section
A-I/6 paragraph 7) were also included ensuring that not only the standards were in
place, but that trainers were qualified to deliver. These provisions sought to include
the major stakeholders such as the companies (Regulation I/14), strengthened by the
ISM Code that was being developed simultaneously, as well as maritime education
and training institutions (Fisher & Muirhead, 2005). These final provisions were
necessary, and responded to the industry’s call for a more robust training regime
(Fuazudeen, 2008) however a training regime translated in technical terms resulting
in an acknowledgment a few years later that the human factor has been somewhat
neglected (O’Neil, 2002).

4.8.1. Addressing the human factor

A total of 32 papers and notes were submitted to the 27th STW subcommittee
meeting (IMO, 1995), the final meeting in respect of the review. Of these, only 4
made reference to human factor relating to fatigue with one of the 4 making
recommendations for provisions to be deleted on the grounds that manning level is
not the purview of the STCW. The decision was to include fatigue under paragraph
VIII/I Fitness for Duty in purely physiological terms. The role of human element in
casualties, including casualty discussions, for example the grounding of the bulk
carrier Rose, where factors such as communication, leadership, teamwork, and
decision making were involved (IMO, 1986d) could have reflected more than a
perfunctory mentioning in the final document considering the founding principle of
the Code states that:
RECALLING that a large percentage of maritime casualties and pollution
incidents are caused by human error,
APPRECIATING that one effective means of reducing the risks associated
with human error in the operation of seagoing ships is to ensure that the

65
 highest practicable standards of training, certification and competence are
maintained in respect of the seafarers who are employed on such ships, …
(IMO, 2001, Resolution 2, p.1.)
There is a gap between this principle and the provisions made. Competence should
be interpreted as also having non-technical skills (Barnett, et. al., 2006). Appendix 5
compares the provisions with the PSFs as identified in the literature. Considering the
social and psychological aspects of the PSFs discussed at the time and their impact
on safe performance (IMO, 1993), the provisions under Fitness for Duty, Regulation
VIII/1, A-VIII/1 (IMO 2001) are insufficient (Smith, 2007). Regulation VIII, A-
VIII/1 and A-VIII/2 are mostly operational while the psychological and social
psychological permeates the operations but go unattended. The crew must be
competent in all tasks, the master is responsible for ensuring his crew is fit for duty,
not knowing the various forms fitness for duty may take and how to identify such,
will compromise the master’s ability to be fully effective.

Noting the existence of sub-standard ships, the impact would have also been greater
to include Bridge Resource Management (BRM) under the compulsory education,
making it the responsibility of MET. Although reference is made in Table A-II/1 and
A-II/2 to knowledge of effective bridge teamwork, the details are absent and
therefore left open to interpretation. Guidance given in B-VIII/2 calls for companies
to issue guidance on BRM. BRM and personnel management, were not mentioned
for officers and masters in charge of a navigational watch on vessels less than 500
gross tonnage.

Later amendments gave attention to non-technical aspects as regards passenger

vessels in the areas of crisis management, crowd management and human behaviour,
but these requirements do not apply to cargo vessels. The model courses are also
ineffective if the provisions are not compulsory, and these model courses have also
been found to be inadequate (Horck, 2006).

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4.9 CURRENT COMPREHENSIVE REVIEW: HUMAN FACTOR
The provisions in the STCW convention as amended for the development of non-
technical skills have been found to be deficient (Kanev, 2003; Pekcan, et. al., 2005;
Barnett, et. al., 2006; Fuazudeen, 2008). Relative to other industries such as aviation,
the provisions for crisis management and human behaviour are considered immature
(Pekcan, et. al., 2005; Barnett, et. al., 2006). Another comprehensive review is
underway which promises improved provisions in the area of the “soft” skills
(Mahapatra, 2007).

4.9.1 Fatigue
Fatigue continues to be of major concern as a key PSF within the maritime industry
(Lang, 2001; MIAB, 2004; Hetherington, 2006; IMO, 2007a & 2008). A step
forward is imminent with the inclusion of mandatory fatigue management training
for seafarers. While manning levels are still discussed, and it is proposed to revise
Chapter VIII to include more explicit provisions for rest schedules (IMO, 2007b), a
submission was also made on the premise that “the best means to improve
understanding of fatigue is to develop and offer courses that provide tangible and
practical methods of fatigue management” (IMO, 2007c, p.15). The recommendation
is for new competence to be added to Table A VI/1-4 to improve personal safety and
social responsibility training in fatigue management. The competence suggested
were, inter alia, importance of obtaining necessary rest; effects of sleep on circadian
rhythm; effects of schedule changes on mariners, fatigue; and effects of physical and
environmental stressors on the seafarer. This proposal also saw the benefit of
increasing fatigue awareness as contributing to a safety base culture on board.

The proposal was supported by the majority and is under consideration. A few
Members were in disagreement as they saw fatigue mitigation only in terms of the
organization of work and therefore no need for training in fatigue management. Yet
it is the position of this writer that the awareness and possible impact on attitude that
may be achieved through training will serve to complement the other efforts such as

67
work scheduling and rest periods, making for a more robust approach to fatigue and
shipboard safety culture (Smith, 2007).

4.9.2 Bridge Resource Management

Accidents such as the Attilio Ievoli where the investigations revealed that the bridge
crew was not clear on their roles and responsibilities, provide evidence for increased
focus on proper BRM. This is being given attention in the current review. It was
suggested and agreed that BRM is made mandatory. Therefore Tables A-II/1 and A-
II/2 are to be amended to include key elements of BRM. It was proposed that key
elements of engine room resource management (ERM) are also considered for
mandatory inclusion (IMO, 2008). Care should be taken that the contents address the
salient issues of teamwork, group cohesion and perception, and that BRM is not seen
solely in terms of work allocation.

4.9.3 Communication and Leadership

Leadership, management skills, situational awareness and decision making are
proposed for inclusion in a new section, A-VI/6 (IMO 2007d). The proposal saw the
need for seafarers in any capacity to receive appropriate training or instructions in
leadership and communication skills. These include both cognitive and social skills.
Details were outlined which attempted to be comprehensive. However this
dissertation is suggesting that there are additional elements which may further
strengthen the provisions such as knowledge of perception and perceptive biases
which play a role in situation awareness, as is discussed in Chapter 5. Cultural
differences and language were also seen as a necessary inclusion in this section, as
proposed by a delegation.

Additionally, another delegation recommended a holistic approach where BRM,

ERM, leadership and communication should be amalgamated as they all relate to the
human behaviour and human resources. However, this recommendation was not
supported (IMO 2008). Instead, it was suggested that training in communication,

68
leadership and situational awareness should be applicable only to deck and engine
officers; but as Mahapatra (2007) rightly observes, any crew member can be thrust in
a leadership role depending on the situation. The decision arrived at by the sub-
committee was to split the proposed Table A-VI/6 and include the major parts of
leadership in Tables A-II/2 and A-III/3 at the management level (IMO, 2008). While
the agreed elements are an improvement, this writer maintains that it would be
beneficial for the on board safety culture, as in the case of fatigue management, to
have all crew given knowledge to assist in their personal and professional
development. The holistic approach proposed should be considered.

4.9.4 Other Human Factor Considerations

Alcohol limits, which appeared on the agenda in the 1980s is also under discussion.
The outcome at the time was to include in Code B, B-VIII/2 parts 4 and 5, guidelines
relating to alcohol and drug abuse. Recommendations are now on the table for
inclusion in the mandatory section. Alcohol and other substance abuse have not been
included for major discussion in this dissertation, although a PSFs this demands its
own account. In one case, the Jacki Moon, the investigator stated that alcohol may
have been a contributing factor to the watch officer falling asleep, combined with
him being fatigued. The purpose of mention here is to caution the approach to
alcohol as a sensitive issue as it relates to the welfare and health of seafarers and that
it should be approached with understanding. A few responses from seafarers
(Appendix 2) revealed that alcohol is used as a coping strategy onboard in times of
stress and depression. Alcohol therefore should not be discussed in isolation of the
influencing welfare factors that are a cause for concern (Kahveci, 2007).

Training for a seafarer safety representative is being discussed as one method to

develop on board safety culture. Such a person would be intricately involved in
aspects of the vessel operations that relate specifically to the occupational health and
safety of the seafarer (IMO, 2007e). This is also an improvement on the existing
situation, but reflects the tendency to compartmentalize knowledge and skills. The

69
presence of such a person should not preclude everyone benefitting from appropriate
knowledge and skills and being informed so as to take their share of personal
responsibility for on board safety culture.

4.10 CHAPTER SUMMARY AND CONCLUSION

The chapter focuses on the discussions surrounding the deficiencies in seafarer
training as regards the “soft” skills. It examined learning theories and delivery
methods to indicate that structures exist for effective delivery, the challenge is to
harness the strengths with the appropriate content. The chapter also notes that
seafarers need to become “culturally literate” (Benton, 2006); culture affects the
interpersonal dynamics on board and impinge on safe operations (Dzugan & Renping,
1999; Benton, 2006; Horck, 2006, 2008a). This view was expressed much earlier
when Lloyd’s Ship Manager (Seafarers training needs…, 1992, p.53) quoted Martyn
Dyer-Smith, psychologist and former navigating officer, as saying “In addition to
focusing on technical skills, training of ‘the seafarer-of-the-future’ may well
increasingly have to include social-psychological dimensions”

The chapter also reviews the STCW convention as one of the pillars of the safety
culture regime of the maritime industry. It looks specifically at the human factor
provisions in light of criticisms that the Convention was limited in that regard. A
retrospective review of discussions leading to the first comprehensive review was
done to ascertain provisions as regards the human factor. It was revealed that the
human factor has been a longstanding agenda item in relation to fatigue and
communication in particular, but also leadership. The review revealed that the
outcome was not commensurate to the level of discussions that took place regarding
the human factor. A current review is underway and the promise of improved
provisions to develop the “soft” skills seems far greater than in the previous
comprehensive review. The hope is that these receive the support of the Member
States.

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 CHAPTER 5

THE HUMAN CONDITION

Idiosyncrasies in Action

What lies behind us and what lies before us are small matters compared to what lies within us –
Ralph Waldo Emerson

5.1 INTRODUCTION
On February 28, 2004, the vessel caught fire and exploded while the crew
was engaged in tank cleaning. Of the 27 crew members aboard, six
abandoned ship and made it to a life raft and were rescued. An unknown
number abandoned ship to the water, three were rescued, one deceased and
the other two died before reaching the hospital. The crew composition was
Greek senior officers and Filipino junior officers and ratings.

The distinctions between the Greek senior officers and Filipino officers and
ratings were remarkable. Filipino officers did not take their meals in the
officers’ mess, were given almost no responsibility and were closely
supervised in every task. The second assistant engineer reported that on
arriving on the vessel for the first time he inquired of his duties and was
sternly told he would be given verbal job orders daily, and was to do only as
he was told and would have no administrative duties beyond making log
entries. There was a lack of trust in the deck department. The surviving deck
crew reported that the chief officer would not sleep beyond short naps in a
chair in the cargo control room during cargo operations. When questioned
as to what they would do if instructed to do something unsafe by one of the
senior officers each crewman replied that they would do as they were ordered.
“Orders from the Greeks were like words from God.”[Author’s emphasis]
(US Coast Guard, 2005, investigation into the explosion and sinking of the
Bow Mariner)

71
The Bow Mariner represents a textbook case for leadership, power, authority,
destructive obedience, cultural diversity, communication, teamwork and violation.
These are all interrelated. Culture may have influenced the autocratic style of
leadership compounded by mistrust on onboard, which impacted poor teamwork,
symptoms of which are poor communication and lack of group cohesion, resulting in
destructive obedience as the subordinates’ response to power and authority.

This chapter, with reference to selected cases (Appendix 1), discusses a selection of
the common cognitive and behavioural human factor challenges impacting safety at
sea. These are described alongside the corresponding psychological theory with a
view to offering insight into the human condition as well as to suggest areas for
education and training. It is believed, to use the maxim, “knowledge is power”, that
an awareness and understanding of the mechanisms leading to such behaviours, will
develop an appreciation in the seafarer for these human idiosyncrasies and provide
him with the knowledge to counter the effects in his work and personal environments.
There are however challenges to engaging the behavioural sciences in a holistic way
such as availability of trainers with seafaring and behavioural sciences background,
the commitment of MET, to name a few, however these are not insurmountable.

5.2 THE BEHAVIOURAL SCIENCES

The literature thus far has shown the importance of the behavioural sciences in
understanding and finding solutions to the human factor challenges to safety culture.
The PSFs explored, pertain to the cognitive and behavioural domain of psychology
and social psychology. Cognitive psychology was developed in response to the need
to understand cognitive limitations and capabilities of human operators of technical
systems (Esgate & Groome, 2005). It involves the study of the mechanisms
underlying sensory cues - sight, hearing, tasting, smelling, touching – and how they
integrate with existing mental repertoires built by culture and socialization and
mediated by culture and context to make judgments and therefore drive actions
(Esgate & Groome, 2005; Chandler, 2008). Cognitive processes are useful

72
mechanisms provided by nature through which humans view and come to understand
the world. Yet these mechanisms are also wrought with “errors” that may have
negative outcomes (Esgate & Groome, 2005).

A useful book was written by Stadler (1987) some years ago on the Psychology of
Sailing: the seas’s effects on mind and body. Although it spoke about sailing, it also
has relevance for merchant shipping. Stadler (1987) premised his book on the fact
that “we sail with mind and body…we do not function on a boat in purely physical
capacity, rather life at sea affects the entire being, behaviour and personality.” He
believes that recognition of the psychological and social psychological phenomena,
which are encountered at sea, can enhance one’s ability to identify and therefore
cope with them. This has to be learnt through education and training, how to
recognize these phenomena and so alerted to the need to at times seek further
information, to question one’s judgment or the judgment of others in times of doubt.
On approaching the Nab Tower, the master thought he saw the light of
another vessel and ordered a starboard helm to avoid collision before going
to the front of the bridge to confirm what he thought he had seen. The second
officer also joined him and confirmed the red light and said he saw another
to the starboard of the first. The master ordered had to starboard helm. When
no further lights were seen he ordered hard to port helm. Shortly afterwards
the vessel collided with the tower. The source of the red light had not been
determined. (excerpt from MAIB, (2000), investigation into the Dole
America collision).

The master in this instance sought confirmation from the second officer, but then
there is the matter of dealing with the idiosyncrasies of others and cultural influences
mediating responses to leadership and authority, as Shakespeare so deftly
demonstrates:
Hamlet: Do you see yonder cloud that’s almost in shape of a camel?
Polonius: By the Mass, and ‘tis like a camel indeed.

73
 Hamlet: Methinks it is like a weasel.
Polonius: It is backed like a weasel.
Hamlet: Or like a whale?
Polonius: Very like a whale.

From Shakespeare’s Hamlet (Act II, Scene II) (quoted from Chandler, 2008)

5.3 PERCEPTION AND SITUATIONAL AWARENESS

Perception is the cognitive area of interest in this dissertation. Perception is of two
types, namely how we perceive objects, particularly visual perception, and how we
perceive others. Perception is the first action in a sequence of actions relating to
situational awareness: First the situation is perceived, that is taking in information,
this leads to comprehension and then projection as to likely future developments and
decision making.15

The study of perception alerts us to the fact that we see differently based on a
number of factors such as culture, gender, moods; and that there are grounds to
sometimes question what we think we see (Zebrowitz, 1990; Geller, 2001; Chandler,
2008). Figure 5.1 has been used in perception exercises to demonstrate how we
might see differently depending on factors of salience to us.

Figure 5.1: Duck or hare?

Source: Chandler (2008)

15
Maritime Resource Management seminar, August 19, 2008 at the Swedish Club.

74
The report on the Dole America noted among the contributory causes, lack of
situation awareness. This is a misnomer as the captain was aware of the situation, but
the situation as he perceived it. To reiterate from Barnett (2005, p.134):
[Seafarers make] mistakes of the kind that all men are liable to make on
occasions. Seeing what they expect to see; not seeing what they should see,
failing to recognize a mistake in a colleague, reacting too late, or not at all, in
the face of the unexpected.

It does not however have to be in unexpected situations. The master expected the
vessel. What this writer calls human idiosyncrasies occur in everyday normal
situations. They are a part of being human. To again repeat an earlier reference
Reason (1990, p.1) notes:
Far from being rooted in irrational or maladaptive tendencies, [or unusual or
unexpected situations – author’s addition] these recurrent error forms have
their origins in fundamentally useful psychological processes. Ernst Mach
(1905) put it well: “Knowledge and error flow from the same mental sources,
only success can tell the one for the other.”

Reason (1990) therefore makes a case for an engagement with the behavioural
sciences if erroneous acts are to be understood and effectively managed. If there had
indeed been a vessel, as the master perceived the situation, then his actions would
have prevented a collision.

To compound the situation for the master of the Dole America, he was sure that there
was another vessel present and the likelihood of an accident, evidenced by his helm
order even before going to the bridge window to have a closer look and asking the
second officer’s opinion. The vessel initially had a pilot who informed the master of
two other inbound vessels. The master therefore may have focused his attention on
what he thought was a situation to avoid, a collision, being “primed” regarding the
passage of the other vessels leading to confirmation bias. In this case the master

75
consulted the second officer who responded in the affirmative. The report however
noted that the second officer had returned not long before from escorting the pilot out;
therefore, his vision might not have adjusted to the darkened bridge; another
perceptive limitation.

Priming is often used in person perception (Zebrowitz, 1990); however, it is possible

to be adapted to situations such as that which obtained on the Dole America, in
which case, priming is a phenomenon where a situation is judged based on recently
activated scripts. The master, having been informed by the pilot, of the inbound
vessels, was “primed” and therefore channelled his expectations in that direction and
confirmed this when he “saw” the red light. Priming may therefore lead to
confirmation bias in terms of seeing what is expected.

Figure 5-2 is another typical picture used in perception exercises, sometimes referred
to as the wife and the mother-in-law. Depending on how one is primed one will see
an old woman or a young woman.

Figure 5-2: The young woman and the old hag

Source: Zebrowitz, L. (1990).

Confirmation bias is the tendency to look for information that confirms beliefs and to
ignore other information that may be contradictory (Esgate & Groome, 2005). The

76
master of the Dole America, due to his expectation of the inbound vessel may have
led himself to believe he saw a red light and if that light was present, he may have
led himself to believe it belonged to a vessel about to collide with his.

Confirmation bias also occurs when cues are used to confirm initial hypothesis and
thus markings are interpreted incorrectly (Hetherington, et. al., 2006). This may have
been the case in the Royal Majesty grounding where the report stated that several
cues indicating that the vessel was off course were present yet these did not alert the
officers to that fact and the vessel ran aground 17 miles off its course.

Another concept of relevance to situational awareness as regards perception is

illusion of control. This is the situation whereby one perceives him/herself to be in
control of an uncontrollable event (Esgate & Groome, 2005). Such a perception
exists in situations where earlier successes were experienced. In the case of the
Green Lily the report indicated that the master had taken his vessel through poor
weather conditions, and this may have contributed to his “over-confidence” in
repeating that act. From the outset of the events the master remained optimistic about
the weather conditions not deteriorating and when it did, he was optimistic about a
successful outcome of the rescue. However, the result was the death of a rescue
personnel.

Illusion of control is also useful in understanding perceptions of risk and therefore

attitude and behaviour towards risks. Persons who feel they are in control or have an
“it will not happen to me” attitude (Geller, 2001) or the machismo and confidence in
the equipment, will be less likely to take precautionary measures; recall the master of
the “unsinkable” Titanic.

None of the actions discussed as regards perception were malicious; these were
genuine beliefs in the situation as was perceived at the time and actions were taken,
or not taken accordingly. There is also a place for bravado and confidence in the

77
social world as nature’s way of imprinting survival models. This is the complexity of
people and what it means to be humans (Geller, 2001). Therefore, the importance of
awareness as regards these human idiosyncrasies cannot be overemphasized.

5.3.1 Complacency and Diffusion of Responsibility

Failure to adequately assess a situation may also be due to complacency.
Complacency is becoming another frequently used term in the maritime industry to
describe a seafarer’s lack of vigilance during watchkeeping (Hetherington, et. al.,
2006). It has been named as one of the manifestations of “rogue behaviour” in the
Nautical Institute’s Alert newsletter (Rogue behaviour is …2008). The understanding
from this label is that operators will monitor less effectively when there is
automation, more so when the automation has been effective over time (Hetherington,
et. al. 2006). Although speaking of the technology, Lützhöft and Dekker (2002) tell
us that automation creates new error pathways. New error pathways may also be
created on the part of the operator as Stadler (1987) observed, “these devices
translate the psychological problems into another medium where they reappear in
more serious forms.” Complacency may be one of those forms where there is over-
reliance on automation, as may have been the case of the Royal Majesty. A
contributory factor in the collision between the Skagern and Samskip Courier, where
both vessels, under pilotage, were proceeding at unsafe speeds for the fog condition,
was cited as both masters’ “over-reliance” on the pilots.

Hetherington, et. al., (2006) in search of an explanation for complacency asks the
question if automation results in “some kind of cognitive lackadaisicalness? This
dissertation is suggesting that such behaviour is possibly a case of diffusion of
responsibility.

The concept diffusion of responsibility was developed in the early years of social
psychology (the 1970s) in response to the murder of a young lady, Kitty Genovese.
What prompted the foray into a series of research was that there were witnesses to

78
the murder yet nobody went to her assistance even after the murderer left and
returned to continue the assault (Aron & Aron, 1986). The incident led to several
studies in pro-social or helping behaviour. The initial research discovered that the
more persons who witness someone in need, the less likely that person will be
assisted, as each person is thinking the other will assist. (Aron & Aron, 1986). Other
explanations have emerged for helping behaviour since then, but diffusion of
responsibility remains a worthwhile concept.

In a modified form, diffusion of responsibility provides a plausible explanation for

complacency on the bridge rather than the more negative “why bother” attitude that
the Alert is suggesting (Rogue behaviour is …2008). In the presence of “others” such
as the pilot or an automated system, perceived as reliable, some of the responsibility
will be diffused. The watchkeeping officers, consciously or unconsciously will
become less vigilant. However, through education along with attitude change, an
appreciation for continuous vigilance may be instilled. It is believed that revelation
of the underpinning mechanisms will serve to bolster the principles and provisions
for watchkeeping.

5.3.2 Distraction
A similar analysis may be applied to distraction, which is another finding in casualty
investigations. It is likely that those who allow themselves to become distracted also
diffused their responsibilities to the automated system, or the other members of the
watch team. For example, the mate who was on watch at the time of the grounding of
the Bunga Teratai Satu (ATSB16, 2001) was said to have been distracted by private
calls his wife was making to their family home. Diffusion of responsibility is also
highly likely in situations of fatigue, particularly when there is a lone watchkeeper, a
possible explanation for the grounding of the Jacki Moon (MAIB, 2005).
Watchkeepers take comfort in the presence of the automation.

16
Australian Transport Safety Bureau

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 5.3.3 Violations
Violations in shipboard operations are yet another human factor contribution to
maritime accidents. Except for accounts in accident investigations where rules were
broken, this area has not been studied in the maritime industry. Violations include
acts such as not adhering to company policies, for example the Attilio Ievoli, where
the master chose to use the west Solent contrary to company instructions;
professional misconduct such as the officer of the watch on the Bunga Teratai Satu
or the pilot on the Crimson Mars who both were distracted by use of their mobile
telephones. Violations stem from a complex interplay of psychological and
philosophical perceptions regarding rules and risks and may therefore affect how a
situation is evaluated.

5.3.3.1 Rules
Attitudes to rules may be based on whether these rules are seen to have moral
underpinnings (Nichols & Mallon, 2006). Nichols (2002) distinguishes between
morals and conventional violations. Moral violations, such as directly hurting
someone, is associated with ethics, versus conventional violations associated more
with etiquette and social acceptability, such as wearing jeans to a formal affair.
Conventional rules are viewed as dependent on authority, and moral rules are seen as
wrong regardless of domain. This view is instructive for the maritime industry.

The question is: Does the seafarer see it as morally wrong to violate rules? Where
rules are perceived as “conventional” and their violation in the interest of commerce
may be supported by the company, then there is no moral dilemma associated with
their violation. Additionally, if the rules and procedures are seen negatively as
creating more work and adding to the stress of the seafarer, then overlooking such
rules will not be the source of any discomfort. However, if rules are seen as a matter
of ethics, and the connection can be made between such violations and morality,
mediated by affect (Nichols, 2002), then perhaps rules will be obeyed. Manuel (2005)
has suggested education in the affective domain to develop such values and attitudes

80
so that a seafarer would behave ethically regardless of the company with which he
works. This dissertation takes that suggestion a step further to suggest that the
content of such affective education comes from the behavioural sciences. An
example of a pilot who refused to fly in an unsafe situation and was fired (Dekker,
2006) represents the attitude that is desirable for the seafarer in the presence of
substandard shipping. The seafarer however has to be empowered with the mindset
to take such actions.

5.3.3.2 Risks
Violations are also mediated by ones perceptions of risk. Geller (2001) notes that
behaviour is determined by perceived rather than actual risk and is related to illusion
of control. Persons with lower perception of risk may also feel they have control over
situations, the Titanic again comes to mind. Also, the master of the Green Lily may
have been operating on perceived risks and therefore made the choice to leave port in
poor weather conditions. This makes the management of safety even more
challenging. At this level, rules, regulations, and procedures are no defences against
such risks, the defences have to come from within where informed choices are made
(HSL, 2002). Vuren (2000) as quoted in the HSL (2002) review, in a study of the
Dutch steel industry found that “enormous risks” were taken and the use of personal
protective equipment was not treated seriously and considered to be unnecessary
burden. The opposite scenario is where protective equipment actually served to
reduce the perception of risk and so the worker engages in more risk taking
behaviours (Geller, 2001).

5.4 TEAMWORK, LEADERSHIP AND POWER

Many years ago there lived an Emperor who was exceedingly fond of fine
new clothes that he spent vast sums of money on dress… one day two
swindlers, calling themselves weavers, arrived. They declared that they could
make the most magnificent cloth that one could imagine; … the clothes made
from it had the special power of being invisible to everyone who was stupid
or not fit for his post…

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 So the Emperor gave the swindlers large sums of money and the two weavers
set up their looms in the palace… They demanded the finest thread of the best
silk and the finest gold and they pretended to work. Now the Emperor was
eager to know how much of the cloth was finished. He was, however,
somewhat uneasy to look. He decided to send his faithful old minister. He will
best be able to see how the cloth looks. He is far from stupid and splendid at
his work. The minister saw nothing. But he did not say so... To the Emperor
he said…"The cloth… is truly magnificent."

The Emperor became anxious to see the costly stuff for

himself…accompanied by a number of selected ministers. He saw nothing.
"What can this mean?"… Am I so stupid? Am I not fit to be Emperor?... he
thought. But aloud he said, "Oh, the cloth is perfectly wonderful. They
advised the Emperor to have some new clothes made to wear in the great
procession the following day… And so the next day the Emperor set off at the
head of the procession. All the people standing by cheered and cried, "Oh,
how splendid are the Emperor's new clothes. But among the crowds a child
suddenly gasped out, "But he hasn't got anything on." And the people began
to whisper to one another what the child had said…The Emperor himself had
the uncomfortable feeling that what they were whispering was… true. "But I
will have to go through with the procession," he said to himself. (Stephen
Corrin, 1964) 17

On November 18, 1997, Green Lily left port Lerwick for the Ivory Coast in poor
weather conditions. The vessel experienced flooding and during pumping out of the
waters the main engine stopped. Attempts at rescue were hampered by severe
weather conditions resulting in a fatality. In addition to lack of propulsion and
failure to start the engine as the main factors leading to the grounding, the
investigators also listed the master’s imprudence to sail in view of the prevailing and
predicted weather conditions and an overly-optimistic attitude about a successful

17
The Emperor’s New Clothes by Hans Christian Andersen (1805-75), adapted by Stephen Corrin.

82
outcome. The report documented an autocratic leadership style resulting in poor
decision making and, not unlike the story above, at least one officer was concerned
about the master’s decision to sail but no one openly questioned him.

Leadership and attitudes to leaders are key aspects of any social organization and
greatly affects positively or negatively subordinates’ responses. Like the ministers in
the story, none of the officers “challenged” the master’s decision, they assisted in
perpetuating a negative situation. “Face-saving” is also a likely response to
leadership, one does not want to expose one’s ignorance of a situation or that one
does not understand, least it is construed as a personality flaw. Like the Emperor in
the story, the master of the Green Lily made no contingency plans, optimistically
expecting a successful conclusion in the face of a worsening situation and no one
questioned his decisions, as they were not themselves empowered to make such a
challenge; the outcome is at a minimum embarrassment when the master is “left
without his clothes”, or worst a casualty, loss of lives, property and damage to the
environment.

Shipboard structure is rigid and maintains the traditional hierarchy (Østreng, 2001).
Like an Emperor, the master is Lord of his vessel or indeed given “god-like” status
“orders from the Greeks were like words from God.” (Bow Mariner). Many accident
reports have cited lack of teamwork as a contributory cause. Such views of
leadership as just described, are inimical to healthy operational, professional and
social relationships on board. Leadership impacts teamwork and accompanying
factors of communication, group cohesiveness, power distance and destructive
obedience. However, the gravity of power relations on board is not commensurate
with the attention it gets in the maritime industry (Sampson, 2003).

5.4.1 Destructive Obedience

Destructive obedience has become a cause for concern in the maritime industry
(Sampson, 2002). In 1963 at Yale University, behavioural scientists were exploring
obedience and the power of social influence. It was discovered that people have a

83
destructive deference for authority that resulted in destructive obedience (Aron &
Aron, 1986). Destructive obedience lies in obeying incorrect orders, (Bow Mariner)
keeping quiet rather than volunteering information (Green Lily) to prevent a negative
situation, or not “challenging” incorrect decisions (Domiat). Policies and procedures
are weak defences against such human conditions as destructive obedience. It is
assumed that no seafarer goes to sea with the intent of causing a grounding or
collision and putting their lives at risk, such human responses should therefore be
understood from the human perspective.

The term power distance has been co-opted to the maritime scenario to explain the
power relations between the master and his sub-ordinates and the negative impact on
shipboard operations. Power relations on the Bow Mariner is stark evidence of its
destructive outcome.

5.4.2 Teamwork and Group Cohesiveness

The investigation into the Bow Mariner explicitly commented on the lack of
cohesion onboard which also impacted communication. It may be extrapolated that
this is directly related to the shipboard culture, a problem with mixed nationality
crew (MARCOM, 1999; Horck, 2006, 2008a). The MARCOM (1999) project
provides a list of national groupings that are incompatible onboard, although Greeks
and Filipinos were not among the list, it does not preclude the development of such
negative group dynamics.

The behavioural sciences begun its foray into intergroup relations influenced by the
events of World War II (Aron & Aron, 1986). In a series of studies it was discovered
that group cohesion may be created through the presence of a superordinate goal18
(Aron & Aron, 1986; Hayes, 1993; Brewer & Miller, 1996; Brown, 2000). Yet what
has been discovered since then is that social/cultural identity, is a more powerful

18
Superordinate goals are situations affecting the groups welfare and which demand that the groups
cooperate to achieve this common objective.

84
determinant of intergroup relations (Brewer & Miller, 1996, Brown, 2000). Social
identity theory explains how a person’s personal identity is intricately associated
with membership in a social/cultural group and affects relationships with other
groups (Hayes, 1993; Brewer & Miller, 1996; Brown, 2000). Negative intergroup
relations on the Bow Mariner may be explained by social identity theory where the
lines of group identity were clearly drawn on cultural differences. The individual
identities of the Greek officers were expressed through their cultural grouping which
affected relationships with the other cultural group, the Filipinos. As such
communication was poor, leadership was autocratic, mistrust and apathy, and a lack
of care for the crew, permeated the shipboard culture and no doubt exacerbated the
disaster.

Another concept of relevance for the Bow Mariner as regards culture is

ethnocentrism. Ethnocentrism is the belief that one’s culture is superior to others.
(Hayes, 1993; Brewer & Miller, 1996; Østreng, 2001). It is not unreasonable to
extrapolate that this situation existed on the Bow Mariner resulting in mistrust of the
Filipinos to perform tasks without being continuously supervised. Ethnocentrism can
lead to prejudice and stereotypes. Although Kahveci et. al. (2002) did not find such
tensions in their research, the hierarchy and social separations on some vessels as
found by Østreng (2001) are pre-conditions for intergroup tensions.

The MARCOM project (1999) proposed the encouragement and promotion of social
activities onboard to help overcome the impact of multicultural crew. Whereas this
may be successful in some situations, it may not be in others. The senior officers on
the Bow Mariner were all of one nationality sharing the same attitude towards their
subordinates, therefore there was no one to initiate these activities. The company
could very well give such directives, but there is no one from the company ensuring
that these are carried out. Intergroup contact has to be carefully orchestrated as such
contacts may lead to heightened tensions (Hayes, 1993; Brewer & Miller, 1996;
MARCOM, 1999; Brown, 2000; Østreng, 2001).

85
Education and training in cultural diversity has also been proposed as a way to
counter such negative effects (Horck, 2006, 2008). Care must however be taken to
combine such education with positive mental models associated with cultural
relativism, that is judging a culture by its own standards (Hayes, 1993). In agreement
with MARCOM (1999), “…the idea is that there is knowledge and with further
research, advances in understanding these issues can be made, companies do not
have to learn by trial and error” likewise the seafarer and the maritime industry as a
whole. However the challenges with companies that have been noted elsewhere in
the dissertation, suggest that the place of such education is with the MET.

5.5 FATIGUE
Fatigue is the third factor affecting seafarers’ performance that this dissertation
explores. Issues of mental health, wellbeing and welfare are grouped under fatigue as
they have implications for its development (Smith, 2007). Fatigue has been discussed
elsewhere in the dissertation. The emphasis here is that fatigue is a major risk factor
for stress, mental health problems such as depression and it is implicated in acute
illnesses of the seafarer (Stevenson, 2002; Smith, 2007) which it is suspected may
lead to premature death (Smith, 2007).

Current legislation, as said before, focuses on the physiological aspects. These

legislation have been found to be inadequate in the face of commercial pressures and
so seafarers or companies falsify the work and rest records (Smith, 2007), again
reference is made to the grounding of the Jacki Moon. Education regarding the
severe negative effects of fatigue is among the suggestions for solutions as part of a
holistic approach. Mental health problems, depression, wellbeing have to be dealt
with from a behavioural sciences perspective.

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5.6 CHALLENGES TO ENGAGING THE BEHAVIOURAL SCIENCES
There is no doubt of the role of the behavioural sciences in addressing issues of safe
behaviour in the actions of the people at the sharp end in the maritime industry. This
has been borne out thus far in the exploration of the issues involved. The maritime
industry has been engaging the sciences in a fragmented manner. Currently the call is
for the introduction of fatigue, leadership, communication and cultural awareness
training from separate directions. This is a piecemeal approach, as the areas are
interrelated. An amalgamated course of study to holistically deliver such courses, as
well as incorporating into the technical aspects would be more beneficial.

This said however, there are a few challenges facing the use of the behavioural
sciences. Firstly there must be qualified persons with seafaring background or
seafaring knowledge to develop and teach these courses. The integration of, and
relevance to seafaring is important.

Secondly, empirical research is needed to ascertain the direct impacts of the PSFs
and how the behavioural sciences can be modified to suit the situations. Cultural
diversity and perceptions based on years of socialization and personality formation
are difficult to impact. Such interventions will require supporting data to ensure
accuracy in intervention methods.

Thirdly, the content must be combined with behaviour and cognitive based
approaches to behaviour change, as discussed in Chapter 4. The traditional methods
of delivery will be ineffective. As HSL (2002) notes, in a case to convince workers in
a metal fabrication plant to wear ear plugs: Those who received lectures on hearing
conservation and threats with disciplinary actions did not increase their usage by
more than 10%. The experimental group that received behavioural based approach
increased their usage by 85-90%. The challenge will probably be in gaining the
commitment of the MET to adapt new ways of teaching.

87
Fourthly, the STCW Convention has to incorporate relevant provisions to ensure that
such education and training become a part of the global standard. Problems with
substandard shipping necessitate that some intervention to develop a safety culture is
also directed at the seafarer who will need to take a stand in promoting safer shipping.
However the implementation of provisions rests on the democratic machinery of the
IMO and at times the machinery does not agree with what may seem a prudent
course of action to others.

5.7 SUMMARY AND CONCLUSION

…there is a psychological world behind the errors to do with people’s
attention, perception, decision making…” (Dekker, 2006, p.120).
The chapter presented some of the human factor challenges to safety culture from a
behavioural sciences perspective. Important is the realization that how we view the
world is mediated by many factors such as culture, socialization, individual
differences, gender, mood, etc. A change in perspective can challenge initially held
beliefs and is especially important for how others of a different culture are viewed,
which may assist in multicultural relations on board. Figure 6.3 overleaf illustrates;
turn the dissertation upside down and the situation appears less negative.

Cognitive interventions and behavioural changes are necessary to combat the human
idiosyncrasies. We possess cognitive models that may be as useful as they may be
dangerous. The problem is that many of us go unaware of such mental forces.
Lützhöft and Dekker (2002) analysing the Royal Majesty accident, presented
insightful explanations of the negative effects when the mental models are not fully
developed for a particular situation, they however focused on the technological and
omitted to see that even if the correct mental models for the automation were in place,
the grounding might still have occurred, as the mental models for human
idiosyncrasies are lacking.

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Figure 6-3: Upside down head
Source: Geller (2001)

A Behaviour based approach is the popular method of addressing attitude change as

regards safety (HSL, 2002; Manuel, 2005; Broadbent, 2006; Al-Hemoud & Al-
Asfoor, 2006). The premise is that behaviour is related to attitude and changing
behaviour will lead to a change in attitude. However, changing attitude also involves
inputting the right content, creating the awareness in the seafarer that as humans
there are inbuilt mechanisms that may lead to erroneous acts. Such an undertaking
belongs in the MET where these may be integrated with other courses of study to
reinforce the lessons of their impact on actions.

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 CHAPTER 6

DISCUSSION
Part I

6.1 INTRODUCTION

This section discusses the information gathered from the responses and other sources
of data. The chapter is divided into two parts. The first part is a discussion of select
information according to the main concepts under exploration: safety culture, human
factor (challenges to safety culture), MET, and the behavioural sciences. The second
section presents a description of the aviation industry’s initiative to develop and
promote a safety culture with specific reference to the use of the behavioural sciences
in its CRM programme.

It is recognized that the data is limited in terms of scientific rigor and therefore
constrained in making generalizations, but it is adequate for exploratory purposes.
The information gathered in the discussions and interviews were in-keeping with
what was found in the literature. Information was gathered from sources as follows:
• 10 email interviews/discussions with seafarers, 2 were currently serving
while 8 were students at the WMU.
• A personal interview with a student at the WMU in his capacity as a seafarer
and as a training manager for a prominent ship management company.
• Two email discussions and one personal discussion from the perspective of
training institutions.
• One seminar session on Marine Resource Management (MRM) at the
Swedish Club (August 18, 2008) and discussions with the Manager, Martin
Hernqvist.
• Discussions and observations on field trips to MET institutions in the
Netherlands and France as part of the WMU’s curriculum for its MET
specialization.

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Details of the topics explored in the discussions are presented in Appendices 2-4.

6.2 SAFETY CULTURE

There is no doubt that safety culture has been firmly established in the deliberations
of the maritime industry. Of the three components of the safety triad, the technology
as a factor in the performance of seafarers has received the least responses. Also, the
literature has indicated that technology has improved resulting in less accidents from
that domain, bringing the human contribution to accidents to the fore (Hetherington,
et. al. 2006; Redmill & Rajan, 1997). The emphasis in the general discussion of
safety culture in high risk industries is now the organization, however emphasizing
the role of the human factor such as management and management decisions. Yet, in
the maritime industry, while the organization’s role is acknowledged and the actions
of the people at the blunt end are not denied, the seafarer at the sharp end holds a
large portion of the responsibility in the discussions of maritime accidents.

There was general agreement among the respondents that safety culture was
important and should be the purview of all involved. This is seen as a way of
improving the industry. One seafarer saw it as important that charterers should be
involved in this discussion as well “what kind of ship is he chartering?” It was also
seen as essential for the seafarer to have the idea about safety culture to not only
protect property and the environment, but “most importantly they need to survive and
[stay] alive for their loved ones.” This comment indicates that the seafarer includes
his health and wellbeing as a factor in safety. While mention is made in the
discussion of fatigue and lone voices regarding occupational health (Nielsen &
Panayides, 2005) are attempting to include seafarers’ health and well being, there is
still room for improvement. The STCW review promises to make provisions for
seafarers’ health awareness training (IMO, 2008), the details remain to be seen.

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 6.2.1 Maritime Resource Management (MRM)
MRM was developed to address the needs for the non-technical skills and to
contribute towards the development of a safety culture in the maritime industry by
imparting these skills to mariners as well as shore based personnel including pilots
and accident investigators. MRM is an expansion of BRM which has incorporated
aspects of the aviation industry’s CRM. The training was instituted as part of the loss
prevention philosophy of the Swedish Club, a marine insurer. The Club sees the need
for a change in culture to promote the right attitudes and behaviour towards accident
prevention in the maritime sector. The course contents are described in Appendix 7.

This initiative can be applauded as a step in the right direction. It seeks to be

comprehensive in addressing the “soft” skills which have been established as critical
to improve performance and therefore safety. It was explained by the manager,
Martin Hernqvist, that not only do they teach the courses, but follow-up visits are
done onboard to observe if the practices are applied. Unfortunately, it is only a few
of the cruise lines that are currently sending their officers to such training.

Two points of concern arose as a result of the visit to the Swedish Club: 1) the
mentality that only officers should have certain knowledge and 2) the benefits of
such training are reserved for those working with more conscientious companies.
These concerns run throughout the dissertation as have already been discussed in
relation to the revision of the STCW Convention. The argument remains that there is
prudence in exposing all seafarers to appropriate aspects of such knowledge during
their cadetship to circumvent the deficiencies in the system that they encounter in
their careers. Not only officers need to develop professionalism, but all crew. The
crew on a vessel is a team. This view is supported by the attitude of the AB in the
Bunga Teratai Satu where he knew the vessel was on the wrong course and did not
inform the watch officer as he thought it was not his place. While power distance
may have been operating here, another reason to expose all crew to such education

92
and training, it is also a matter of teamwork, everyone feeling a part of the team and
therefore takes responsibility.

6.3 HUMAN FACTOR CHALLENGES TO SAFETY CULTURE

Both the literature and the discussions with seafarers have identified similar factors
that affect performance on board. Fatigue, stress, health and wellbeing as well as
non-technical performance issues such as leadership, communication and cultural
differences have been shown to affect performance.

6.3.1 Fatigue
The dissertation has grouped health and wellbeing issues under fatigue as fatigue has
been shown to have both physiological and psychological dimensions (Smith, 2007)
affecting health and which may also be exacerbated by family issues ashore. Family
problems and attempting to fix things ashore from the ship, as one seafarer pointed
out, as well as home sickness, have been the “Achilles’ heel” 19 of the seafarer
(Thomas, 2003: Kahveci, 2007). One seafarer paradoxically explained the
importance of being safe so as to return to family and simultaneously working
unsafely for the family’s sake. This is the explanation when asked about ever having
done something that was considered unsafe on the job: “sometimes you have to do it
for the sake of others. You are forced to do it to be good in your work for giving your
loved ones a good life.” The watch officer on the Bunga Teratai Satu (Appendix 2)
was preoccupied with a private call to his family and so missed changing course and
the vessel ran aground; but to re-emphasize the point, if the AB had been a team
player, the watch officer would have been duly alerted.

The literature has indicated that seafarer’s health and wellbeing are two areas in need
of great attention in the maritime industry (O’Neil, 2001; Nielsen & Panayides, 2005;
Thomas, 2003: Kahveci, 2007) and are associated with fatigue (Smith, 2007). Mental
health issues, depression, possibly leading to suicide. As the training officer

19
Area of vulnerability

93
interviewed (Captain X) revealed that during his time serving he dealt with three
suicides on three different ships in the space of one year. There are also a number of
contentious issues of welfare and rights in the industry (Mukherjee & Mustafar, 2005;
Kahveci, 2007; Donner, 2008; Zhang, 2008, Mukherjee n.d.).

The consensus regarding life on board is that it is lonely, the seafarer feels isolated
and it affects his mental state, although some find job on board enjoyable, which is a
function of the care the company shows. As Captain X explained, he lost his father
while serving and could do nothing but cry alone in his cabin. As the captain he felt
there needed to be that distance [between him and the crew], so there was no
emotional support. The seafarer writing in the Nautilus (My battle with ‘the black
dog’ 2008) about his depression, underwent counseling and recommended that all
seafarers read the book Getting Over Depression (cognitive therapy). Such
expressions of loneliness and isolation have been verified in studies where seafarers
described life on board as tantamount to being in prison (Kahveci, 2007).

The behavioural sciences may help in raising awareness regarding fatigue and its
effects. It may also assist if the STCW implements the provisions for fatigue
awareness training. Dealing with fatigue only in physiological terms may be
undermining the gravity of the situation and influencing perceptions of being in
control, being able to stay awake. It was revealed in the investigation of the Jacki
Moon accident that hours of work were falsified and fatigue was a contributory factor.
One seafarer interviewed also indicated that he has worked while tired and
“thankfully no incident happened.” In his extensive review and research on fatigue,
Smith (2007) concluded that of all the possible approaches to fatigue management:
regulation, enforcement, awareness, campaigns, training and guidance – everyone is
deficient in the maritime industry. A robust and holistic approach is necessary which
Smith (2007) and this author believe, can lead to a culture that benefits the industry
as a whole.

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 6.3.2 Teamwork
Issues relating to group relations, leadership, power and communication were
discussed as a part of teamwork because ultimately it is a team effort that runs the
ship and these factors impact the cohesiveness of the team and therefore performance.
As one seafarer put its:
It is very important for seafarers to understand that the safety of the ship
depends on the total collaboration of all on board and that safety does not
only mean taking care of one’s machineries or doing one’s assigned duties,
but looking after each other’s affairs also count.
This statement is instructive for creating a philosophy among seafarers and therefore
the importance of education and training at all levels and not senior officers only, as
the current STCW review is proposing; again the AB’s response in the Bunga
Teratai Satu incident emphasizes this need.

Not speaking out for various reasons, chief of which has been cited as power distance
(culture) in the literature, is also a major problem on board as revealed by accident
investigations. The behavioural sciences have a rich tradition of research and
practices in team management, group relations and leadership that may be harnessed
to instill values and attitudes where each seafarer shares the responsibility of a safe
ship and is empowered with the knowledge and confidence to speak out on issues.
Although the STCW makes provisions for such training, the literature and the
interviews suggest that these are not enough. It was indicated that courses on
leadership, group relations, communication, cultural awareness and perception
(Appendix 2) were taught in the schools that the seafarers attended. However they
were not all exposed to all these courses to the same degree. Only five had courses
on cultural awareness and perception. This variation is also supported by the three
training institutions that responded to the questions (Appendix 4).

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 6.3.2.1 Communication
While communication difficulties stemming from language, grammar, vocabulary,
tone, pitch etc. affect performance, also important are communication problems
associated with culture. Communication is essential for healthy social relationships
on board which are constrained by cultural differences (MARCOM, 1999; Dzugan &
Renping, 1999; Sampson & Zhao, 2003; Horck, 2006, 2008a). The responses by the
seafarers support that communication problems exist and that cultural differences
create problems in this regard (Appendix 2).

Power distance and destructive obedience are also associated with communication
problems. One seafarer explains how communication misunderstanding operates
from two sides:
[On the one hand] The captain is giving an order and somebody thinks,
aggressive captains…do not allow anybody to speak. [On the other hand] bad
orders are given and you keep silent not to make a problem and do it.

Additionally, Captain X explains:

Sometimes the respect the master is expecting is not there. Like a junior
officer from Asia or so, will stand when the master enters the bridge and walk
after him but one from Europe or other developed country may not. A ship is
not a democracy it is a high risk environment, and so it is necessary to have
structure, but at times the master may act as a dictator and this can hinder
communication, so it [power distance] has to be taken into consideration.
But there is no structured training for these things.

In addition to healthy social relationships, and safe ship board operations,

communication may also assist on the individual level combating psychological
tensions. Simple strategies such as talking may assist in relieving some of the
psychological effects (Horck, 2008a), rather than destructive coping strategies, such
as drinking, smoking, becoming aggressive (Appendix 2). To repeat the saying

96
“knowledge is power,” one has to have the knowledge in order to use it. Empowering
the seafarer with such knowledge combined with the right attitude and technical
skills, will go a far way in contributing to safety as sea.

6.3.3 Situation Awareness

Situation awareness is another of the important factors that impacts the performance
of the seafarer. It is associated with the cognitive domain and affects how situations
and objects are perceived as may be extrapolated in the cases of the Domiat where
the master thought he saw another vessel approaching, or the Green Lily where the
master did not perceive the gravity of the situation. Except for being named in
casualty investigations, situational awareness has not been studied in the maritime
industry. It is seen as important however and it is included in the CRM training
course. Where it is discussed, the approach is not holistic as the cognitive elements
associated with sensory perception is absent. Kristiansen (2005) has given some
useful insights into the effects of being at sea on the perceptive abilities of the
seafarer. Issues of autokinesis, which makes a single point of light appear to move;
or refraction, when the direction of a light is interrupted on passing through different
media may result in misinterpretation of the direction of other vessels or objects
(Kristiansen, 2005). These phenomena work in tandem with those perceptive biases
discussed in Chapter 5 and impact the decision making process. Questions that
should arise to assist in correctly making a decision for visual perception is whether
the object if moving or stationary?; is the source of light a marker or another vessel?;
is the object moving away or coming towards my vessel? (Kristiansen, 2005). In
order to effectively utilize these simple techniques on has to be aware of the
phenomena which come though education. The master of the Dole America may
have faced a similar situation when he thought he saw a light which he used as the
basis of his decision to change course, leading to the collision, the report noted that
the source of the light was not determined.

97
6.4 MET
MET varies across countries as borne out by the METNET project (Schröder, et. al.,
2003). The responses given in this regard also demonstrate that seafarers are
exposed to different types and levels of training in the non-technical skills, reflective
of the different training regimes. The discussions with training institutions also
testify to this. Two responses from training institutions indicated that their
curriculum had been impacted by the discussions of safety culture whereas another
had not been impacted (Appendix 4). It is as a result of such variations (both from
the literature and the discussions) that the proposal is made to include education and
training for the non-technical skills within the standards of the STCW.

STCW is the standard bearer for the education and training of seafarers. Some MET
institutions are in a compliant stage, while others are operating at a stage of
excellence, yet others are at the avoidance stage (Manuel, 2005). Making provisions
mandatory in the STCW would at least ensure those in the compliant stage, which it
is suspected are in the majority, are educating and training in the soft skills. There is
no question as to the need for the technical skills, provisions are not questioned
regarding the importance of familiarization training, the seafarer is learning to
manage all aspects of his profession except himself. All the sources of data have
provided evidence that the “soft” skills are important. The industry now demands it,
the seafarers also demand it for their personal, operational and professional survival.
The root of the “soft” skills lies in the behavioural sciences and therefore it is
inevitable that they become a part of the curriculum of MET.

6.5 BEHAVIOURAL SCIENCES

The importance of the behavioural sciences was underscored by the cases as well as
the interviews. They were seen as necessary for personal, operational and
professional reasons. Captain X opines that psychology would be helpful:
After a while when the seafarer goes ashore he has tunnel vision, should have
counselling, do a debrief before going to family…The seafarer cannot make

98
 full use of port chaplains because sometimes he cannot go ashore because of
duties..
Captain X also believes that company personnel should be exposed to such education
in diversity management and psychology. It would be useful even if persons are not
professional psychologists, issues can be adequately identified and informed
decisions can be made.

The other persons who responded to questions have noted the importance of courses
in leadership, communication etc. mentioned above, as contributing to harmonious
relationships on board as well as safety. One response from an institution was
uncertain as to whether teaching the behavioural sciences would be helpful. However,
the other two responded that they would be helpful, with one clarifying that such
courses should be taught by professionals in seafaring and supported by proper on
board training.

6.6 SUMMARY OF PART I

This preceding section presents an overview of the findings from responses and the
other sources of data. All evidence points to the use of the behavioural sciences in
every aspect of shipping that is non-technical. While the results from the discussions
cannot be generalized, they do corroborate what was found in the literature. The
MRM training has reported success in the behaviour and attitudes of personnel of
Star Cruises which has been associated with a dramatic reduction in accidents and
near misses since they have started using the programme (Hernqvist, 2008). This
suggests that there is a place for the use of the behavioural sciences in the education
and training of seafarers.

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 DISCUSSION
Part II
LESSONS FROM AVIATION

Parallels have often been drawn between the aviation industry and the maritime
industry. There are similar discussions regarding technological development and its
impact on human factor and the role of the organizations in developing a safety
culture (Batteau, 2001; Hudson, 2001; Ek, 2006). Concerns also abound in the
aviation industry relative to the role of the human factor in safety culture as regards
issues such as violations, leadership, communication, power distance, and decision
making mediated by cognitive biases and perception (Hawkins, 1993; Kern, 2001;
Dahlström, 2007). However, the aviation industry is said to be ahead of the maritime
industry relative to addressing human factor concerns and training in the “soft” skills
in a holistic way (Pekcan, et. al., 2005; Barnett, et. al. 2006; Fuazudeen, 2008).

Similar to the maritime industry, the aviation industry has had to cope with a culture
of reactive response to accidents (Kern, 2001) but have moved beyond to proactively
addressing its human factor concerns. Crew resource management (CRM) is the
aviation industry’s human factors training programme which is defined as “the
effective utilisation of all available resources to achieve safe and efficient operation”
(Dahlström, 2007). The behavioural sciences are an intricate aspect of this training
programme. Appendix 8 is an indication of the topics covered in a section of a CRM
course 20 showing areas of basic psychology, information processing as it affects
decision making, fatigue and personality theory, to name a few. CRM is mandatory
training and is no longer seen as training for pilots only but for all persons involved:
cabin crew, engineers, mechanics, technical staff, air traffic controllers, and in some
cases dispatchers and ramp agents (Dahlström, 2008 personal communication).

20
This was obtained in personal communication with Dahlström.

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The maritime industry lags behind in this regard. Although it has embraced some of
the principles of CRM into BRM, it is not compulsory. MRM which is more
comprehensive, is only being utilized by a select few. Deliberations are only now
underway to make aspects of BRM mandatory, and this will be limited to deck and
engine officers (IMO, 2008), and the details are to be seen.

Another perspective of this dissertation, which is done in the aviation industry, is the
incorporation of such “soft” skills at all levels in the training of the seafarer. The
incorporation of the behavioural sciences in aviation is at all levels as regards the
sharp end, that is, the pilots. Dahlström (personal communication, 2008) explains
that a pilot receives basic human factors training as a student in “Human
Performance and Limitations” creating awareness of the human potentials and
failings in terms of cognitive and behavioural mechanisms. This course is fully
incorporated into their initial qualifications for licensing. Subsequently, the student
does a “Multi Crew Cooperation” course which has a significant portion of human
factors/CRM training. On arriving at his first airline he again undertakes the
company’s full CRM training. The industry then has regulatory requirements for
CRM when a pilot is changing operator, when changing aircraft type and when being
upgraded to commander.

The lesson to be derived from the aviation industry is a holistic approach to the
human factor. To reiterate, the suggestion to amalgamate communication, leadership
and BRM at the recent STW sub-committee meeting considering the comprehensive
review of the STCW convention (IMO, 2008), was not supported. Additionally, the
final decision was to separate aspects of the competence table making the BRM and
leadership training exclusive to engine and deck officers. This has probably been the
shortcoming of the regulatory training regime. Issues concerning the human factor
are approached in an ah hoc manner and are fragmented. As shown in the syllabus at
Appendix 8, all these areas are interrelated and impact each other. Aviation has come
to acknowledge the need for a holistic and integrated approach. Staff at all levels are

101
beneficiaries of training to enhance knowledge and awareness, providing them with
suitable skills to contribute more effectively to their organizations. While it is
acknowledged that there are aspects that may not be suitable for some levels of staff,
there are basic elements to which all should be exposed. Courses may be tailored for
appropriateness. The maritime industry would benefit from adopting a few more
lessons from the aviation industry.

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 CHAPTER 7
CONCLUSION

BEYOND A BOUNDARY
We cannot discover new oceans unless we have the courage to lose sight of the shore. Anonymous

Beyond a Boundary is the title of an autobiographical novel by West Indian

(Caribbean) writer C.L.R. James. The subject matter is the game of Cricket, famous
in the West Indies. In the novel, the “boundary” is presented in its literal sense as the
outer parts of the cricket field where maximum “points” are scored. It also acts as a
metaphor, going beyond the boundaries of the cricket field to discuss the social and
political implications of the game. The point is, there are realities beyond the
boundaries we place on ourselves. While possibilities may exist, they are limited and
hindered by boundaries. To quote Bertrand Russell from Hawkins (1993, p.16): “Not
only will men of science have to grapple with sciences that deal with men but – and
this is a far more difficult matter – they will have to persuade the world to listen to
what they have discovered.”

While the discoveries of this dissertation may not be about persuading the “world,”
as the literature does reveal that there are those converted to the possibilities of the
behavioural sciences in the maritime industry, yet others need persuading at the
junctures where global changes can be made, namely MET and STCW Convention.
The objective of the study was to identify and examine the potential benefits to the
maritime industry of an education in the behavioural sciences towards achieving a
safety culture. Attempts to meet this objective took the form of an extensive use of
the literature, case studies of accidents, discussions with persons in the industry and
field trips, to ascertain the prevailing situation regarding the concepts of interest,
which were safety culture, the human factor, STCW Convention, MET and the
behavioural sciences. Figure 8-1 attempts a diagrammatic presentation of the key
concepts and their relationships.

103
 A
C
C
Human I Safety
Factor D Culture
E
N
T
Performance Cognitive ,
shaping S behavioural
factors skills
acquired

STCW

MET
Behavioural
Sciences

Figure 7-1: The key concepts and their interrelationship

Source: Author

The figure illustrates the path from human factor to safety culture which is thwarted
by accidents resulting from PSFs. It is suggested that education and training
regarding the failings of the PSFs at the MET level, utilizing the behavioural
sciences as set by the standards of the STCW, will result in the necessary cognitive
and behavioural knowledge and skills to complement the technical competence and
therefore circumvent accidents leading to a safety culture.

The research was predicated on the following issues:

• There are problems in the maritime industry as regards safety.
• Safety culture is seen as an approach to improve safety.
• The human factor plays a substantial role in accidents.

104
 • Many aspects of the human factor are behavioural, that is, belonging to the
psychological and/or social psychological realm.
• The IMO has opened the topic for debate and finding solutions, yet the
regulatory regime is lacking in addressing it substantially and holistically.
• Maritime education and training has a role to play in transferring skills and
knowledge that resides within the behavioural sciences so as to enhance the
human factor contribution to a safety culture.

In exploring these issues towards recommendations for action, four research

questions were developed:
• What are the human factor challenges to arriving at a safety culture?
• What provisions are there in the STCW Convention to address these
challenges?
• What is the role of MET in meeting these challenges?
• What can an education in the behavioural sciences contribute towards
meeting these challenges?

It was found that safety culture was a concept used in all high risk industries to
signify the desire to attain optimum levels of safety to ensure operations are of such
standards so as to minimize the risk of accidents. However, the human factor, a key
element in any safety culture agenda, also poses challenges towards achieving such a
goal. The challenges lie in the PSFs associated with what the dissertation describes
as human idiosyncrasies. While the research acknowledges the role of the
organization and the technology in contributing to accidents, it also notes that human
idiosyncrasies should not be denied. People are therefore seen as systems in their
own right and should be engaged as such.

In the maritime industry, the people have been neglected on a meaningful level even
though there is much discussion of the human element. The human factor is about the
relationship between people and the tasks they perform at work, mental capacity for

105
processing information relevant to their job, their motivation, health, welfare and
their relationships with colleagues (Kristiansen, 2005). Yet the science of man is
absent in a holistic way from the training and deliberations regarding the human
factor and its place in the overall maritime system.

Some work is ongoing in the industry by way of the IMO in terms of promoting the
subject and taking steps in the current review of the STCW to strengthen the
provisions. However, the current comprehensive review reveals that the provisions
are still applied in an ad hoc way when a holistic approach would be suitable. The
wider industry, in a fragmented way, is doing its part with the more forward looking
institutions and professional bodies proactively developing measures to address the
lack of “soft” skills among seafarers. Casualty investigation departments within
States and individual researchers are undertaking studies to inform decisions. All this
will however come to naught if such efforts are not channeled in the right direction.

The industry grapples with sub-standard shipping and therefore a top-down

organizational strategy should be complimented by a bottom-up strategy targeting
the actors at the sharp end, the seafarers. A safety culture entails more than just safe
operations. The human factor needs to be committed to the cause. The “soft” skills
are not fully developed in the seafarer leading him to be a victim of his
idiosyncrasies. The current status of job satisfaction, health and welfare of the
seafarers is undesirable; tensions among multinational crew are evident, culture that
affects group relationships and communication, are all reasons to suggest engaging
the human factor in their capacity as feeling, sensing beings.

Additionally, performance on the job is affected by factors that are purely human, as
Kristiansen (2005) calls it the “human condition.” Issues of perception and cognitive
biases that may lead to misinterpretation of information are vital to operational safety
onboard. These are all aspects of the human condition that must be understood from
the perspective of people. The people skills and knowledge offered by the

106
behavioural sciences are also useful for personal development and are transferable to
careers beyond seafaring. In brief, the behavioural sciences promise to contribute to
the overall development of the seafarer, professionally, operationally and personally.

The study concludes that this is best done through the training regime of the STCW
Convention to ensure that as many institutions as possible include such education in
their curricula and spread the benefits widely. Companies are interested in training
officers, if they train at all. Every member of the crew is a part of the team and
his/her actions contribute to the overall safety culture of the vessel. Thus MET has a
role to play in producing the seafarer of the future. It is believed that with awareness
through education and the development of appropriate skills through training, all
seafarer will learn to recognize these human conditions and take appropriate action at
the necessary times. Therefore, the dissertation wishes that the role of the individuals
at the sharp end is emphasized as their responses to on board culture and operations
is ultimately where it matters, the system is a psycho-socio-technical system. HSL
(2002) provides an approach to individual response with which this writer is in
favour. The individual response is thus:

questioning attitude + rigorous and prudent approach + communication = safety

The seafarer would thus be empowered through education and training to elicit those
responses: A questioning attitude would entail being able to “challenge” decisions or
seek further information if situations appear unclear; rigorous and prudent approach
involves thinking through situations, here the elements of perception would be
alerted to; and communication in its many manifestations as verbal, cultural, group
and social. However the obstacles to such individual responses, as the dissertation
has explored, will have to be overcome. The focus of this dissertation is mainly about
content being incorporated in the education and training regime, and a holistic
approach to engaging the behavioural sciences at all levels of the training process
among all levels of seafarers. There is evidence of much discussion on the subject

107
matter, there are educational tools and effective delivery methodologies available,
however if the right content is missing, and the fragmented approach continues, then
all these efforts are in vain.

7.1 CONTRIBUTIONS OF THE STUDY

Although there are a number of limitations, the study revealed the status of
discussions and actions on the human factor in the maritime industry. Further
research is needed, but as a contribution to the area of convergence for safety culture,
human factor, MET and the behavioural sciences, the study is expected to:
• Create an awareness of the behavioural and cognitive limitations of humans
that may contribute to accidents;
• Offer explanations to phenomena that were hitherto not discussed in the
maritime industry and therefore adding these phenomena to the discussions;
• Offer an additional area for consideration in devising strategies towards
developing a safety culture in the maritime industry;
• Create an awareness of the existence of theories and applications within the
behavioural sciences that may be harnessed to create safer shipboard cultures;
• Highlight the need to consider a review of the content and context within
which seafarer education is offered.
• Open a discussion on the holistic application of the behavioural sciences in
the STCW Convention.
• Highlight the need to not only focus on officer training in the “soft” skills, but
recognize that all crew are a part of the team and needs human skills.
• Point to areas for further research.

7.2 RECOMMENDATIONS
The study presents adequate evidence to conclude that the behavioural sciences are
needed to develop the “soft” skills within the maritime industry. They are being
utilized in other industries, and the maritime industry now demands their holistic
approach. The following recommendations are therefore made, that:

108
 • The current review of the STCW Convention considers broadening the scope
of its provisions for the “soft” skills to include cognitive and perceptive
elements. The aviation industry’s CRM is there as a guide, or an expansion of
the MRM programme.
• The current review of the STCW Convention considers the holistic approach
suggested by one delegation.
• The current review of the STCW Convention considers making the
provisions for the “soft” skills applicable to all crew. Model courses
appropriate to each level may be developed.
• MET institutions consider reviewing their curriculum to ascertain their level
of responsiveness to industry’s needs. What is needed are partnerships
between MET and industry, as suggested in Sudhakar’s (2005) model, a top-
down and a bottom-up approach to ensure all elements in the safety triad are
addressed.
• MET institutions consider creating partnerships among themselves to share
methods, resources and information. The two models of education and
training presented in this dissertation may be replicated throughout other
institutions.

7.3 LIMITATIONS AND CHALLENGES OF STUDY

There are a number of limitations to this study. It must be borne in mind that the
study was exploratory and the main aim was to seek out the issues with regards to the
key concepts. Limitations are:
• The study is an exploratory study and therefore more work is needed to
include empirical data to come to more definitive conclusions;
• Interviews with seafarers were limited in number which prevents
generalizations.
• Responses from seafarers included only officers. The perspective of other
crew is important.

109
 • Responses from MET institutions were poor which limited more concrete
conclusions about MET.
• Lack of responses from potential participants. Participants who had initially
indicated a willingness to be interviewed later abdicated.

Optimum safety culture may be an ideal for an industry as global as the maritime
industry, but its principles are worth pursuing as they will lead to improvements
which are needed in the system. The seafarer is a key component of this system and
should be involved as human beings on their terms, this is the only way to come to a
full understanding of the human factor in order to develop effective interventions.

110
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 APPENDICES

Appendix 1 – Maritime Accident Cases

The main cases used throughout the dissertation are listed in this appendix. The first
5 case summaries were used for detailed analysis and the reminder, listed at the end
of the appendix, were used as supporting material.

Green Lily – Refrigerated general cargo vessel. (MAIB,21 1999).

Details of the case may be found at:
http://www.maib.gov.uk/cms_resources/green_%20lily_pub_1999.pdf

Summary
The vessel left port Lerwick in the Shetland Islands on November 18, 1997 on its
way to the Ivory Coast. Weather conditions were poor. Early on the 19th of
November the vessel experienced flooding which was controlled but the main engine
stopped during pumping out of the flood waters. Efforts to restart the engines were
unsuccessful. Shetland Coast Guard was advised of the situation. Subsequently
“Mayday Relay” broadcasts were made. Three tugs proceed and rescue operations
commenced. Poor weather conditions exacerbated the situation and hampered the
rescue operations resulting in one casualty. The members of the crew were from
Croatia and the Philippines.

Analysis
The main cause of the accident was listed as grounding due to lack of propulsion and
failure to start the engine in time to prevent the vessel drifting ashore.

Contributory causes were listed as the master’s imprudence to sail in view of the
prevailing and predicted weather conditions. He failed to make contingency plans at
each stage of the incident and instead, remained overly-optimistic about a successful
conclusion. The report noted that an autocratic management style resulted in decision

21
Marine Accident Investigation Branch

127
making shortcomings not being identified. There was no commercial pressure from
shore to leave in the weather. The master made this decision on his own. The
investigator indicated that at least one officer was concerned about the master’s
decision to sail but no one openly questioned him.

Dole America – Refrigerated cargo vessel (MAIB, 2000).

Details of the case may be found at:

http://www.maib.dft.gov.uk/cms_resources/dole%20america.pdf

Summary
On November 7, 1999 the vessel collided with the Nab Tower in the eastern
approaches to the Solent after departing berth at Portsmouth on her way to Antwerp.
The vessel left port with a pilot, who before disembarking told the master that there
were two inbound vessels. which were confirmed on radar. On approaching the
tower, the master thought he saw the light of another vessel and ordered a starboard
helm before going to the front of the bridge to confirm what he thought he had seen.
The second officer, who was the only other person on the bridge besides the
helmsman, joined him and confirmed the presence of a red light and said he saw a
second to starboard of the first. The master ordered hard to starboard helm. When no
further lights were seen he ordered hard to port helm. From his position at the front
of the bridge he could not see the Master was unaware of the vessel’s heading and
her exact position in relation to the tower. Shortly afterwards the vessel collided with
the tower. The crew was from Norway, India, the Philippines, Ecuador and Poland.

Analysis
The investigator indicated the immediate cause of the accident to be the master’s
inappropriate and unquestioned helm order to port. Contributory causes included the
master’s perceived need to alter course for what he took to be a crossing vessel, his
lack of situational awareness and the probability that fatigue and stress might have
adversely affected his perception and decision making abilities. A dedicated look

128
out was not posted on the bridge. The personnel on the bridge all had other duties.
The lack of a predetermined pilotage passage plan was also seen as a contributing
factor. Its absence let to distraction at a point when neither the master nor the second
officer had time to sufficiently appraise themselves of the changing situation.
Additionally, the second officer was asked to verify the light after returning from
outside to the darkened bridge. The report speculated that due to power distance the
second officer did not question the master’s order to port. The source of the red light
had not been determined. The investigator commented on an autocratic style of
leadership.

Domiat – Bulk Carrier. (SMI22 2004)

Details of the case may be found at:

http://www.sjofartsverket.se/upload/listadedokument/engelska/haverirapporter/domia
t-eng.pdf

Summary
The vessel ran aground on June 7, 2004 on its way from St. Petersburg to a not yet
defined port in India. A passage was planned to go through the Sound via Flintrannan.
The second deck officer planned the route which was approved by the master. After
loading, the draft was several meters beyond the limit of the Sound. This was pointed
out to the master by the chief officer and one of the third officers. The Master
neglected the information and the ship ran aground. The crew was all Egyptian
nationals.

Analysis
The investigator noted the circumstances to be the small draft, the master approving
the route plan and a hierarchic order on board. The report noted that the manner in
which the master neglected the officers’ apprehensions and their adherence to his
standpoint reveal that the cooperation on board was unsatisfactory. It shows a
devastating respect for the opinions of a superior. The investigator reported that
22
Swedish Maritime Inspectorate

129
during a visit on board an obvious hierarchic atmosphere was present where the
officers seemed afraid to voice their opinions in the presence of the master. At a
questioning one referred to the opinion of the master.

Reference was made to the contents of the Bridge Resource Management in relation
to clear assignment of duties and responsibilities and good cooperation on board
which were lacking on the Domiat. Comments included the use of available
resources and the evaluation of new information to avoid tunnel-vision.

Bow Mariner – Chemical tanker. (USCG23, 2005).

Details of the case may be found at:

http://www.dieselduck.net/library/09%20accidents/USCG%20Bow%20Mariner.pdf

Summary

On February 28, 2004, the vessel caught fire and exploded while the crew was
engaged in tank cleaning. The ship sank 45 nautical miles east of Virginia. Of the 27
crew members aboard, six abandoned ship and made it to a life raft and were rescued.
An unknown number abandoned ship to the water, three were rescued, one deceased
and the other two died before reaching the hospital. The crew composition was
Greek senior officers and Filipino junior officers and ratings.

Analysis
The cause of the casualty was listed as the ignition of a fuel/air mixture, either on
deck or in the cargo tanks. The ignition source could not be precisely determined.
Contributory causes were listed as the operator and the senior officers not properly
implementing the company and vessel Safety, Quality and Environmental Protection
Management System (SQEMS).

23
United States Coast Guard

130
The report noted that the distinctions between the Greek senior officers and Filipino
officers and ratings were remarkable. Filipino officers did not take their meals in the
officers’ mess, were given almost no responsibility and were closely supervised in
every task. The second assistant engineer reported on arriving on the vessel for the
first time he inquired of his duties and was sternly told he would be given verbal job
orders daily, and was to do only as he was told and would have no administrative
duties beyond making log entries. The report noted a lack of trust in the deck
department. The surviving deck crew reported that the chief officer would not sleep
beyond short naps in a chair in the cargo control room during cargo operations. There
was lack of group cohesion. When questioned as to what they would do if instructed
to do something unsafe by one of the senior officers each crewman replied that they
would do as they were ordered. One comment received was that orders from the
Greeks were like words from God.

Attilio Ievoli – Chemical tanker. (MAIB, 2005)

Details of the case may be found at:
http://www.maib.gov.uk/cms_resources/Attilio%20Ievoli.pdf

Summary

The vessel ran aground on June 3, 2004 on Lymington Banks in the west Solent after
leaving Fawley Marine Terminal, Southampton headed towards the English Channel
via the west Solent and Needles Channel. The master, second officer and a cadet
were on bridge. Neither the second officer nor the cadet was sure of who was
responsible for plotting positions. The master was not paying attention to the
navigation of the vessel being distracted using the ship’s mobile telephone. The
master instructed the second officer to remove the pilot flag, who informed the
master, before departing, that the vessel was north of the planned track. The master
did not hear. The crew consisted of 13 Italians, one Russian and two Ukrainians.

131
Analysis
The human factors analysis was carried out by QinetiQ’s Centre for Human Sciences.
The Centre reported that the human factor failures started with the master’s decision
to use the west Solent, contrary to company instructions. The crew was not clear on
the roles and responsibilities of each other. Task performance were not coordinated,
and there was little overt management and supervision. The report extrapolated that
power distance was at work as the second officer was reluctant to question the
master’s authority or competence. Poor teamwork and cultural differences among
team members led to role confusion among them.

Supporting Cases

• The grounding of the Royal Majesty on June 10, 1995. The vessel was off course
by 17 miles. Human factor contribution was the officers’ reliance on the
automated system. (NTSB24, 1997).

• The grounding of the Bunga Teratai Satu on November 2, 2000 at the north end
of Sudbury Reef. Human factor contribution was listed as the mate had become
preoccupied with private phone calls. (ATSB, 200125)

• Jackie Moon, general cargo vessel ran aground on September 1, 2004 at Dunoon
Breakwater, Firth of Clyde, Scotland. Chief Officer who was sole person on
watch fell asleep. Human factor contribution was listed as fatigue and alcohol
consumption. Falsification of hours of work and rest due to commercial pressures
were discovered. (MAIB, 2005).

• Grounding of the Crimson Mars on May 1, 2006 in the River Tamar, Tasmania.
Miscommunication between pilot and helmsman. Human factor contribution was

24
National Transportation Safety Bureau
25
Australian Transport Safety Bureau

132
 listed as ineffective bridge resource management and distraction caused by
pilot’s use of mobile telephone. (ATSB, 2006).

• Collision between Skagern and Samskip Courier in the Humber Estuary on June
7, 2006. Ships collide in dense fog. Both were going at unsafe speeds for the
condition. Human factor contribution was listed as both masters’ over-reliance on
the pilots. (MAIB, 2007).

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Appendix 2 - Responses from Seafarers

The topics discussed were to further explore the research questions as to the human
factor challenges to safety culture, the status of education as regards the non-
technical skills and the role of the behavioural sciences. The rationale was to discuss
with the seafarers their opinions and perspectives on the concepts as they are the
ones directly affected. Questions are indicated with underlining in bold and the
responses follow.

Of the persons approached, ten were responsive. Two were active seafarers on the
job and eight were students enrolled at the WMU at the time of the study. These
took the form of personal communication via email where responses to the questions
were sent and follow-up discussions done via email if clarification was needed.

Biographical Data

This information was sought to have an idea of the experience of the seafarer
supporting their opinions.

Qualification Current position Type of vessel How long have How long
currently on or you been a in current
last employed seafarer rank
on
1 Engineer – Certification Chief Engineer Offshore supply 33 years 8 years
III/2 management level intermittently
2 BSc Second Engineer Bulk carrier 10 years 4 years
3 Captain ocean going Chief Mate Feeder 10 years 3 years
4 Master Mariner, Maritime Pilot No vessel pilot 20 years 4 years
Maritime Pilot for 4 years
5 Class 3 Deck Officer 2nd Officer container 4 years 2 years
6 Master, Class I Chief Officer Container & 16 years 5 years
LPG Gas continuous and 10 continuous
Tanker years temporary and 10
years
temporary
7 Deck Officer, 3rd Deck Officer Bulk carrier 5 years 1 year
operational
8 Deck Officer 2nd Deck Officer Bulk carrier 3 years 2 years
9 Merchant Class I Chief Engineer Passenger 10 years 6 years
(inland waters)
10 Class I Masters Licence Masters Container vessel 18 years 10 years

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What do you think are some of the factors that affect a seafarer’s performance
of his duties onboard? Choose as many and you may add others not mentioned?

Factors affecting performance at sea Number of

responses
Stress 10
Fatigue 10
Family problems ashore 10
Does not understand the technology 6
Not properly trained 9
Lack of resources from company 8
Personality problems (does not get along with 8
others)
Too much technology on board ships today 5

Others factors added were: one respondent each: a) stringent regulations which
involve a lot of paper work and commercial pressures b) frustration c) homesickness
d) alcohol and attitude of only working for the money and not caring for the
profession.

Multiculturalism

The following explored the issue of multiculturalism and communication on board to

ascertain the level of group interaction. Except for 2 persons they all sailed on
multicultural vessels with 4 persons sailing on vessels with 3-4 different nationalities,
and 4 sailing with more than 5 different nationalities.

Did you have any difficulties getting along with any of the nationalities?

Difficulties getting along with other nationalities onboard

Yes 2
1 Not really but the ship was very segregated, working but not socializing
No 5

Did any of the nationalities have difficulties getting along with each other?

This question was asked as it is more likely that persons feel more comfortable
relating seemingly negative information about others than themselves. All 8 who
have been on multicultural vessels answered yes to this question with one explaining

135
that it was during a time when there was national conflict between the countries of
the persons onboard.

Did you personally have any communication difficulties (talking with and
understanding each other) because of different languages?
The role of communication in safe operations has been established in accident cases
as well as in research (Dzugan; MARCOM, 1999; Horck, 2006, 2008). Five persons
of the 8 who sailed with multinational crew said yes they had communication
difficulties.

Did you witness any communication difficulties (talking with and understanding
each other) among other members of the crew because of different languages?
All 8 said they had witnessed communication difficulties among others in the crew.

Did you personally have any difficulties (getting along with each other) because
of different cultures?
4 persons said yes they had difficulties because of culture.

Did you witness any difficulties (getting along with each other) among crew
because of different cultures?

7 persons said they had witnessed difficulties among others due to culture.

Any other difficulties you can think of due to the mixed nationalities onboard?

• Other difficulties mentioned were in terms of sign language the movement of

the head to signify yes or no, was different in some cultures.
• In some companies there were different salaries depending on nationality and
that caused problems.
• 5 persons mentioned that meals were a problem. The type of food and
difficult for the catering department to suit all the tastes.

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 • Culture clashes occurred when one nationality says something that another
found offensive.
• One person who mentioned food as an issue also spoke of hygiene, religion,
and music, as causing difficulties.

Maritime Education and Training

This section was explored to ascertain the extent to which courses geared towards the
non-technical were offered in MET, how they were delivered and the seafarers’
perceptions of the value of such courses.

While at training school did you do any studies on topics such as

Non-technical courses that were completed Number of

responses
Leadership 7
Group relations 7
Communication 9
Cultural awareness 5
Perception 5

The respondents were invited to name other courses but there was no indication of
other courses taught relating to the non-technical. One person indicated that the
communication studies he did was only for radio.

Do you think that these courses would be helpful for safety reasons onboard?

The agreement was that such courses would be helpful for safety reasons. Comments
received were:
• In my country, leadership and group relations courses are necessary because
most people become officers whilst young and are made to manage older
people with lots of experience on the job and if not well handled may easily
lead to conflict, as there is always the “we had done it this way” syndrome.

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 • All these courses teach how to understand and deal with a micro-society, they
will definitely be helpful for enhancing safety onboard. To have safety
onboard in the first place you need a well functioning society.

• They would be helpful for safety reasons, but in an effort to reduce classroom
time most of these courses have been reduced or eliminated in the UK and in
training institutions elsewhere they are not even mentioned.

• Awareness is the key, if you have background to all of these you can probably
survive onboard especially where safety is concerned.

• Assist in interaction with your colleagues

• It is very important for seafarers to understand that the safety of the ship
depends on the total collaboration of all on board and that safety does not
only mean taking care of one’s machineries or doing one’s assigned duties,
but looking after each other’s affairs count.

• It prepares you for life onboard. It does assist you in dealing with problems
that will pop up from time to time.

• By helping to understand the situation but cannot solve the problem. I mean
people will act according to their own culture especially in urgent situations
when our reflexes guide our behaviours.

In terms of such courses helping to improve safety, 9 persons agreed and one was
unsure, but think it would be useful for group interaction. Comments were:

• Yes they would be helpful but it is preferable to work with one nationality
crew or at least same culture

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 • Everything which is sincerely applied can be useful
• Don’t know if such courses improve one’s safety awareness…think it helps
more in the area of interaction plus man management.

How were these courses delivered?

Methods of delivery of non-technical courses Number of
responses
Formal classes only 4
Integrated in other courses only 1
Formal classes and general discussions 2
Formal classes, general discussions, integrated in 2
other courses
Not delivered 1

The method of delivery varied from formal classes only to some receiving
instructions in formal classes plus informal discussions and being integrated in other
courses.

Which one of the following do you think play the greatest role in safety on
board?
This question was asked to ascertain the seafarer’s perception as it relates to who is
responsible for safety as a comparison with the different paradigms as to which of
the factors in the safety-critical system is responsible for safety.

Aspects of the safety system Number of

responses
The technology only 0
The organization only 1
The seafarer only 4
The organization and the seafarer 2
All 3 3

For those believing the seafarer only plays the greatest role for safety on board, the
comments were:
• The seafarer is an element of the organization and he uses the technology, he
is the most important factor

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 • It is the seafarer who uses the technology and who follows the directives of
the organization. Seafarers who are safety conscious and safety aware can
create working environment even for rouge organizations with little
technology.

• He/she is responsible to follow the procedures established to safeguard

against identified risks, and eventually identify hazards not foreseen.

• The seafarer is the whole in everything

Persons who thought that all 3 were important had this to say:

• Technology is no better than the user, the organization is made up of

seafarers (at least partly). All are equally important but today I would say
that we do have the technology and the organization in most cases but the
lack of training of seafarers is the problem. Partly there is a total lack of
seafarers and in addition many available seafarers are not competent.

• A technology which is used with capable and educated seafarers under the
supervision of the highly organized/sensible organization can make a
difference.
• Technology is been used to help in the reduction of human errors, the
organization is coming up with new regulations so as to improve safety
onboard; the seafarers are at the end of the chain that is they are there to
implement these regulations and also meet up with the required knowledge
and skill to combat the demands required to operate these technologies.

Do you think your shipping company is serious about safety?

This question is to explore the perceptions regarding the company’s approach to
safety to ascertain company’s involvement. Six persons indicated that their company,
or the last company they worked with was serious about safety. One comment was

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the company tried to make the ship a “home away from home”. Another gave a
general comment that some companies are not doing their best with regards to safety
“at the end of the day, shipping is all about returns. Profit. Making shareholders
happy. So shipping companies will compromise safety for profit.”

Other comments were:

• I think only from the side to comply with the regulations. Some companies do
not respect their own regulations.

• The written procedures are mainly to satisfy the requirements for

certification of the ship. Some are even “copy and paste” form other types of
ships, without proper consideration with the ship’s reality. For instance,
procedures and checklists in a language not understood by all.
This bears out the findings from the literature that companies vary in attitudes to
safety.

In your job have you had to do anything that is considered not safe but you do
anyhow?
This was a general query and not necessarily a reflection of present company or the
last company with which the seafarer was employed to explore issues of violations.
Six persons said they had done things that are unsafe in their jobs. Except for one
person, these acts were external to the seafarer to meet commercial pressures or the
extrapolation can be made that one had to carry on to preserve ones job:
• In an effort to keep schedule and because of commercial concerns masters
have to dock vessels in small ports without pilotage assistance and to run at
full speed in restricted visibility. The distance between small, island states
around the Caribbean is also so small that there is very little time for the
body to recover between leaving a port and arriving at another. Though
companies do not explicitly say they want the ships to run at an optimum it is

141
 understood that a Master who does otherwise for the sake of safety may be
replaced.

• Trying to combat fire without the protective gear; anyway the reaction was
spontaneous and the vessel was saved from massive destruction.

• Sometimes you have to do it for the sake of others. You are forced to do it to
be good in your work for giving your loved ones a good life.

• Sailing with defective machinery form homeport under instructions from

management and when you refuse to go with the ship you are thought to be
incompetent and you risk your job, and being the only shipping company you
had to do it anyway.

• As chief mate assuming the watch keeping from 04h00-08h00 after

loading/discharging , which took around 12 hours at least of continuous work.
I felt tired, thankfully no incident happened.

• For lack of appropriate material and tools.

In your job ever seen anyone doing anything that is considered not safe but he
does it anyhow
Nine persons said they had seen persons doing things that were unsafe similar to
what they had done personally, such as working without proper equipment, and
working while tired. One comment was that some persons worked while tired to
make overtime. Others indicated that persons were ordered by officers to do things
that were unsafe “a motor man went into a partially ventilated enclosed space to
work given an order by the second engineer.” One indication was that a particular
person committing an unsafe act did not believe in the probably consequences.

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Another indicated that a crew was working aloft without a safety belt as he refused
to wear it.

Health Issues (Mental)

Isolation has been named as one of the factors affecting seafarers mental health and
possibly leading to depression (Thomas, 2003; Kahveci, 2007). These may affect
performance but are not openly dealt with in the maritime industry. Recently
concerns have been raised regarding depression with one seafarer giving his
experience in the Nautilus (My battle with the black dog, 2008). Health issues are
associated with fatigue. Regarding isolation, with associated feelings of loneliness,
four of the 10 said they felt lonely/isolated on board. One indicated he felt lonely on
both single and multi-national vessel alike as his loneliness was homesickness. The
other three indicated they felt lonely more on multinational vessels, with one
commenting that “being the only black officer amongst Eastern European officers, I
sometimes felt that I was segregated from the group.” This feeling comes on mostly
in the officers’ saloon or at mealtimes. Similarly, the others felt lonely at social
gatherings, and at the end of work period when there is time to think about the family.
Drinking, recreation, entertainment (movies) going ashore and keeping busy with
work were used as coping strategies.

Five persons have experienced others saying that they felt lonely on board. Reasons
given were personal problems and multinational crew. Coping strategies are similar,
entertainment, going ashore, keeping busy, trying to call home. One comment was
“you can even see that in their face, they are holding on just because of the money
and sometimes drinking heavily.”

Eight persons said they have felt depressed on board. Job related issues, multicultural
crew, homesickness, home problems, and too much work, have been given as
reasons for the onset of depression. Coping strategies for depression included

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focusing on work, looking forward to leave time, drinking, entertainment, quit the
job, and crying.

In terms of knowing of other crew members who have said they were depressed,
seven persons said yes. Coping strategies used were drinking or smoking, quitting
the job, sometimes they talk to others, isolate themselves or become aggressive.

A description of life on board in general was sought to ascertain the type of

environment which may affect mental health. The responses were:
• Crew life can be fun, interesting with a busy schedule, however a supportive
family is essential.
• Life onboard is no more fun; mostly everyone tires to do his job so as to get a
clean cut for the next contract.
• Was fun though labouring as vessel was continuously sailing and calling in
ports throughout day and night.
• Unique, abnormal, and sometimes fun because you can visit other places.
Good experience that you could meet different people with different traits and
personalities.
• Life onboard was very secure. Work and environment was dangerous but you
were provided with most of the things… a kind of protected society away from
reality. Interesting and satisfying work.
• Boring routine, uncomfortable, unhealthy environment.
• Terrible, but very good money which you will never get on shore even as a
manager.
• Life onboard varies with the type of ship, type of trade, nationality of crew,
how the company deals with its crew, area of trade. I would say it is ok.
• Isolated.
• Stress, fatigue and isolation.
The responses vary, but show that life on board may have negative effects on health
and wellbeing.

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Safety Culture
There was general agreement that safety culture was important and should be
discussed by all, administrations, management [companies] and seafarers, if the
maritime industry is to improve. One person saw it as important that charterers
should be involved in this discussion as well “what kind of ship is he chartering?” It
was also seen as essential for the seafarer to have the idea about safety culture to not
only protect property and the environment, but most importantly they need to survive
and [stay] alive for their loved ones.

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Appendix 3 – Interview with Training Manager

Interviewee: at sea for 25 years, retired 4 years ago. Training manager for ship
management company.

It is said that a large percentage of accidents are caused by human factors. Do

you agree with such a statement or do you see other issues?
The real problem is not investing enough in human resources, it is not valued. It’s
just hire and fire. If you check many companies they don’t have HR policy, just
short term HR.

What about issues of leadership?

You learn on the job. No course. Bridge resource management is not mandatory, it
depends on the company and it is not enough.

Communication?
Communication among crew is in English but it is not mandatory, they may put
together enough words to say something, but it is difficult, and sometimes
communication is with body language and that can be a problem. Cultural
differences can pose a problem, example some crew leave their duties and go pray
(Indonesians), the captain is suppose to handle this, has anybody bother to sensitize
him? There can be confrontation is captain stops them. They need education. The
ship is out in the sea and is a 24hr operation cannot compromise safety that way.

Give you an example, cocoa cola, the parent company wants to set up a company in
another country, he sends the person there to live for a short while to see if he likes it,
get a feel of the place. Shipping is anti-social life and anti-people. As long as you are
on the ship and working that is it.

146
What about power distance, is it a problem?
Sometimes the respect that a master is expecting is not there like a junior from Asia
or so will stand when the master enter the bridge and walker after him but one from
Europe or developed country may not. A ship is not a democracy it is a high risk
environment so the hierarchy, it is necessary to have structure. But at times the
master may act as a dictator and this can hinder communication, so this has to be
taken into consideration. But there is no structured training for these things. Power
distance sometimes as well between superintendent and captain. Master can divert if
somebody sick and superintendent might say carry on

How would you describe life on board.

Social life onboard ship is lonely. Somebody can sit in the room and not come out
and nobody enquires after him. There is no regard for culture and crew compatibility.
Some crew get on well together and some do not. Desires of crew sometimes not
considered, like some cultures have tea. Italian officers don’t offer tea. Not sensitive
to cultural needs. Or they can have pasta as meal and what about the other crew,
power abuse onboard.

No regard given to emotional and psychological needs. Crew lounge is small, cabins
next to smoking room, space is cramped sometimes no space. No regard, no strategic
planning to take care of crew needs. Sometimes they [seafarers] go ashore there is
problem to pass time, they go to pubs or go shopping. Some companies have a
welfare fund and the master pockets that, others use it to organize more focussed
outings.

Are there conflicts on board?

Fights occur sometimes. This is because of stress build up. A lot of time its because
of food. People are working whole day and when they come to the mess room and no
proper dinner, this is a cause of unhappiness and conflict. On land you go to
restaurant or you have a nice dinner at home.

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Have you had any experience of someone committing suicide on board?
Suicides occur. I have had 3 suicides on ships three different ships in one year that I
have been on, these were for personal reasons. People don’t have friends onboard to
talk with. We used the fridge room where all ships vegetable and meat are stored to
store the body until we got to port we let the body off and carried on. No counselling
you are left to deal with it on your own.

What do you think about introducing subjects into maritime education and
training regarding such matters of leadership, communication, how to deal with
life onboard.
Psychology would help. After a while when seafarer go ashore they have tunnel
vision, should have counselling, do a debrief before going to family. My father
passed away while I was on ship, all I could do is cry in my room, no emotional
support and as the captain you have that power distance.

Sometimes as well, a power struggle between captain and chief engineer. The chief
engineer want to exercise power and the captain is in charge and this cause group
struggle with the deck and engine. Being in the engine room for long affects their
minds sometimes, being in that environment for long. The model course “personal
safety and social responsibility” is there but it is not enough, need to learn how to
deal with people. Need to invest in people, people are neglected. It is like you are a
casual labourer, you work for today and that is it, no regard, so if somebody offers
more money I go. Companies do not employ a psychologist. No company employs a
psychologist. They would say the money is too much, don’t want to invest.

What about the Port Chaplains?

Cannot make full use of the Chaplains because sometimes we cannot go ashore
because of duties. Some ports have no chaplains.

148
Also the life is lonely no support, now one of my colleagues is detained, the
company is still paying him, but sometimes they are abandoned. No body to support
you if you are in problems.

The proposal is to have such courses from entry into school and build on the
knowledge throughout each year.
I agree, but it is not the seafarer alone needs this education. Company should ensure
training in diversity management undertaken by all involved in ships safety. Issues
can be identified, even if the person is not a professional psychologist, issues can be
identified so when they are making decisions they have information, they are aware
about the things that affect seafarer. They should also make it mandatory for senior
management level dealing with crew to have a degree or diploma or some
qualification in human resources.

Lack of caring of seafarers affecting the recruitment, job satisfaction is important.

Shipping needs an overhaul in that regard. Training is just the same, some guy come,
and the white board and push the slides and thinking “when this one finishes, he will
be getting more money than me.” All stakeholders must be involved. Shipping is cut
and dry, lack of compassion. For example, you are entering like the English channel,
you are up the whole night because you take pilot, next day you have to deal with all
who come to the ship and survey and check and the stores come, this come, that
come, and nobody says, ok they have been up the whole night, nobody cares. It’s
like you have sold our soul. The thought process in the industry has to change.
Awareness has changed, people want more, its like Maslow’s hierarchy of needs.
Small things such as designated air conditioning on bridge, or some show of care,
makes a lot of difference.

What are your thought on how to arrive at safety culture?

Loyalty, build the crew loyalty, with that safety culture will come automatically, you
carry out the company policy willingly. Now it is done more reluctantly and you

149
have to be policed. There are shipping companies with good HR policies. They map
a career path for junior officers, they stay with the company, this builds loyalty. To
achieve a safety culture a lot has to be done at the basic level making the seafarer a
part of the team, not just hiring and firing. Root cause of ill treatment is money, don’t
want to invest, and attitude of owners.

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Appendix 4 – Responses from MET Institutions

QUESTIONS RESPONSES
Maritime Academy 1 Maritime Academy 2 Training Centre
Do you see safety yes Yes – safety culture has never yes
culture as a been a high priority item with
challenge for the maritime employees, it has
maritime been with the shipping
industry? companies
Is the topic Yes it is Yes but not enough. All Not really, it depends on
discussed in your aspects of safety need to be the lecturer
training discussed and applied. We
institution among need to show more by example
the prospective rather than discussion. We
seafarers? have plenty of room for
improvement.
Whose is By my understanding that Everyone, not just employers, Companies,
responsible in the the logical sequence of such but educational institutions as administrations, MET,
maritime industry are: IMO – Maritime well everyone… the seafarer.
to work towards a Administrations – Shipping
safety culture? companies - MET
What actions First of all it is the I can’t answer this one Create regulations,
relative to implementation of all STCW, ISM
seafarer training instruments where the
has the industry elements of Quality
taken towards Management algorithms
achieving a safety exist (ISM Code, STCW…)
culture? as safety culture anticipates
the reflections to
deficiencies and projection
of situation developments
Has the Yes it has. Every course has Yes, we are incorporating it No courses are offered
discussion on case studies relating to into our labs and lecturers as that are not a part of the
safety culture safety that is influenced by well as our practical training STCW. There are no
impacted on any the level of safety culture of aboard ship. courses on leadership,
course delivery in seafarers. The courses are delivered with culture, communication
your institutions? All types of delivery general lecture, problem-based and so on.
methods are used and learning, case studies etc.
assessment is by exams. All required outcomes are
The courses are done from assessed on content
first year step by step knowledge. Safety is an add on
that in most cases is not
assessed. These courses are
done primarily 1st and 3rd year.
Do you have any To invest in MET No response Yes, by teaching courses
suggestions as to To develop STCW outside the STCW such
how the industry mandatory provisions for as bridge resource
could go about shipping companies for management. And discuss
developing a organization of proper on- with seafarers about
safety culture board training. safety onboard.
Do you think Yes, I do, if these sciences Unsure Yes. But if those courses
teaching are delivered by are offered nobody will
behavioural professionals in seafaring take them. We used to
sciences to and supported by proper discuss implementing
seafarers will be onboard trainng. courses outside the
helpful STCW in our school but
if it is not compulsory the
seafarers are not taking it
as they have to pay and

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QUESTIONS RESPONSES
Maritime Academy 1 Maritime Academy 2 Training Centre
they also don’t want to be
away from work too
much because of the
money. We don’t teach to
regular students.

152
Appendix 5 – Non-technical aspects of the STCW Code Parts A and B geared
towards the human factor.
CODE Part A Column 1- Human Factors
Competence
CODE Part A – Column 2 – Knowledge, Corresponding Performance
understanding and proficiency26 Shaping Factors 27
Table A-II/1 – Maintain a Through knowledge of effective bridge leadership, teamwork,
safe navigational watch, teamwork procedures. language, communication,
p.30. cultural diversity, decision
- Respond to emergencies - Precautions for the protection and safety of making, situation awareness,
p.33 passengers in emergency situations. health, stress, fatigue

- Use Standard Marine - Adequate knowledge of the English

Navigational Vocabulary as language to enable the officer to use charts leadership, teamwork,
replaced by the IMO and other nautical publications, to understand language, communication,
Standard Marine meteorological information and messages cultural diversity, decision
Communication Phrases concerning ship’s safety and operation, to making
and use English in written communicate with other ships and coast
and oral form. p.34 stations and to perform the officer’s duties
also with a multilingual crew, including the
ability to use and understand the Standard
Marine Navigational Vocabulary as replaced
by the IMO Standard Marine Communication
Phrases.

leadership, teamwork,
language, communication,
- Operate life-saving - Knowledge of survival at sea techniques cultural diversity, decision
appliances. p. 38 making, situation awareness,
health, stress, fatigue

Table A-II/2 – Establish Effective bridge teamwork procedures. leadership, teamwork,

watch-keeping language, communication,
arrangements and cultural diversity, decision
procedures. p.45 making, situation awareness,
health, stress, fatigue

- Plan and ensure safe - Ability to explain the basic principles for communication, cultural
loading, stowage, securing, establishing effective communications and diversity, decision making,
care during the voyage and improving working relationship between ship health, stress, fatigue
unloading of cargoes. p.51 and terminal personnel.

- Monitor and control - responsibilities under international

compliance with legislative instruments affecting the safety of the ship, leadership, teamwork,
requirements and measures passengers, crew and cargo. language, communication,
to ensure safety of life at cultural diversity, decision
sea and the protection of the - actions to protect and safeguard all persons making, health, stress, fatigue

26
Where recommendatory provisions have been given in Part B of the Code this will be listed
accordingly.
27
Performance Shaping Factors compiled from the literature relating to the maritime industry,
including IMO documents. Hetherington et. al. (2006) also listed safety climate and safety culture,
which are important but relates specifically to the organization, although it is acknowledged that the
PSFs are also affected by safety climate and safety culture.

153
CODE Part A Column 1- Human Factors
Competence
CODE Part A – Column 2 – Knowledge, Corresponding Performance
understanding and proficiency26 Shaping Factors 27
marine environment… on board in emergencies
p.55-56
leadership, teamwork,
-Organize and manage - A knowledge of personnel management, language, communication,
crew. p. 57 organization and training on board ship. cultural diversity, decision
making, health, stress, fatigue
Table A-II/3 – Respond to - Precautions for the protection and safety of leadership, teamwork,
emergencies. p.64 passengers in emergency situations. language, communication,
cultural diversity, decision
making, health, stress, fatigue
Table A-II/4 – Contribute to - Ability to understand orders and to teamwork, language,
monitoring and controlling communicate with the officer of the watch in communication, cultural
a safe watch. p.71 matters relevant to watch-keeping duties. diversity, health, stress,
fatigue
Table A-III/1 – maintain a - Duties associated with taking over and leadership, teamwork,
safe engineering watch. accepting a watch language, communication,
p.76 cultural diversity, decision
- Routine duties undertaken during a watch making, situation awareness,
health, stress, fatigue

- Use English in written and Adequate knowledge of the English language

oral form. p.77 to enable the officer to use engineering language, communication
publications and to perform engineering
duties.

Table A- III/2 – Monitor – Responsibilities under international leadership, teamwork,

and control compliance instruments affecting the safety of the ships, language, communication,
with legislative passengers, crew or cargo. cultural diversity, decision
requirements and measures making, health, stress, fatigue
to ensure safety of life at
sea and the protection of the
marine environment.
Maintain safety and security
of vessel, crew and
passengers and the
operational condition of
life-saving, fire-fighting and
other safety systems. p. 91 leadership, teamwork,
language, communication,
- Organize and manage - A knowledge of personnel management, cultural diversity, decision
crew. p. 91 organization and training on board ships. making, health, stress, fatigue

Table A- III/3 as required under A-III/2

Table- III/4 -Understand - Engine watchkeeping procedures teamwork, language,

orders and be understood in communication, cultural
matters relevant to diversity, health, stress,
watchkeeping duties. p.94 fatigue

Section A-V/2 – Crowd - Crowd management training leadership, teamwork,

management training. p.108 communication, health,
stress, fatigue, decision-
-Safety training for making
personnel providing direct
service to passengers in
passenger spaces p.110

154
CODE Part A Column 1- Human Factors
Competence
CODE Part A – Column 2 – Knowledge, Corresponding Performance
understanding and proficiency26 Shaping Factors 27

Table A-V/2 – Crisis - Leadership skills leadership, teamwork,

Management and Human - stress handling (ability to identify the communication, cultural
Behaviour Training development of symptoms of excessive diversity, decision making,
personal stress and those of other members of health, stress, fatigue
- control response to the ship’s emergency team.
emergencies p. 114
- Understanding the stress generated by
- Control passengers and emergency situations can affect the
other personnel during performance of individual and their ability to leadership, teamwork,
emergency situations. p. act on instructions and follow procedures. communication, cultural
115 diversity, decision making,
- Human Behaviour and responses health, stress, fatigue
- Establish and maintain
effective communication. Ability to establish and maintain effective
p.116 communications

Section A-V/3 Similar requirements to Section A-V/2

Table A-VI/1-1 survive at - Principles concerning survival leadership, teamwork,

sea in event of ship language, communication,
abandonment. p.123 CODE B: recommends elementary first aid cultural diversity, decision
to be part of the early stage of basic vocational making, health, stress,
training fatigue.

Table A-VI/1-4 - Importance of adhering to safe working teamwork, language,

-Observe safe working practices at all times. communication, cultural
practices. p. 130 - Ability to understand orders and to diversity, health, stress,
communicate with others in relation to fatigue
- Understand orders and be shipboard duties
understood in relation to
shipboard duties. p. 130 - Importance of maintaining good human and
working relationships aboard ship.
- Contribute to effective - Social responsibilities: employment
human relationships conditions; individual rights and obligations;
onboard ship. p. 130 dangers of drug and alcohol abuse.

CODE B: Comment on the significance of

communication and language bearing in mind
communication needs onboard and the
presence of multinational crew.

Recommends the adoption of a common

language as important in promoting safety by
reducing error in communication.
Table A-VI/2-1 –Manage - Apportionment of food and water in survival leadership, teamwork,
survivors and survival craft craft language, communication,
after abandoning ship. p. cultural diversity, decision
134 - Management of injured persons, including making, health, stress, fatigue
control of bleeding and shock.

Table A-VI/3 – Control - Communication and co-ordination during leadership, teamwork,

fire-fighting operations fire-fighting operations. language, communication,
aboard ships. p.139 cultural diversity, decision
- Management and control of injured persons making, health, stress, fatigue

155
CODE Part A Column 1- Human Factors
Competence
CODE Part A – Column 2 – Knowledge, Corresponding Performance
understanding and proficiency26 Shaping Factors 27

Table A-VI/4 – Apply leadership, language,

immediate first aid in the Details as to training requirements presented communication, cultural
event of accident or illness diversity, decision making,
on board. p.142 health, stress, fatigue

- Provide medical care to

the sick and injured while
they remain on board
Section A-VIII/2 parts 2, 3, - Principles applying to watchkeeping leadership, teamwork,
3-1. generally. language, communication,
Part 3. Watchkeeping at Sea - Principles to be observed in keeping a cultural diversity, decision
navigational watch. making, situation awareness,
Part 3-2 Principles to be - Lookout health, stress, fatigue.
observed in keeping an - Watch arrangements etc.
engineering watch
CODE B: Guidance regarding fitness for
duty – Prevention of fatigue in relation to
hours of work or rest. Administration should
consider the keeping of records of hours of
work or rest.

- No Guidance on watchkeeping at sea.

CODE B. Guidance on Keeping a

navigational watch. Bridge resource
management – companies should issue
guidance on proper bridge procedures. Review
use and allocation of bridge resources. Details
Code B pp. 270-272.

The Table outlines those areas identified as needing human-human relations as well as operational
duties where the human factors that may contribute to accidents are salient. In bold in Column 3 have
been inserted the performance shaping factors (identified in the literature) that would impact those
areas.

156
Appendix 6 – Problem Based Delivery Method Adapted by Dokuz Eylul
University School of Maritime Business Management, Kaynaklar Campus in
Turkey

Source: Asyali, et. al. (2003).

157
Appendix 7 – Aspects of the ABC approach to developing non-technical skills adapted
by Warsash Maritime Centre, Southampton Institute, UK.

Antecedents
Within the Warsash training course, the lecturer inputs are descriptions and explanations of the
following:
• Models of human error
• Error chain analysis
• Situational leadership
• Interpersonal influence
• Cultural awareness
• Situational awareness
• Effective communication

These teacher led activities are antecedent to student-centred activities described under the behaviours
section below.

Behaviours
There have been a number of training programs produced that aim to improve the higher order
cognitive skills of the students within specific context (Woods, 1983; Wales & Nardi, 1985; Resnick,
1987). These techniques have been adapted at Warsash to try and improve students’ social skills such
as communication and co-operation. Some of the techniques used are:
• Having students justify their solutions to one another;
• Having students evaluate other students solutions;
• Allowing students to make and correct errors;

Other studies have been directed at trying to generate training techniques to improve general problem
solving skills that would be transferable into different contexts of application (de Bono, 1985;
Covington, 1987; Resnick, 1987. These techniques have also been adapted at Warsash to improve the
students’ cognitive and metacognitive skills:

• Considering multiple sides of an issue (lateral thinking);

• Considering consequences;
• Selecting goals and planning strategies;
• Prioritizing factors involved in a situation;
• Generating and evaluating evidence;
• Using perceptual rather than logical thinking;
• Extensive practice of solving problems;
• Teaching the use of heuristic strategies;
• Use of graphical representations to show the structure of
problems
Consequences
“Debriefing is the key to the entire learning process, during which trainees’ knowledge and attitudes
are applied, tested, analysed and synthesized.” (Ellman, 1977).

A student-centred debriefing technique has been shown to be more effective because students learn
better through self-discovery and self-analysis than by lecture. The student-centred debriefing
technique draws upon students’ professional expertise and motivation to perform well, and it helps the
lecturer understand the students’ performance.
Source: Pekcan, C., Gatfield, D. & Barnett, M. (2005).

158
Appendix 8 – Maritime Resource Management (MRM) Course Contents

Attitudes and Management Skills

The human nature and its weaknesses are discussed. The trainees learn to be aware of
"hazardous thoughts", that can induce accidents, and the opposite, "safe thoughts".
The concept of Common Terminology is introduced.

Cultural Awareness

Cultural differences and how to deal with them. The following characteristics are
used to describe cultural differences: Group-Individual, Power Distance, Uncertainty
Avoidance, Feminine-Masculine, and Short-Long Term.

Communication and Briefings

This module deals with common errors in communication, the importance of "closed
loop communication" and how you achieve a good communication climate. Briefings
and debriefings are mandatory in aviation and should be applied also on ships.
Practical guidelines are given on how to perform briefings and debriefings.

Challenge and Response

The importance of a Challenge and Response environment is emphasised, defined as

a "supportive environment", in which everybody feels free to question assumptions
and actions, and in which positive responses are the norm.

Short Term Strategy

Short Term Strategy is a practical method for dealing with any type of task, but
especially useful in abnormal or emergency situations when use of all available
resources is necessary.

Authority and Assertiveness

In this module, behaviour in terms of authority and assertiveness is discussed.

Reasons for and the dangers of extreme combinations of authority and assertiveness
are analysed.

Management Styles

Different leadership styles are discussed and how to deal with them. The
performance/human relation management grid is used.

159
Workload

The dangers of too low and too high workload are discussed and systematic ways to
avoid them. Methods like task analysis, delegation and rotation of tasks are
addressed.

State of the Ship

The state of the ship is generated by the combination of the team members' personal
states of mind. The underlying reasons for different states of mind are discussed, as
well as the importance to detect and take action on state extremes and differences
between the crew members.

Human Involvement in Error

Here, underlying causes of accidents in terms of externally and internally induced

errors are discussed, and the importance of responding to and learning from errors.

Judgment and Decision Making

Factors affecting judgment and decision making and the process of decision making
are addressed. The importance of detecting and avoiding hidden pressure is
emphasized.

Leadership in Emergencies

Transferring an emergency situation from the unanticipated, fast reaction type toward
the anticipated, slow reaction type is discussed, and the necessity to apply different
leadership styles in different emergency situations Attitudes & Management Skills.

Crisis and Crowd Management

Together with the above modules, this module meets the STCW requirement for
theoretical training in C&C management. It covers mental and physical reactions in a
crisis situation, how to deal with them, how to deal with a crowd and finally a
method for personal crisis debriefing.

Automation Awareness

This module addresses the consequences of increased automation on ships' bridges. It

discusses different levels of automation, characteristics, advantages and dangers with
automation and some guidelines for learning to work in automated environments.

Source: http://www.swedishclub.com/mrm_main.php?id=50&menuid=61

160
Appendix 9 – Crew Resource Management

As part of Multi Crew Co-operation course at Lund University School of Aviation.

This section presents the syllabus for 15 out of the total 25 hours of theoretical
training.

Syllabus below is presented in a form equivalent to that of the teaching sessions.

Each session is one or two hours and the course ends with a summary and a course
evaluation. During the session lectures are mixed with practical discussions and
cases, some of them mentioned in the syllabus, to analyse the implications of the
theoretical knowledge. (Dahlström, 2008, personal communication).

COURSE SYLLABUS
INTRODUCTION COCKPIT MANAGEMENT
• Presentation of course contents and • Situational awareness revisited
learning objectives o Factors that affect SA
o Presenting the questions and o How to develop SA skills
considering the facts • Cooperation
o Conclusions through cases and o Benefits and problems
discussions • Group dynamics
o Flight safety – the key in every o Theories of group dynamics
item of the syllabus o Group think and risky shift
• Introduction to human factors and crew • Leadership
resource management o Personal traits of a leader
• Statistics of human factor related o Leadership styles
accidents o Leadership styles in different
• The SHEL model cultures
• Case: British European Airways • Communication
06/17/1972; Hawker Siddeley Trident o Verbal and non-verbal
1C (G-ARPI) communication
o Levels of communication
o Effective communication
• Conflict
o Types of conflict
o Escalation of conflict
o Conflict resolution
BASIC PSYCHOLOGY PERSONALITY
• Information processing • Personality and behaviour
• Attention and vigilance • Types of personality
o Mechanisms of attention and o “The big five”
vigilance o Basic personality types
o Hypovigilance o Behaviour which complicates
o Management of attention and communication
vigilance o Behaviour which facilitates
• Situation awareness (SA) communication

161
 COURSE SYLLABUS
o Definition of SA • Attitudes
o The three levels of SA o The origin of attitudes
• Human perception o Components of attitudes
o Senses and perception • Case: KLM Royal Dutch Airlines and
o Factors that affect perception Pan American World Airways
• Memory 03/27/1977 Boeing B-747-206B (PH-
o Memory management BUF) and Boeing B-747-121 (N736PA)
• The learning process
o Principles of learning
o Learning methods
ERRORS STRESS, FATIGUE AND SLEEP
• “Pilot Error • Workload
• Different categories of error o Effects of different levels of
• Sources of error workload
• Sources of error according to the SHEL- o Management of workload
model • Stress
• The chain of error o Sources of stress
o Effects of stress
o Stress management
• Fatigue and tiredness
o Types of fatigue and tiredness
o Effects of fatigue and tiredness
o Management of fatigue and
tiredness
• Sleep
o The circadian rhythm
o The sleep cycle
o Conditions for good sleep
• Jet lag
DECISION MAKING AUTOMATION
• Information processing and human • History of automation
thinking • Benefits of automation
• The decision making loop and CRM • Problems with automation
loop • Presentation and interpretation of
• Common errors when making warnings
conclusions • Automation complacency
o Representation • Future development in the field of
o Access automation
o Confirmation • Case: Air Inter 01/20/1992 Airbus
• Skill-, rule- and knowledge-based A320-111 (F-GGED)
decision making

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