Risk mitigation - it s all about the human element Commodore David Squire, FNI Editor Alert! The Nautical Institute
A Nautical Institute project, sponsored by Lloyd s Register Foundation The International Maritime Human Element Bulletin Improving the awareness of the Human Element in the maritime industry
The human element what is it? A complex multi-dimensional issue that affects maritime safety, security and marine environmental protection which involves the entire spectrum of human activities performed by ships crews, shore-based management, regulatory bodies, recognized organizations, shipyards, legislators, and other relevant parties (IMO Resolution A.947(23))
The human element what is it? It is about people It is about people in their working and living environments It is about their relationship with equipment, procedures and the environment It is about their relationships with other people (International Civil Aviation Organisation)
The human element what is it? The human element embraces anything that influences the interaction between a human and any other human, system or machine Alert! Issue 1. October 2003
Human error 100% 80% of all accidents at sea are as a result of operator human error
The human input When seeking the root cause of an incident, it is invariably the human input to the design, manufacture or operation of a system that has been a contributory factor
The human input Can be as a result of: Faulty hardware or software programming errors Failures to follow a proper systems engineering approach to the design and build of a ship and its systems Failing to meet the user needs Failing to follow the principles of human centred design Insufficient/inappropriate training Inadequate operating and maintenance instructions
Human element considerations will raise human element issues which, if not addressed can become hazards
Risk mitigation the human element Design it out Design for the User Who is the user or operator? What tasks does the operator need to perform to operate/maintain the equipment? What is the worst case scenario for the operator? What is the physical operating environment? What training/skills does the operator need or have? What will be the consequence of human error? Courtesy US Coast Guard
Risk mitigation the human element Design it out Design for spatial relationship Arrangement/orientation of the crew work station must replicate the actual world to be monitored or controlled Multiple components of a single system should be visually related Controls and instruments should face the right way Courtesy US Coast Guard
Risk mitigation the human element Design it out Design for operational expectations In the western culture, red is associated with danger, yellow with caution and green with an all clear signal. In a stressful situation, colour coding in violation of cultural expectations could contribute to a serious accident Provide cues built into the system that guide the operator to behave in a certain way, e.g. a control or switch with a T-handle is an invitation to pull whereas one in the shape of a mushroom will cause an initial push reaction from the operator Courtesy US Coast Guard
Risk mitigation the human element Design it out Design for feedback Feedback gives the operator information as to whether the action that was taken had any effect or not, e.g. if an operator shuts off a valve from the bridge, the green light goes dark and the red light comes on, to tell the operator that the valve is shut. Courtesy US Coast Guard
Risk mitigation the human element Design it out Design for safety in the path of least resistance In a shipboard environment where an operator has a multitude of tasks to accomplish, he will naturally exert the minimum energy necessary to complete each task, e.g. if in order to operate a frequently used valve, the closest way to get there from the operator s normal position is by stepping over piping or other hazards, he will do so, even if there is another longer safer passage available Courtesy US Coast Guard
Risk mitigation the human element Design it out Design for accessibility Equipment and system layout and arrangement must be designed keeping operability, maintainability and accessibility in mind Courtesy US Coast Guard
Risk mitigation the human element Design it out Design for consistency Avoid the risk of human error through changes in design, policy, or procedures, e.g. a display that appears in a specific location on a panel on one console should appear in the same location on another console for the same type of equipment Courtesy US Coast Guard
Risk mitigation the human element Design it out Design to eliminate ambiguity Job tasks should be designed so that there is only one way to complete a task, e.g. an assembly should only be able to fit in one way the right way and not be able to assembled in an improper manner Courtesy US Coast Guard
Risk mitigation the human element Design it out If the problem cannot be designed out Shield against it, e.g. provide a handrail on a stairway or a guard cover on a flywheel Warn of the problem visual alarms (labels, lights) or audio alarms (horns, bells, announcements) Provide easily understandable procedures or job aids to allow the operator to avoid the problem Train and re-train Courtesy US Coast Guard
Risk mitigation the human element Train and re-train Training (STCW) Training & drills (SOLAS) System specific training Enclosed space entry training Maritime Resource Management Onboard continuation training Table top exercises Refresher training Navigational audits Technical audits
Risk mitigation the human element Accidents & near misses Reporting Health and safety reports Minutes of safety meetings Accident/near miss reports Investigating Internal accident investigation Safety accident investigation Feedback Safety posters Safety alerts/bulletins Confidential reporting scheme summaries (CHIRP, MARS) Accident investigation reports Lessons learned
Risk mitigation the human element Lessons learned an all-too-familiar trend of accidents that should never have happened Many have human or operator error as causal factors and all reflect a failure to properly comply with the Safety Management System (SMS), in accordance with the provisions of the ISM Code
Risk mitigation the human element Risk assessments Assessing the risks associated with carrying out an operation or task should not be a tick-in-the-box exercise Generic risk assessment templates and checklists do not cover all eventualities Carrying out a risk assessment before undertaking an operation or task should not be a one person function Tool box talks encourage collective thinking and should involve both experienced and lesser-experienced personnel It is sometimes the lesser experienced (and the most junior) who will identify a hazard that has not been previously thought of
Risk mitigation the human element Risk assessments Navigational planning is a form of risk assessment ECDIS, makes the planning process easier, but only if the operator of the system is properly trained in its use and is fully aware of its capabilities It is the master s responsibility to cross-check the navigational plan before departure, but each OOW also has a responsibility to look ahead when taking over the watch, to ensure that the planned route does not stand the ship into any danger Important to maintain a proper visual and radar lookout not just to monitor other vessels but also to positively identify aids to navigation that are positioned to direct the ship away from a hazard
Risk mitigation the human element Procedures Procedures outline the steps to be followed to accomplish specific tasks Operational, maintenance and emergency procedures are crucial elements of the safety equation, e.g: The COLREGS specifically Part B, the Steering and Sailing Rules Procedures for the operation and maintenance of machinery and systems Procedures for the maintenance and launching of lifeboats and liferafts Procedures for the action to be taken in the event of a fire or manoverboard
Risk mitigation the human element Procedures Some procedures need to be committed to memory, especially the COLREGs, and those procedures related to emergency situations BUT there is no reason why the latter should not be supported by an aide memoire, provided it does not become just another tick list Others will have to be followed to the letter, especially in the case of the operation and maintenance of complex systems
Human element considerations will raise Risk mitigation Design it out Train & re-train human element issues Reporting & investigating accidents & near misses Lessons learned Risk assessments Procedures which, if not addressed can become hazards
Risk mitigation - it s all about the human element Thank you! Issues 1 to 38 of the Alert! bulletins and associated centrespread features can be downloaded from http://www.he-alert.org/en/all-issues.cfm Bound editions of Issues 1 to 12 and 13 to 21 can be purchased From the Nautical Institute Publications Shop at: http://www.nautinst.org/en/shop/ The Alert! Videos are 4min films that can be viewed online or downloaded to a PC or Mobile device, aimed at anyone with an interest in the Maritime Human Element Each video corresponds to one of the first 21 editions of the award winning Alert! Bulletins downloadable from: http://www.he-alert.org/en/videos.cfm