STEVE HARDING REDUCING HUMAN ERROR MAIN HEAD Blame seafarers for their mistakes DECK HEAD Blaming seafarers for maritime accidents, "human error," is rather pointless, Steve Harding explains BODY In the film of the same name, the self-righteous parents of South Park join in a song that: 'Blames Canada, with all its hockey hubbabaloo' for the fact that their children - Kyle, Stan, Cartman and Kenny - are the devil incarnate. A satire, of course, but like all good satire rather closer to the truth than many would ever dare to admit, not least the shipping establishment who, to a man (and they are nearly all men!), will unite as one to pillory the seafarer whenever a ship generates bad publicity. While it is a policy beloved of minor-league politicians, notably here in Europe, demonizing seafarers takes the debate on shipping safety nowhere. Nor do the equally pointless, but routine statements from officials along the lines of: '80% of all accidents at sea are due to the human factor'. Unless monkeys are now responsible for the design and construction of ships, all accidents at sea come down to some form of human fallibility. Nonetheless, what cannot be denied is individual human error is invariably a significant contributory influence on most, if not all shipping incidents. Maintaining the risk of human error as low as reasonably practicable is, therefore, a key paradigm to be resolved. But how? SUBHEAD Procedures Traditionally human errors are prevented through the implementation of a technology or prescriptive procedure that places barriers or interlocks in a system to physically stop the operator making a catastrophic decision, e.g., setting a railway signal to green before the points for the intended line are set. However, this is not so easy when dealing with 'fuzzy' issues like compliance with the collision regulations at sea; ask two maritime experts to offer an opinion and expect to receive at least three different interpretations of the rules. And, as previously mentioned in more than one of these articles, inappropriate human factors technology can actually make matters far worse. Returning to the Battle of Jutland, the following is an extract from a British battleship's procedures for extracting munitions from the magazine: Cannot move loading lever to "open Bottom Flash Door" unless both hopper doors are closed; cannot put loading lever to "Ram" until bottom flash door is fully open; cannot put loading lever to "Withdraw" until rammer has completed its stroke And so on, the list stretching to more than 50 items each telling the seafarer what he cannot do to perform his required task. With this procedure and the related interlocking technology in place it's unlikely any battleship would ever self-destruct. Mind you, there was also little risk the gunners would receive their shells, at least not quickly in a battle situation in accordance with training dating back to the days of Nelson. Simply to allow them to fulfil the task in the way that suited them, the seafarers on Royal Navy ships at Jutland smashed or otherwise disabled the interlocks with disastrous results. SUBHEAD Giving seafarers more freedom Returning to the here and now, collisions at sea due to seafarers' navigation failure continue to present a significant risk to life, property and the environment. Those with a specific interest in the subject are invited to refer to, amongst others, the website of the Nautical Institute (www.nautinst.org). In general terms, academia is increasingly adopting a more social science based approach towards improving this behaviour. That is, seeking to establish what makes the seafarer tick; what they are good at, thereafter adopting appropriate means to enhance these skills whilst curbing or otherwise controlling weakness as it is necessary to do so. In effect, allowing greater self-determination on the part of the seafarer rather than imposing unrealistic prescriptive controls. To coin a catchphrase from an advert, a case of: 'Yes you can' than the 'No you cannot' philosophy of the past. All of which sounds like a load of old psycho hubbabaloo. And to be fair, such thinking has yet to find much favour in the shipping establishment; it requires the adoption and acceptance of the viewpoint that the seafarer is the solution to improved safety at sea, not the problem. SUBHEAD Handheld chart displays Fortunately, and to quote from Lloyds List, while shipping regulators increasingly seek entropy, the real world continues to deliver practical solutions, including the enhancement of seafarer skills. One example is the recent development of small electronic information management devices for use by ship's crew in performing navigation-related tasks. In addition to displaying operating manuals and navigation publications, these can act as multi-function devices with an array of applications, including onboard surveillance, surface moving map, electronic messaging, and display of live weather. Some will even be fully installed systems with multiple functions to support all ship's navigation. As I'm not aware this technology has a name as such, lets call it the electronic chartroom or ECR. Because, quite simply, on one portable device the navigator can now perform all the tasks previously undertaken in the ship's chartroom. In reality ECRs are simply commercial off the shelf or COTS technology adapted for use at sea. Specifically, a notepad PC or similar with wi-fi (wireless) interface to a central database storing, and proactively collating through suitable communications links to shore the information required to navigate the ship. While I might question the use of 'Starbucks' (IEEE 802.11(b)) technology for the communications; you can do a lot better, nothing wrong with that I say. This may be contrary to popular belief on where I stand with respect to the use of new technology to deliver information to ships' navigators. SUBHEAD Situation awareness I'm no Luddite. Clearly any data that improves a seafarer's situation awareness (SA) should enhance safety at sea particularly as studies have shown that a large proportion of human error problems in the maritime domain can be can be labelled as "loss of SA". Indeed, this would exactly align with the philosophy to which I ascribe that greater self-determination is the only way of effectively managing safety at sea, and regulators should do everything in their power to deliver the tools that make it so. However, before sending the salesmen out to Piraeus to convince a sceptical industry that ECRs are the way forward, other studies reveal that one of the consequences of increasing technology levels on ships is actually a loss of SA. All very confusing! The reason for the dichotomy: In some cases, seafarers may rely too much on the automation and fail to check and monitor its performance; conversely, once supplied with new technology they may lose confidence in their own activities to perform the tasks manually, obviously defeating the purpose of automation in itself. In other words, if ECRs are to be beneficial they must align with, and be an enhancement to the seafarers' tasks as they are performed and not seek to impose an alien concept simply because it suits the technology or, worse, the supplier's gimmicky sales pitch. In short, true human factors considerations must be taken into account in the design and evaluation of ECRs. Fortunately, and to the dismay of IMO officialdom no doubt; a body never backwards in coming forwards to find a limp excuse for yet another Grand Tour in the name of standards development at someone else's expense - invariably the ship owner, much of this work has already been completed by the US Department of Transportation for Electronic Flight Bags or EFBs. You didn't think I coined the phrase 'ECR' just like that did you? Stick DOT-VNTSC-FAA-03-07 into 'Google' and you'll find the relevant document; be warned: it's 3.40 mb. This is an excellent reference source in my opinion. Certainly it provides essential guidance to anyone contemplating the development and application of ECRs, indeed any technology designed to enhance ships' navigators' SA. Nevertheless, a word (or two) of caution from the US DoT report to equipment suppliers and regulators alike: "It is often difficult to measure workload differences between tasks, particularly because workload is often shifted around by new technology rather than eliminated. "Designers and evaluators should be aware of workload tradeoffs. "They should ask how the workload is redistributed, and not just whether the workload is decreased or increased." (Section 2.1) SUBHEAD Task analysis Put another way, no technology, particularly navigation technology should ever be used at sea unless and until a full and detailed analysis has been performed to evaluate and understand its actual impact on the seafarer's tasks, because only through a task analysis is it possible to develop and implement design that effectively deals with the human factor. And what is a task analysis? It would take too long to describe here, but cutting straight to the quick, it's expensive and involves direct and detailed consultation with a wide range of seafarers on a wide range of ships observing what they actually do to complete tasks rather than what they should, perhaps, be doing; I've been involved with a number of task analysis studies in recent years. That's a lot of capital to tie up on what could well be a speculative build of equipment with a limited production run. Thus, one would like to think the maritime authorities would offer similar financial and other support to those developing ECRs that its aviation colleagues have obviously been giving to suppliers of EFBs, particularly the attention paid by the regulators to ensure the design of equipment used on aircraft is underpinned by the task analysis necessary to effectively address the human factor. Alas, if past record is any guide; and it usually is, I rather doubt it. Still, should ECRs ultimately prove to be a problem rather than a solution as a consequence of what would be, ultimately, a failure on the part of the regulator, no doubt those responsible can always blame the seafarer when, or if two ships collide. 1 HUMAN ERROR IN MARITIME OPERATIONS: ANALYSES OF ACCIDENT REPORTS USING THE LEXIMANCER TOOL, Michelle R. Grech, et al, University of Queensland 2 Grech, M., & Horberry, T. (2002). Human Error in Maritime Operations: Situation Awareness and Accident Reports. Paper presented at the 5th International Workshop on Human Error, Safety and Systems Development, Newcastle, Australia.