Human Factor and Organizational Issues

Human Factor and Organizational Issues
CONSTANTA MARITIME UNIVERSITY

(Course support)
Constanta
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Content
Introduction.................................................................................................................... 5
1. Human factor ............................................................................................................. 6
Types of human factors ............................................................................................ 6
Human factors engineering ....................................................................................... 8
Human factors engineering/ergonomics model: Elements that enhance
human performance and safety .............................................................................. 10
2. Human errors ........................................................................................................... 12
Human characteristics and the working environment ............................................. 12
Addressing human error ......................................................................................... 14
3. Human performance and limitations...................................................................... 18
Human process information .................................................................................... 18
The human senses ................................................................................................. 19
Memory and its limitations ...................................................................................... 20
Managing human performance limitations .............................................................. 21
4. Team development and teamwork ......................................................................... 23
Team types ............................................................................................................. 23
Team building ......................................................................................................... 24
5. Motivation................................................................................................................. 27
6. Task analysis ........................................................................................................... 30
Action oriented approaches .................................................................................... 30
Cognitive task analysis techniques ......................................................................... 33
Evaluation of Task Analysis Methods ..................................................................... 35
7. Vigilence, checking errors and error recovery ..................................................... 37
The error making process ....................................................................................... 37
The error recovery process ..................................................................................... 37
Team errors and Performance Shaping Factors ..................................................... 38
Shared errors and Performance Shaping Factors .................................................. 39
Failures to detect and Performance Shaping Factors ............................................. 41
Failures to indicate/correct and Performance Shaping Factors .............................. 41
Summary on Team Errors and Performance Shaping Factors ............................... 42
8. Fatigue and workload .............................................................................................. 44
9. Social factors - organizational and group level .................................................... 50
People, technology, environment and organizational factors .................................. 50
Human factors issues in the marine industry .......................................................... 53
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10. Safety culture and situational awareness ........................................................... 55
Safety culture .......................................................................................................... 55
Situational awareness ............................................................................................. 57
11. Human decision making ....................................................................................... 59
12. Comman styles and leadership ............................................................................ 65
13. Organizational issues............................................................................................ 71
14. Organizational change .......................................................................................... 73
Bibliography................................................................................................................. 79
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Introduction
Over the last 40 years or so, the shipping industry has focused on improving ship structure and
the reliability of ship systems in order to reduce casualties and increase efficiency and
productivity. Weve seen improvements in hull design, stability systems, propulsion systems,
and navigational equipment. Todays ship systems are technologically advanced and highly
reliable.
Yet, the maritime casualty rate is still high. It is because ship structure and system reliability are
a relatively small part of the safety equation. The maritime system is a people system, and
human errors figure prominently in casualty situations. About 75-96% of marine casualties are
caused, at least in part, by some form of human error. Studies have shown that human error
contributes to:
84-88% of tanker accidents
79% of towing vessel groundings
89-96% of collisions
75% of allisions
75% of fires and explosions
Therefore, if we want to make greater strides towards reducing marine casualties, we must begin
to focus on the types of human errors that cause casualties.
One way to identify the types of human errors relevant to the maritime industry is to study
marine accidents and determine how they happen. Accidents are not usually caused by a single
failure or mistake, but by the confluence of a whole series, or chain, of errors. In looking at how
accidents happen, it is usually possible to trace the development of an accident through a number
of discrete events.
A Dutch study of 100 marine casualties found that the number of causes per accident ranged
from 7 to 58, with a median of 23. Minor things go wrong or little mistakes are made which, in
and of themselves, may seem innocuous. However, sometimes when these seemingly minor
events converge, the result is a casualty. In the study, human error was found to contribute to 96
of the 100 accidents. In 93 of the accidents, multiple human errors were made, usually by two or
more people, each of whom made about two errors apiece. But here is the most important point:
every human error that was made was determined to be a necessary condition for the accident.
That means that if just one of those human errors had not occurred, the chain of events would
have been broken, and the accident would not have happened. Therefore, if we can find ways to
prevent some of these human errors, or at least increase the probability that such errors will be
noticed and corrected, we can achieve greater marine safety and fewer casualties.
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1. Human factors
1.1.
Types of human factors
The latest studies on human factors proposed three categories for human factors that contribute to
accidents in the offshore oil industry, including tanker operations: individual factors, group
factors, and organizational factors (in Figure 1.1). Other researchers focus on individual vs.
organizational causes.
Researchers have found that although the majority of immediate causes are attributable to
individuals (e.g. operating personnel), the majority of contributing, or underlying, factors can
be attributed to the organizational context or group dynamics that influence the individual.
Similarly, once an accident sequence has begun, organizational influences may allow the
sequence to continue, resulting in an accident. Therefore, the culture, incentives, operating
procedures, and policies of organizations have important effects on the safety of marine systems.
Figure 1.1. Human factors vs. human errors
Individual human factors. Although most researchers recognize the importance of the
organizational safety culture, the role of the individual operator is critical. The competence,
perceptual judgments, stress, motivation, and health risks (such as work over-load) of an
individual operator are critical to the chain of events that may cause an accident or oil
spill. Two of the most recognized and studied individual factors as related to the maritime
industry are described here: inadequate knowledge and fatigue.
Other individual factors. In some studies were contend that people are basically rational, but
their goals and risk attitude may not always match those of the organization, due to
policies that may inadvertently encourage undesirable behavior.
People typically act to receive awards and avoid negative consequences, but more
weight is generally given to potential negative consequences to themselves, such as being
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caught and punished, rather than how specific behaviors may contribute to catastrophic
accident risks. Production pressures, an organizational factor, may contribute to risk-taking
behaviors, because the potential for reward for high production may outweigh the consequences
of the worst-case scenario, especially for activities where that risk seems particularly remote.
Another component of individual human factors can be attributed to a lack of preparedness for
crises. Operators may be extremely proficient in routine day-to-day operations; however,
because crises occur so rarely and are not always well predicted, an operator may be poorly
prepared to deal with such an event.
Finally, people have a tendency to ignore information that is inconsistent with their beliefs until
it becomes irrefutable. This has been cited as a cause for unrealistic optimism in a variety
of industries where accident risks are characterized by uncertainty. Only when faced with
inevitable, catastrophic consequences do people acknowledge the potential for disaster, at
which point intervention may not be possible.
Figure 1 . 2 . Relationship between sleep loss, fatigue, and accidents
Inadequate knowledge. A United States National Research Council study cited inadequate
general technical knowledge as the cause of 35% of marine casualties: Mariners often do not
understand how the operation works or under what set of operating conditions it was designed to
work effectively.
In the same study, 78% of mariners ascribed a lack of understanding of the overall system
of the ships they work on as a contributing factor to accidents. Moving among different
sizes and types of vessels can cause confusion and compromise decision-making abilities if
mariners are not familiar with the ship-specific systems.
When people take actions that increase the risk of failure, it is often because they have
encountered a rare event that is not part of their training or general awareness, and they are
unaware of how their actions will affect the system or are unaware that they are contributing
to accident risk.
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Mariners are charged with making navigation decisions based on all available information.
Too often, we have a tendency to rely on either a favored piece of equipment or our memory.
Many casualties result from the failure to consult available information (such as that from
radar or an echo-sounder). In other cases, critical information may be lacking or incorrect,
leading to navigation errors (for example, bridge supports often are not marked, or buoys may
be off- station).
An human factors study by the United States Coast Guard identified the need for automated
design approaches that incorporate human factors into the design and use of automated systems,
so that operators will understand the concept of operations and form appropriate mental
models during initial learning and routine use. The integration of existing equipment and
skills with new systems, such as navigation electronics, was identified as especially important.
While not having adequate information may cause an individual to make an error, the fact that
he or she is not adequately trained for his or her position is reflective of an organizational human
factor - in this case, an organizational failure.
Group factors. At the group level, the relationships among individuals, the members of a
vessel crew, for example, or between a supervisor and subordinate, may influence safety.
Group factors may overlap with organizational factors, but in the marine oil transportation
industry, the dynamics at the group level, such as crews or duty sections, can be extremely
important to overall safety.
An important group factor for vessel operations is the atmosphere that exists within operational
units, such as a vessel crew. The maritime tradition of iron men on wooden ships has
been cited as a contributor to risk-taking behavior. Overconfidence or bravado may contribute
to actions that violate a companys stated safety policies. Pressure from the organization or
company to meet unrealistic demands with the number and qualifications of available personnel
may encourage irresponsible or risk-taking behavior as crew stretch to meet demands from
supervisors.
Reporting channels are also critical to safety considerations at the group level. Informal
communication channels can be as important as or more important than formal ones for
encouraging open and proactive communication of safety concerns. Direct communications
between operators can be a powerful source of organizational memory and can contribute
significantly to accident prevention, especially in regards to maintenance practices. In the
marine transportation industry, this kind of organizational knowledge is best realized onboard
vessels where crew members are retained long-term. With new crewmembers or trainees, it is
extremely important that their work be subject to diligent oversight and inspection, as close
supervision can have the dual benefits of educating employees while minimizing risks.
1.2.
Human factors engineering
Understanding human capabilities and limitations is a primary means to overcome opportunities

for human error. A significant amount of research has been conducted to identify the factors that
shape and influence human behavior and performance in a work environment. These factors
include such diverse issues as:
How the workplace is designed
Human-system interfaces (e.g., ease of use and accessibility)
How employees are selected for particular jobs (e.g., knowledge, skill, and ability
requirements)
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How job aids such as operational or maintenance manuals or procedures are written
and/or illustrated
Human-computer interaction
Physical, visual, and auditory access for maintenance and operation
How company policies and practices are presented to, and enforced on, the work force
Training personnel and a myriad of other human behavioral and psychosocial issues that
affect personnel performance.
The application of the results of this research to the design of tools, equipment, tasks,
workplaces, procedures, hardware, software, the working environment, and even to
company/organizational design, is known as Human Factors Engineering (HFE). Those who
practice in this discipline are called Human Factors Engineers, Human Factors Professionals, or
Ergonomists.
HFE is a unique and specialized engineering discipline that combines specific academic
education and experience of the humans behavioral (i.e., social, physiological, psychological)
and physical (i.e., size, strength, endurance) capabilities and limitations with that of the
traditional engineering requirements to produce a human-system interaction that maximizes the
best of both. This discipline allows for the human and system to work safely and efficiently.
HFE has broad areas of specialization and applicability. Therefore, for the purpose of these
Guidance Notes, the focus of HFE is a domain of specialization largely concerned with human
anatomical, anthropometric, physiological, behavioral, and biomechanical capabilities and
limitations as they relate to human activity and the human-technology environment.
There are several formal definitions of HFE, including the following by the International
Ergonomics Association:
The scientific discipline concerned with the understanding of the interactions among humans
and other elements of a system, and the profession that applies theory, principles, data, and
methods to design in order to optimize human well-being and overall system performance
Ergonomics, which is often synonymous with HFE in Europe, tends to focus on the
biomechanical, physiological, and anthropometric capabilities and limitations that humans
possess as they relate to the design of systems.
The general approach of HFE in mitigating human error in the workplace as a means to reduce
risk to human performance and safety is as follows (in order of preference):
Design the workplace so that human error cannot occur.
Design the workplace so that if an error does occur the consequences can be mitigated to
an acceptable level.
Provide training to prevent the error.
Provide hazard identification labels to warn personnel of possible hazard.
Write a procedure or create a company policy to attempt to prevent the error from
occurring. Proper design is the preferred approach, as it is the most preventative
measure to take for workplace design.
The driving force behind the inclusion of HFE in the design of any offshore installation is that
efficient and safe operational performance starts with good design. To conclude, integrating HFE
design practices and principles that reflect human capabilities and limitations into a design
project, as discussed in these Guidance Notes, will help result in installations that are more costeffective, safer, and easier to operate and maintain. The earlier that HFE is integrated into a
design cycle, the more cost-effective the HFE effort will become and the greater the potential
impact on overall business performance.
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1.3.
Human factors engineering/ergonomics model: Elements that enhance human

performance and safety
Figure 1.3 encapsulates four high-level elements that influence safety and efficiency in job
performance:
o vessel or offshore installation design and layout considerations,
o workplace ambient environmental elements,
o management and organizational issues related to operations, and
o the personnel who operate the vessel or offshore installation.
Insufficient attention to any of these elements may adversely affect safety, productivity, and
efficiency. It is important that these elements be at the core of any HFE implementation effort.
The structure and selection of activities described herein help promote this model and associated
elements.
Figure 1.3. Human factors engineering/ergonomics model
Management and organizational considerations. This aspect of the model covers management
and organizational considerations that impact human performance and safety throughout a
systems lifecycle. The implementation of an effective design and safety policy that includes
human factors engineering and ergonomics will help create an environment that helps to
minimize risks and reflects a good corporate safety culture for both system operations and to
personnel. The commitment of top management is essential if this policy is to succeed. This
commitment throughout the lifecycle means that it begins in early development with adequate
resources to address HFE in design as well as the policy and personnel management required
once the installation is operational.
A study performed by the University of California at Berkeley found that 80% of all offshore
accidents in U.S. waters were due to human error, and 80% of those occurred during operations.
In 1995, the USCG launched a major initiative, called Prevention-Through-People (PTP), to
reduce human error as a causative factor in maritime accidents when its research found that from
75-90% of all at-sea accidents were human-induced. This report also introduced the term
human element to describe those factors which cause or contribute to human error. The
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preceding statistics illustrate the importance of the management considerations and commitment
to implementing a comprehensive HFE program from inception through operations in order to
achieve the human performance and safety goals.
Design and layout considerations. Design and layout considerations include those related to the
interfaces between personnel (users, operators, maintainers) and equipment or systems.
Examples of interfaces include: controls, displays, alarms, video-display units, computer
workstations, labels, ladders, stairs, and overall workspace arrangement.
Designers and engineers should consider the ultimate users cultural, psychological, and
physiological capabilities, limitations, and needs that may impact work performance. In terms of
cultural and regional influences on personnels behavioral patterns and expectations, this
includes understanding that there are different cultural meanings with regard to color, control
movement compatibility, or that bulky clothing is needed when using equipment in cold weather.
As a result, hardware and software design, arrangement, and orientation must match the
associated characteristics and expectations of the users.
Awareness of potential physical differences (e.g., male/female, tall/short, Northern European
versus Southeast Asian) is required so that the design, arrangement, and orientation of the work
environment will reflect the full range of personnel given the characteristics of the users and the
required tasks.
The likelihood of human error may be increased if these factors are not considered in the
workplace design. Additional training, operations and maintenance manuals, and more detailed
written procedures cannot adequately compensate for human errors induced by poor design.
Ambient environment considerations. The ambient environment addresses the habitability and
occupational health characteristics related to human whole-body vibration, noise, indoor climate,
and lighting. Substandard physical working and living conditions can undermine effective
performance of duties, causing stress and fatigue. For example, working conditions that include
high noise workplaces may lead to ineffective voice communications. Ambient environmental
considerations also include the appropriate design of living spaces that assist in recovery from
fatigue.
Considerations related to people. Personnel readiness and fitness-for-duty are essential for
safety. These are especially important as tasks and equipment increase in complexity, requiring
ever-greater vigilance, skills, and experience. The following factors should be considered when
selecting personnel for a task:
Knowledge, skills, and abilities that stem from an individuals basic knowledge, general
or specialized training, and experience
Bodily dimensions (anthropometrics) and characteristics of personnel such as stature,
shoulder breadth, eye height, functional reach, overhead reach, weight, and strength
Physical stamina; physiological capabilities and limitations, such as resistance to and
freedom from fatigue, visual acuity, physical fitness, and endurance
Psychological characteristics, such as individual tendencies for risk-taking behavior, risk
tolerance, and resistance to psychological stress.
Choosing the correct personnel for the job or task is critical to overall safety and performance.
Selection of personnel who do not have the requisite skills, training, or tools can adversely affect
safety by reducing personnel efficiency and increasing the potential for error.
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2. Human errors
It has been estimated that up to 90% of all workplace accidents have human error as a cause1.
Human error was a factor in almost all the highly publicised accidents in recent memory,
including the capsizing of the Herald of Free Enterprise, Chernobyl and Three-Mile Island
incidents and the Challenger Shuttle disaster. In addition to these acute disasters some industries,
notably health-care, experience long-term, continuous exposure to human error. The costs in
terms of human life and money are high. Placing emphasis on reducing human error may help
reduce these costs.
2.1.
Human characteristics and the working environment
In order to address human factors in workplace safety settings, peoples capabilities and
limitations must first be understood. The modern working environment is very different to the
settings that humans have evolved to deal with. Below are provided details on the main factors
involved, including:
Attention - the modern workplace can overload human attention with enormous
amounts of information, far in excess of that encountered in the natural world. The way
in which we learn information can help reduce demands on our attention, but can
sometimes create further problems.
Perception - in order to interact safely with the world, we must correctly perceive it and
the dangers it holds. Work environments often challenge human perception systems and
information can be misinterpreted.
Memory - our capacity for remembering things and the methods we impose upon
ourselves to access information often put undue pressure on us. Increasing knowledge
about a subject or process allows us to retain more information relating to it.
Logical reasoning - failures in reasoning and decision making can have severe
implications for complex systems such as chemical plants, and for tasks like maintenance
and planning.
Attention. Attention on a task can only be sustained for a fairly short period of time, depending
on the specifications of the task. The usual figure cited is around 20 minutes, after which, fatigue
sets in and errors are more likely to occur. This is why air traffic controllers are obliged to take
breaks from their attention-intensive work at regular intervals. However, there are a number of
other reasons why the attentional system is responsible for errors. These include:
Information bottleneck it is only possible to pay attention to a small number of tasks at once.
For example, if an air traffic controller is focussed on handling a particular plane, then it is likely
that they will be less attentive to other aspects of safety, or other warning signals (although this
depends on the nature of the signal).
Habit forming - if a task is repeated often enough, we become able to do it without conscious
supervision, although this automatisation of regular and repetitive behaviour can force us into
mistakes.
Perception. Interpreting the senses - one of the biggest obstacles we face in perceiving the world
is that we are forced to interpret information we sense, rather than access it directly. The more
visual information available to the perceiver, the less likely it is that errors will be made. Bearing
this in mind, systems that include redundant information in their design may cause fewer
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accidents. An example of this was the change in electrical earth wire colour coding in the 1970s
to include not only colour, but also a striped pattern.
Signal detection - the more intense a stimulus (such as a light or a noise), the more powerful the
response elicited (such as brain activity or a physical movement). This has implications for the
way danger signals are perceived at work. For instance, the order in which the severity of danger
is signalled on rail tracks is single red (most dangerous), followed by single yellow, then double
yellow and finally green (no danger). Research suggests there may be some merit in swapping
the order of the yellow signals, as the double yellow is more intense and thus more noticeable
than the single yellow signal. However, this point must be offset against the fact that the current
system provides automatic mechanical failsafe if a yellow bulb blows, and the psychological
notion that double yellow serves a useful role as a countdown to the single.
Memory. Capacity - short-term memory has an extremely limited capacity. In general, people
can remember no more than around seven individual items at a time. This has safety implications
in areas such as giving new workers a set of instructions to follow from memory or attempting to
remember the correct sequence of procedures within a new task. However, trained individuals
are able to retain larger chunks of information in memory. For example, chess grandmasters can
remember the location of more pieces on a chessboard than can a novice because they see the
pieces not as single units, but as parts of larger conceptual units which form coherent wholes.
Accessibility - even when items are stored in memory, it is sometimes difficult to access them.
There has been much research into the ways in which recall of information can be improved. For
example, research has shown that people are much more likely to remember information if they
are in similar conditions to when they encoded the information. This was illustrated in a study
involving divers who were given lists of words to learn on dry land and underwater. Words
learned on the surface were best recalled on the surface, and those learned underwater best
recalled underwater. This has implications for training programmes, where albeit under less
extremely contrasting situations, staff trained in an office environment may not be able to
remember relevant details on the shop floor.
Levels of processing - another way in which information can be more reliably remembered is to
learn it at greater depth. For instance, if it is necessary to remember lists of medical symptoms,
then it helps to understand more about the conceptual framework behind the list. If only the
surface features (such as the words on the list) are remembered, then there is a higher chance of
information being forgotten.
Logical reasoning. Humans are not very good at thinking logically, but in technological
situations, logical procedures are often necessary (for example, troubleshooting a complex
system which has broken down). Illogical behaviour is a common source of error in industry.
During the Three Mile Island incident, two valves which should have been open were blocked
shut. The operators incorrectly deduced that they were in fact open, by making an illogical
assumption about the instrument display panel. The display for the valves in question merely
showed that they had been instructed to be opened, whereas the operators took this feedback as
an indication that they were actually open. Following this, all other signs of impending disaster
were misinterpreted with reference to the incorrect assumption, and many of the attempts to
reduce the danger were counterproductive, resulting in further core damage.
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2.2.
Addressing human error
The types of problems caused by these factors are often unavoidable. In certain situations,
human beings will always make mistakes, and there is a limit to what can be done to modify
behaviour itself.
As it is inevitable that errors will be made, the focus of error management is placed on reducing
the chance of these errors occurring and on minimising the impact of any errors that do occur. In
large-scale disasters, the oft-cited cause of human error is usually taken to be synonymous
with 'operator error' but a measure of responsibility often lies with system designers. For
instance, during the Second World War, designers attempted to introduce a new cockpit design
for Spitfire planes. During training, the new scheme worked well, but under the stressful
conditions of a dogfight, the pilots had a tendency to accidentally bail out. The problem was that
the designers had switched the positions of the trigger and ejector controls; in the heat of battle,
the stronger, older responses resurfaced.
Recent research has addressed the problem of how to design systems for improved safety. In
most safety-critical industries, a number of checks and controls are in place to minimise the
chance of errors occurring. For a disaster to occur, there must be a conjunction of oversights and
errors across all the different levels within an organisation. This is shown in the figure below
from which it is clear that the chances of an accident occurring can be made smaller by
narrowing the windows of accident opportunity at each stage of the process.
Factors such as training and competence assurance, management of fatigue-induced errors and
control of workload can eliminate some errors. But errors caused by human limitations and/or
environmental unpredictability are best reduced through improving system interface design and
safety culture.
System design. A good system should not allow people to make mistakes easily. This may sound
obvious, but all too commonly system design is carried out in the absence of feedback from its
potential users which increases the chance that the users will not be able to interact correctly
with the system. A set of design principles has been proposed which can minimise the potential
for error.
Accurate mental models. There is often a discrepancy between the state of a system and the
user's mental model of it. This common cause of erroneous behaviour arises because the user's
model of the system and the system itself will differ to some extent, since the user is rarely the
designer of the system. Problems that can arise as a result of this discrepancy are illustrated by
the Three Mile Island incident. In this incident, the system had been designed so that the display
showed whether the valves had been instructed to be open or closed. The most obvious
interpretation to the user was that the display reflected the actual status of the system.
Designers need to exploit the natural mappings between the system and the expectations and
intentions of the user.
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Figure 2.1. The Swiss cheese model of accident causation
Another example of the importance of user familiarity with the working system is demonstrated
by a laboratory study which examined how useful it was to give staff an overview of a fictitious
petrochemical plant's structure and day-to-day functioning. One group was given rules about
which buttons to press if a dangerous situation arose; another was given the rules and an
overview of the workings of the plant. Both groups were equal in their ability to deal with the
expected problems, but when new problems arose, only the group which understood the plant's
functioning were able to deal with the situation.
Managing information. As our brains are easily distracted and can overlook necessary tasks, it
makes sense to put information in the environment which will help us carry out complex tasks.
For example, omission of steps in maintenance tasks is cited as a substantial cause of nuclear
power plant incidents. When under time pressure, technicians are likely to forget to perform
tasks such as replacing nuts and bolts. A very simple solution to this problem would be to require
technicians to carry a hand-held computer with an interactive maintenance checklist which
specifically required the technician to acknowledge that certain stages of the job had been
completed. It could also provide information on task specifications if necessary. This would also
allow a reduction in paperwork and hence in time pressure.
Reducing complexity. Making the structure of tasks as simple as possible can avoid overloading
the psychological processes outlined previously. The more complex the task specifications, the
more chances for human error. Health-care systems are currently addressing this issue. With the
that a leading cause of medical error in the United States was related to errors in prescribing
drugs, a programme was undertaken to analyse and address the root causes of the problem. A
computerised system of drug selection and bar-coding reduced the load on memory and
knowledge on the part of the prescriber, and errors of interpretation on the part of the dispenser,
resulting in an overall reduction in prescription errors. Examples such as this emphasise the fact
that reducing task complexity reduces the chance of accidents.
Visibility. The user must be able to perceive what actions are possible in a system and
furthermore, what actions are desirable. This reduces demands on mental resources in choosing
between a range of possible actions. Perhaps even more important is good quality feedback
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which allows users to judge how effective their actions have been and what new state the system
is in as a result of those actions. An example of poor feedback occurred during the Three Mile
Island incident; a poorly-designed temperature gauge was consistently misread by experienced
operators (they read 285 degrees Fahrenheit as 235 degrees), which led them to underestimate
the severity of the situation.
Constraining behavior. If a system could prevent a user from performing any action which could
be dangerous, then no accidents would occur. However, the real world offers too complex an
environment for such a simplistic solution: in an industrial operation, a procedure which could be
beneficial at one stage in the process may be disastrous at another. Nevertheless, it is possible to
reduce human error by careful application of forcing functions. A good example of a forcing
function is found in the design of early cash machines. People used to insert their card, request
cash, take it and walk away, leaving their cash card behind. It was a natural enough response, as
the main objective of the action had been achieved: obtaining money. The task was thus mentally
marked as being complete before all necessary stages of the transaction had been carried out.
After a great deal of thought, the systems designers came up with a very simple solution which
has been effective ever since: as the target objective of the task was to obtain money, placing this
stage at the very end of the transaction would avoid the problem. Hence, the card is now given
back before the money is. Functions such as this relieve the user of the responsibility of deciding
what actions are appropriate whilst interacting with the system, and are very effective in
preventing dangerous incidents.
Design for errors. In safety-critical systems, such as nuclear power plants, numerous safety
systems are in place which can mitigate accidents. One approach is defence in depth
(implementing many independent systems simultaneously); another is fail-to safe state system
design. However, designers must assume that mistakes will occur, and so any useful system must
make provision for recovery from these errors. Another consideration is that the design should
make it difficult to enact non-reversible actions. Although this is an underlying principle of
design, it needs to be applied carefully. For instance, most home computers have a recycle bin
or trash folder, in which all deleted files are stored. They are recoverable from here, but when
this folder is emptied, files cannot be recovered at all. Attempts to empty this folder result in a
message asking the user to confirm deletion. The problem is that the user is often asked to
confirm such requests, and, learns to associate the appearance of the warning message with the
pressing of the 'OK' button.
The result is that the pop-up messages may not be read, and on occasion, files are accidentally
destroyed. A safer option would be to use this type of pop-up box less regularly, and to require
different user input each time.
Standardisation. When systems are necessarily complex but have been made as accessible and
easy to use as possible and errors are still being made, then standardisation is sometimes used as
an attempt to make the situation predictable. It has been suggested that medicine is one of the
areas most amenable to standardisation. For instance, resuscitation units in accident and
emergency hospitals vary considerably in their design and operation.
This diversity, coupled with the movement of staff between hospitals, mean that errors can be
made and delays occur. Another example where standardization might be of use in medicine is
across different brands of equipment, since staff often do not have training in all the available
designs. If all hospital equipment had standard placement and design, then all staff would be able
to locate and operate equipment with ease.
One problem with standardisation is that if any advances in design or usage are made, then it is a
very costly process to re-implement standardisation across all departments of an industry. Also, a
standardised system may be ideal for one set of tasks, but very inefficient for another set. Such
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practical considerations have tended to limit the application of standardisation as an approach for
reducing human errors.
User-centred design. Another basic principal of design is that it should be centred around the
user at all stages from initial conception, through evolution and testing, to implementation. In
practice however, systems designers are often given a brief, create the system and impose it upon
the users without appropriate feedback. This can result in unexpected system behaviour and
over-reliance on manuals which themselves have been written by the system designers from their
own perspective. Systems designed in this way will be opaque to the end user, and this can
hinder effective interaction. Designers of computer interfaces often fall into this trap.
Safety Culture. Attribution of accidents to human failures at the sharp end of an industry may
not provide a full picture of all the factors involved. The management of the organisation must
also take responsibility for decisions which affect the safe functioning of the organisation as a
whole. Unwise decisions at this level are more difficult to link directly to an accident, as they are
often implemented well before an accident occurs, and they do not make their presence urgently
felt. Good decisions at this level can create a culture of safety which can remove the precursor
conditions for accidents or ameliorate their consequences.
Safety Culture is a term that was first introduced after the Chernobyl disaster in 1986. The safety
culture of an organisation is the product of the individual and group values, attitudes,
competencies and patterns of behavior that determine the style and proficiency of an
organisations health and safety programmes. A positive safety culture is one in which shared
perceptions of the importance of safety and confidence in preventative measures are experienced
by all levels of an organisation.
According to the Health and Safety Executive (the statutory body that ensures that risks to health
and safety from work activities are properly controlled), factors that create this positive culture
include:
leadership and the commitment of the chief executive;
a good line management system for managing safety;
the involvement of all employees;
effective communication and understood/agreed goals;
good organisational learning/responsiveness to change;
manifest attention to workplace safety and health;
a questioning attitude and rigorous and prudent approach by all individuals.
If one or more of these factors is lacking, an organization may be prone to corner-cutting, poor
safety monitoring, and poor awareness of safety issues. In these settings, errors are common and
disasters more probable. Impoverished safety culture contributed to major incidents such as the
Herald of Free Enterprise disaster and a number of recent rail crashes. It has also been found that
workers in poor safety cultures have a macho attitude to breaking safety rules, and tend to
ascribe the responsibility of safety to others.
Human error is inevitable. Reducing accidents and minimising the consequences of accidents
that do occur is best achieved by learning from errors, rather than by attributing blame. Feeding
information from accidents, errors and near misses into design solutions and management
systems can drastically reduce the chances of future accidents. Hence, studying human error can
be a very powerful tool for preventing disaster.
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3. Human performance and limitations
To understand human performance fully, the way we attend to things, perceive, think, remember,
decide and act, we first need to understand how human beings process information, how we use
our brains. Operational personnel onboard make many decisions every day, and perform vital
safety-critical tasks. Information processing is fundamental to doing these effectively.
3.1.
Human process information
Human beings basically process information in five stages.

Stage 1: Gathering information. First we must gather information. We do this by using our
senses (sight, hearing, touch or smell) to collect information using our receptors, which
transform information into sensations. Stimuli can either originate from an external source such
as sound, or from an internal one, such as thirst or hunger.
Stage 2: Perception or assessment. Once we have gathered this information, we must make
sense of it. This involves perception and assessment, arguably the most important stage in the
whole process. Our brain gives the information an initial once-over to see whether it is
meaningful. At this point we must satisfy our human need to understand our environment. To do
so we rapidly create an internal model (like a pattern) with which we are comfortable. The
resulting model or pattern is influenced in two ways: by the raw sensory information we
perceive; and either by previous experience, or our current expectations. Here we are most
vulnerable to being fooled either by the information itself, or by our own expectations, our
eagerness to make the input fit what we have seen before. So, depending on our interpretation,
our brain takes preliminary steps to work out how the information is to be dealt with. If our brain
has seen it all before and it is commonplace, the information is directed via the automatic
program path. If the information is new or complex, our brain assigns it to the full conscious
evaluation/decision route.
Stage 3: Evaluation and decision making. If the information is complex or new, our brains will
deal with it by giving it full and conscious attention. We may make the decision immediately, or
store the information for a later decision. This will require the use of memory. Our initial
evaluation may show that the input is familiar, so we can deal with it using well-known
procedure or method that has worked before. Doing so will still require a small amount of our
conscious attention, but for the most part of our response is directed automatically. On the other
hand, our initial evaluation might be that this new information is complex or unfamiliar. When
this occurs, we have to think more deeply (apply significant cognitive resources) to resolve the
situation. Quite often this will require such a level of concentration and brainpower that our
ability to attend to other matters will be reduced or even disappear.
Stage 4: Action/response. Our action or response occurs either consciously, with full awareness,
or subconsciously using our automatic programs. If it is performed consciously, we act and/or
speak with full attention. If it is performed subconsciously, we act as if we are on automatic
pilot. Visualize an automatic task you can perform while doing other things, for example,
driving a car while maintaining a conversation. But if the driving task becomes more difficult,
such as attempting to parallel park in a particularly tight spot, our brain will revert to the 100 per
cent full-attention requirement, and we stop our conversation. So while we can do more than one
thing at a time, our brain is limited by being able to process only one thing at a time.
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Stage 5: Feedback. The final stage is feedback, which allows us to confirm that what we are
getting is what we are expecting. Feedback is not just a one-time deal. It occurs continuously
throughout the various stages of information processing to ensure the information we are
receiving continues to fit our expectations. The feedback stage provides the opportunity for:
Clarifying details of the information;
If need be, seeking out additional information;
Refining the information;
Making small or large corrections with our actions and/or responses;
Identifying emerging hazards.
The whole process is repeated as often as necessary, so that either the status quo is retrained, or
necessary changes are implemented. When performing any skilled task we continuously monitor
both environment and the consequences of our action to form a closed loop feedback system.
This provides us with valuable opportunities to assess both emerging errors and hazards.
Identifying errors in a timely manner means that corrections can be made, and ensures the action
continues as intended.
The mariners should have a basic awareness and understanding of how individuals process
information. This helps to better understand and accept error in ourselves and in others. This
understanding of information processing is particularly useful when analyzing errors, as it helps
us to determine whether they are the consequence of one, or a combination of, the following:
Deficiencies in receiving stimuli/information through our senses (not enough
information);
Deficiencies in perception/assessment of the information (not deciphering the
information accurately);
Deficiencies in the evaluation and decision-making processes;
Failure to monitor or respond to the feedback properly;
Effect of external factors detrimental to the process overall, such as excessive workload
or fatigue.
High workload, and periods with a high volume of information to be processes in a short
timeframe, can cause information overload. This may lead to degraded performance and an
increased likelihood of error.
3.2.
The human senses
Vision. Vision is vital in maritime activities, think of the number of activities under visual
supervision. Vision can be improved by ensuring you have appropriate environmental
conditions, like illumination of working area, and ensuring that protective eyeware is clear and
suitable for use when is necessary. An individuals lack of colour discrimination, or defective
color vision, may make it difficult to distinguish between red and green. This can lead to error in
tasks where color discrimination is necessary.
Hearing. Continuous exposure to high levels of noise can be very fatiguing. It affects cognitive
tasks such as memory recall. Whenever possible, you should try to remove or eliminate the
source of noise, rather than attempting to reduce it by such things as wearing ear protection. In
noisy environments, use appropriate communication headsets where possible, bearing in mind
that ear plugs and headsets may restrict you from hearing warnings from other team members, or
being aware of approaching hazards. If you are wearing headsets or ear defenders, exercise
caution and keep a very good lookout.
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Touch. Touch is a vital sensory input especially for engineers, as components are often fitted and
removed within very confined spaces, with limited visual cues. This means the engineer often
has to rely on feel when fitting and /or removing components. Working in a confined space also
increases the risk of error, because of reduced dexterity, lack of visibility, and limited space for
tools and lighting. These tasks may also require the use of extensive personal protective
equipment such as heavy gloves, which will reduce your sensitivity to touch.
3.3.
Memory and its limitations
Memory is the ability to store and retrieve information, and is part of our normal learning
process. It allows us to develop consistent responses to previously memorized data. We compare
sensory data so that we can decide what to do, based on our previous experiences. Because of
this, our memory stores are vital to the decision-making process. It is generally agreed we have
three types of memory: sensory memory, short-term memory, long-term memory.
Sensory memory. Our sensory memory only retains information for a second or two; for
example, an image or photograph may be retained briefly before it is overwritten by something
new.
Short-term memory. Our short-term memory allows us to store information long enough to use
it, hence why we often call it our working memory. Short-term memory holds information for
about 15-30 seconds. Information in short-term memory can be lost very quickly through
interference, distraction, or simply by being replaced with new information.
The short-term memory can be improved by:
Mental repetition one way to increase our ability to recall information from short-term
memory is to revise it regularly to keep it top-of-mind.
Chunking this involves putting gaps between, or grouping, three to four letters or digits.
Chunks are much easier to remember than a long, unbroken string.
Linking link the data from short-term memory to something you know from your longterm memory.
Record the data the best way to be able to ensure accurate recall from short-term
memory is to write information down for future reference.
Long-term memory. Our long-term memory enables us to store a vast amount of information. It
stores general information, factual knowledge, and memories of specific events. Long-term
memory is classified in two types, semantic memory and episodic memory.
Semantic memory. Semantic memory is our store of factual knowledge about the world, such as
learnt concepts and relationships. It does not relate to time and place, but rather refers to the rules
by which we understand the things around us. This type of memory involves knowledge
associated with data, skills, knowledge and things we are able to do for a purpose. It is our
memory for meaning. It is generally believed that once information has entered semantic
memory, it is never lost. Occasionally, it may be difficult to locate, but it is always there.
Episodic memory. Episodic memory refers to our store of events, places and times, and may
include people, objects, and places. It is almost automatic, allowing us to place our experiences
in context.
The improvement of the long-term memory can be done using:
Pre-active the knowledge think about the procedure before carrying it out. Go through
it in your mind and mentally rehearse the steps you are going to perform.
Use visual imagery to learn new information information can be remembered by
associating it with a familiar place or person. This might sound a little out there, but
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visual imagery is a powerful memory aid. In general, the weirder or more bizarre the
association, the more likely you are to remember it.
Use physical context you remember information better if you learn it in the actual place
in which you will apply this skills. This is why learning emergency evacuation drills is
better onboard than in the classroom, and why practicing techniques using a simulator is
more effective for knowledge transfer.
Ask questions do not just study material by re-reading it, but by asking yourself
questions, so the information is more deeply encoded. For example, under what
circumstances would I use this information? If I dont remember the information what
could happen?
Information processing characteristics. Our information processing system is essentially a
single pipeline where information goes in at one end; is processed sequentially; and eventually
comes out at the other end. The information is processed centrally and in the sequence it is
received. This means that high-priority or important information may not necessarily be
processed first. All processing of information uses part of our limited capacity, so we can easily
top out with information overload. In other words, we can take in only so much at any given
time. New information can easily replace old information, particularly if the information is held
in our short-term memory. Preoccupation, fatigue and stress can reduce information processing
capacity and therefore performance. We tend to be most reliable under moderate levels of
workload that do not change suddenly and unpredictably. When workload is excessive, the
likelihood of human errors is increased. High workload and times when a high volume of
information must be processed in a short time can cause performance to decrease dramatically.
3.4.
Managing human performance limitation
The senses can be affected by personal protective equipment, or by extremes of stimulus such as
low light or excessive noise. Before to begin any activity should consider how protective
equipment might affect whether you complete the task successfully.
Maritime activities require a reasonable standard of eyesight. To ensure good eye health, have
frequent eyesight checks. Colour discrimination is also important, especially if the tasks are to be
performed in low or poorly lit areas.
Colds, flu and ear infections can affect our hearing capability. Generally, we have poor control
over vestibular input. Use communication equipment such as headsets in noisy environments.
Continued exposure to very loud noise leads to fatigue and therefore a higher potential for error.
Our attention mechanism is limited, once its capacity is exceeded, performance will degrade. It is
important therefore, that physical and mental workloads are maintained within reasonable levels.
It can also be difficult to maintain attention for long periods on complex tasks. Think about
scheduling appropriate breaks during the task, and ensuring workload is maintained at an
appropriate level.
It is very easy for our perception to be fooled, for example through visual illusions. Our
assumptions can also lead us to an incorrect perception. One example of this is carrying out an
inspection. The person in charge is normally checking to ensure that everything is correct.
Because of this can sometimes see what expect to see. In reality, is expected to find something
wrong, rather than simply checking that everything is as expect it to be.
Effective decision making for seafarers starts with good situational awareness and a realistic
assessment of the data and/or feedback. The next step is evaluating your available options and
selecting and implementing the best/safest/most efficient option. This is not simply a one-off or
stand-alone process, but rather a continuous cycle involving the updating of situational
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awareness, the evaluation of the appropriateness (or otherwise) of the decision, and coming up
with, (and assessing) alternatives where necessary.
Because our memory is fallible, it is vital that we refer to the manuals/data etc. rather than
relying on recall from memory. This applies even if the information to be remembered or
recalled is relatively simple. If you are at all ensure of the memorized information, check it.
Noting something down temporarily can avoid the risk of forgetting, (or confusing) information,
but using personal notebooks to store this information long term is dangerous, as that data is not
amended and can rapidly become outdated. Use appropriate checklists to help with tasks
requiring a number of independent steps and mentally rehearse the task before you start, that will
help you recall its individual task elements.
There is more chance of making errors if the task involves new steps. Error can also result from
wrong perceptions of the available information or sensory input. To avoid this, carry out each
task as if it were the first time, and before you start the task, mentally rehearse procedures and
ask others how appropriate your plan is. If the task is difficult, or has an unusual and unexpected
outcome, stop and review the situation and, where necessary, ask for help or clarification.
Experience and regular supervision is also vital here in order to interpret feedback for personnel
with limited experience, or those under training. In some activities, incorrect actions or errors
may not give instant feedback. New tasks or incomplete feedback can lead to incorrect
interpretation. To assess the feedback you have received accurately, you need an internal
reference to a learnt standard.
For this reason, inexperienced personnel, or personnel under training, require high levels of
guidance and supervision, as they may not have the required store of experience in their longterm memory to accurately assess the feedback received. Take the time to evaluate all feedback
during a task, especially when the feedback is different to what is expected. Regrettably
feedback or poorly conducted activity may take the form of a catastrophic failure. Sometimes the
fault can lie dormant in the system for a considerable time.
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4. Team development and teamwork
Many researchers state the importance of well-functioning teamwork in managing risk and error.
A study conducted in maritime sector stated that the shipping industry is itself an error-inducing
system, because of its distinctive characteristics (i.e. the structure of the industry, international
regulations, economic pressure, and the social (hierarchical) organization on board the vessels).
The potential for change lies in the human relations, and in the importance of facilitating
teamwork. Teamwork is a crucial factor in affecting safe performance. The crew should be
trained to work as a team, and the equipment should be designed to maintain teamwork.
According to this study the key factors in teamwork that facilitates safety in the shipping
industry are monitoring, speaking up when necessary, sharing and checking the teams mental
models, and having a shared responsibility. But what constitutes a team, and what is teamwork?
In the literature an inconsistency in definitions and explanations of team and teamwork is
evident. One of the most common definitions of a team is:
two or more individuals with specified roles interacting adaptively, interdependently, and
dynamically toward a common and valued goal.
In addition, a team is often characterized as having heterogeneous and distributed expertise. A
team can also be a subgroup of a bigger team. Teamwork may be defined as a set of interrelated
thoughts, actions, and feelings of each team member that are needed to function as a team and
that combine to facilitate coordinated, adaptive performance and task objectives resulting in
value-added outcomes.
4.1.
Team types
Teams are complex in nature, and there is a lack of consensus around the typology of teams.
Some researchers proposed integrated teamwork skill dimensions, that is supposed to be
common for all types of teams. In general, previous research tends to share this focus on teams:
that there are factors common for all team types. This research does not distinguish between the
different types of work that teams perform, and act as if one common model is applicable for all.
However, there is reason to assume that there are different types of teams working within the
same organization or in different organizations and domains. Another study identified different
team types based on the kind of work and tasks the teams are engaged in. In different team types,
factors relevant for team performance will vary. Also was argued that there is a division between
team specific factors, team generic factors, task specific factors, and task generic factors. Team
and task generic factors are factors that can be applied across team types. Team and task specific
factors, on the other hand, depend on team type characteristics and team members.
The Big Five in teamwork Model. As previously mentioned, in different organizations there are
various types of tasks and teams. Nevertheless, was claimed that there are several common
features that facilitate teamwork across domains, team goals, and tasks. Based on this review
they derived the Big Five in Teamwork Model (Big Five model), a model that consists of five
core components of teamwork and three coordinating mechanisms (eight components). The three
coordinating mechanisms are necessary to get the optimal value of the core components.
The factors of teamwork in the Big Five model are team leadership, mutual performance
monitoring, backup behavior, adaptability and team orientation. The coordinating mechanisms
are shared mental models, mutual trust, and closed-loop communication. Some of these factors
are very similar to the factors important for safe teamwork in the shipping industry.
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The following are the definitions of the five factors in the Big Five model:
Team leadership: The ability to direct and coordinate the activities of other team
members, assess team performance, assign tasks, develop team knowledge, skills, and
abilities, motivate team members, plan and organize, and establish a positive
atmosphere.
Mutual performance monitoring: The ability to develop common understandings of
the team environment and apply appropriate task strategies to accurately monitor
teammate performance.
Backup behavior: The ability to anticipate other team members needs through
accurate knowledge about their responsibilities. This includes the ability to shift
workload among team members to achieve balance during high periods of workload or
pressure.
Adaptability: The ability to adjust strategies based on information from the
environment through the use of backup behavior and allocation of intrateam resources.
Altering a course of action or team repertoire in response to changing conditions
(internal or external).
Team orientation: The propensity to take others behavior into account during group
interaction and the belief in the importance of team goals over individual members
goals.
The definitions of the three coordinating mechanisms are as follows:
Shared mental models: An organizing knowledge structure of the relationships among
the task the team is engaged in and how the team members will interact.
Mutual trust: The shared belief that team members will perform their roles and protect
the interests of their teammates.
Closed-loop communication: The exchange of information between a sender and a
receiver irrespective of the medium.
In different studies was acknowledged that a teams engagement in the factors and the
coordinating mechanisms (components) will vary in different tasks as the teams get the
experience of working together over time. Nevertheless, they proposed that the coordinating
mechanisms will have minimal variance across team type or team task. Shared mental models
are considered especially important in teams experiencing stressful conditions. Also,
communication is invaluable in teamwork, particularly in complex environments, such as
emergency situations. However, this depends on the message being received and understood
correctly, hence the coordinating mechanism of closed-loop communication.
4.2.
Team building
With good team-building skills, you can unite employees around a common goal and generate
greater productivity. Without them, you limit yourself and the staff to the effort each individual
can make alone.
Team building is an ongoing process that helps a work group evolve into a cohesive unit. The
team members not only share expectations for accomplishing group tasks, but trust and support
one another and respect one another's individual differences. Your role as a team builder is to
lead your team toward cohesiveness and productivity. A team takes on a life of its own and you
have to regularly nurture and maintain it, just as you do for individual employees.
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Team building can lead to:
Good communications with participants as team members and individuals
Increased department productivity and creativity
Team members motivated to achieve goals
A climate of cooperation and collaborative problem-solving
Higher levels of job satisfaction and commitment
Higher levels of trust and support
Diverse co-workers working well together
Clear work objectives
Better operating policies and procedures
The first rule of team building is an obvious one: to lead a team effectively, you must first
establish your leadership with each team member. Remember that the most effective team
leaders build their relationships of trust and loyalty, rather than fear or the power of their
positions.
Consider each team member ideas as valuable. Remember that there is no such thing as a stupid
idea.
Be aware of team member unspoken feelings. Set an example to team members by being open
with them and sensitive to their moods and feelings.
Act as a harmonizing influence. Look for chances to mediate and resolve minor disputes; point
continually toward the team's higher goals.
Be clear when communicating. Be careful to clarify directives.
Encourage trust and cooperation among your team. Remember that the relationships team
members establish among themselves are every bit as important as those you establish with
them. As the team begins to take shape, pay close attention to the ways in which team members
work together and take steps to improve communication, cooperation, trust, and respect in those
relationships.
Encourage team members to share information. Emphasize the importance of each team
member's contribution and demonstrate how all of their jobs operate together to move the entire
team closer to its goal.
Delegate problem-solving tasks to the team. Let the team work on creative solutions together.
Facilitate communication. Remember that communication is the single most important factor in
successful teamwork. Facilitating communication does not mean holding meetings all the time.
Instead it means setting an example by remaining open to suggestions and concerns, by asking
questions and offering help, and by doing everything you can to avoid confusion in your own
communication.
Establish team values and goals - evaluate team performance. Be sure to talk with members
about the progress they are making toward established goals so that members get a sense both of
their success and of the challenges that lie ahead. Address teamwork in performance standards.
Discuss with your team:
o What do we really care about in performing our job?
o What does the word success mean to this team?
o What actions can we take to live up to our stated values?
Make sure that you have a clear idea of what you need to accomplish. That you know what
your standards for success are going to be; that you have established clear time frames; and that
team members understand their responsibilities.
Use consensus. Set objectives, solve problems, and plan for action. While it takes much longer
to establish consensus, this method ultimately provides better decisions and greater productivity
because it secures every team member commitment to all phases of the work.
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Set ground rules for the team. These are the norms that you and the team establish to ensure
efficiency and success. They can be simple directives (Team members are to be punctual for
meetings) or general guidelines (Every team member has the right to offer ideas and
suggestions), but you should make sure that the team creates these ground rules by consensus
and commits to them, both as a group and as individuals.
Establish a method for arriving at a consensus. You may want to conduct open debate about
the pros and cons of proposals, or establish research committees to investigate issues and deliver
reports.
Encourage listening and brainstorming. As supervisor, your first priority in creating consensus
is to stimulate debate. Remember that members are often afraid to disagree with one another and
that this fear can lead your team to make mediocre decisions. When you encourage debate you
inspire creativity and that's how you'll spur your team on to better results.
Establish the parameters of consensus-building sessions. Be sensitive to the frustration that can
mount when the team is not achieving consensus. At the outset of your meeting, establish time
limits, and work with the team to achieve consensus within those parameters. Watch out for false
consensus; if an agreement is struck too quickly, be careful to probe individual team members to
discover their real feelings about the proposed solution.
Symptoms that signal a need for team building:
Decreased productivity
Conflicts or hostility among staff members
Confusion about assignments, missed signals, and unclear relationships
Decisions misunderstood or not carried through properly
Apathy and lack of involvement
Lack of initiation, imagination, innovation; routine actions taken for solving complex
problems
Complaints of discrimination or favoritism
Ineffective staff meetings, low participation, minimally effective decisions
Negative reactions to the manager
Complaints about quality of service
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5. Motivation
In a specialized manner, motivation is mentioned as a factor influencing consumer decision

making, involvement and satisfaction. Motivation is also an underlying element to explore
reasons behind individual decision of participating in a group event on board ship.
The most common meaning of motivation is the reason or reasons one has for acting or
behaving in a particular way and the general desire or willingness of someone to do
something. The act of being motivated then can be described as being moved to do something.
However the definition does not differentiate between intrinsic or extrinsic motivation; intrinsic
being a motive born naturally from ones within, and extrinsic being the one originated outside
oneself. Simply, if one has intrinsic motivation to perform a certain act, the act itself would be
motivating. Then again, if one has extrinsic motivation, the end result would be the goal that
motivates one to act. Though neither of these motivation types indicates that either process or
goal will be the sole enjoyable aspect for the acting person.
In tourism research the more frequently used motivation theory is the push and pull-theory. It
was first introduced in 1977 and subsequently became most commonly used motivation theory in
related literature. Was argued that there are push factors, which are embodiment of intrinsic
needs to break off the stress or escape the routine. The pull factors then are those extrinsic
appealing features that pulls individual towards a certain place or activity. Additionally, was
stated that motivation and satisfaction are two factors, which should be observed jointly rather
than separately, emphasising on the relationship between the two items.
In addition to push and pull motivation theories, there are two psychological motivation
approaches, behavioural and cognitive approach, which are both commonly used in consumer
and psychology studies. In cognitive theories, motivation is the drive that individual has towards
reaching a final goal, based on certain information. Whereas in the behavioural schools drive
theories, a persons biological need produces unpleasant state of arousal: Individual wishes to
reduce the tension, and motivation is thus engendered.
The cognitive theories seem to relate to the pull motivation factor, which is external (extrinsic) to
the consumer and involves cognitive process of information analysis rather than action based on
deep emotions. The behavioural approach again resembles the effect of push factor, where one is
trying to break off or improve from the current state due to stress or other internally formed
needs.
Additionally, it can be detected that push motivation is largely internal (intrinsic) and drivebased. This perspective gives a justification for deeper consideration of motivation formation
process when making managerial decisions. In addition to making destinations more appealing
or creating a place for escape, company should examine the sources of information search
(cognitive theory) and possible internal needs of an individual to efficiently address his/her
possible demands.
One of the most well-known behavioural drive-motivation theories in the academic motivation
research is hierarchy of needs, which will be used here to elaborate push motivation further. In
indicated papers was stated that there are five basic need categories, which are hierarchical
towards each other. On the lowest level is the physiological needs followed by the need to feel
safe. Belongingness (or love) then tops the safety needs and it is followed by ego and selfactualisation needs, latter being the one on the top of the whole hierarchy. However it was stated
that this need hierarchy is not a comprehensive theory on motivation. Additionally was claimed
that multiple motivations could affect the behaviour of an individual, rather than a singular one.
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Though this hierarchy model is very rational, it has been criticised by many in academic fields.
Another researcher argued that self-actualisation is not a basic need by concept and was
identified the scarce amount of evidence existing for this type of hierarchy. In service
environment, it might be likely that some basic needs exist for the services. Additionally, though
the hierarchy is questioned, the theory still covers some basic needs of human nature, which can
be utilised to differentiate motivation factors.
Likewise, the pull motivation resembles cognitive schools expectancy theories, where expected
desirable outcomes pull out the behaviour rather than push it from within. More clearly, the pull
factors are motives aroused by the destination itself rather than being born within. Some of the
pull factors are scenic attractions, cultural and historical attributes, as well as climatic
characteristics. The push factors can be exempli gratia self-development, exploration and
improvement of kinship. These motivation factors can influence each other.
Figure 5.1. The motivational model for hedonic tourism
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A classical interpretation of push and pull-motivation theory is found in Figure 5.1, where push
factors are characterised as consumer dispositions, id est. internal needs, motives and drives. The
push factors are then described as marketing stimuli that refer to the factors external to the
consumer, which are advertising, destination and services.
Figure 5.2. Motivational dimensions
The two main motivational forces are approach (seeking) and avoidance (escape). Approach is
described to be seeking intrinsic rewards, and avoidance to be escaping surrounding
environments. The main aim of this model was to emphasise how it is ineffective to categorise
factors into reasons and benefits.
According to different researchers, it might be more sensible to analyse motivational factors and
their means ends, rather than sort them into rigid motivation groups. However the basic idea
behind theories is similar: They both declare tourism motivation as combination of two basic
factors, escaping life (push) and seeking experience (pull).
Moreover, there seems to be basic needs that push consumer to initiate decision-making process.
Therefore despite the stiff motivation classification, categorising motivational factors into push
or pull group might be beneficial for an overall understanding of consumer decision-making.
However to gain a more comprehensive view on the motivational factors, the categorisation
should integrate aspects from escaping and seeking, as well as cognitive and behavioural
motivation to make the analysis constructive.
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6. Task analysis
Task analysis is a fundamental methodology in the assessment and reduction of human error. A
wide variety of different task analysis methods exist, and it would be impracticable to describe
all these techniques here. Instead, the intention is to describe representative methodologies
applicable to different types of task.
The term Task Analysis can be applied very broadly to encompass a wide variety of human
factors techniques. Nearly all task analysis techniques provide, as a minimum, a description of
the observable aspects of operator behavior at various levels of detail, together with some
indications of the structure of the task. These will be referred to as action oriented approaches.
Other techniques focus on the mental processes which underlie observable behavior, e.g.
decision making and problem solving. These will be referred to as cognitive approaches.
Task Analysis methods can be used to eliminate the preconditions that give rise to errors before
they occur.
They can be used as an aid in the design stage of a new system, or the modification of an existing
system. They can also be used as part of an audit of an existing system.
Task analysis can also be used in a retrospective mode during the detailed investigation of major
incidents. The starting point of such an investigation must be the systematic description of the
way in which the task was actually carried out when the incident occurred. This may, of course,
differ from the prescribed way of performing the operation, and Task Analysis provides a means
of explicitly identifying such differences. Such comparisons are valuable in identifying the
immediate causes of an accident.
6.1.
Action oriented approaches
Hierarchical Task Analysis. Is a systematic method of describing how work is organized in

order to meet the overall objective of the job. It involves identifying in a top down fashion the
overall goal of the task, then the various sub-tasks and the conditions under which they should be
carried out to achieve that goal. In this way, complex planning tasks can be represented as a
hierarchy of operations - different things that people must do within a system and plans - the
conditions which are necessary to undertake these operations.
Hierarchical Task Analysis commences by stating the overall objective that the person has to
achieve. This is then redescribed into a set of sub-operations and the plan specifying when they
are carried out. The plan is an essential component of Hierarchical Task Analysis since it
describes the information sources that the worker must attend to, in order to signal the need for
various activities. Each sub-operation can be redescribed further if the analyst requires, again in
terms of other operations and plans.
The question of whether it is necessary to break down a particular operation to a finer level of
detail depends on whether the analyst believes that a significant error mode is likely to be
revealed by a more fine grained analysis. For example, the operation charge the reactor may be
an adequate level of description if the analyst believes that the likelihood of error is low, and/or
the consequences of error are not severe.
If the consequences of not waiting until the pressure had dropped were serious and/or omitting to
check the pressure was likely, then it would be necessary to break down the operation charge
reactor to its component steps. Unfortunately, until the analyst has broken down the operation
further, it is difficult to envision how a sub-operation at the next lower level of breakdown might
fail, and what the consequences of this failure might be.
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In practice, a consideration of the general quality of the PIFs (e.g. training, supervision,
procedures) in the situation being evaluated will give a good indication of the overall likelihood
of error in the specific operation being evaluated. Similarly, the consequences of errors can be
evaluated in terms of the overall vulnerability to human error of the subsystem under
consideration.
By considering these factors together, it is usually obvious where the analysis should be
terminated. Differing levels of detail may be necessary for different purposes, e.g. risk analysis,
training specification or procedures design.
There are two main ways for representing a Hierarchical Task Analysis description: the
diagrammatic and tabular format.
Diagrams are more easily assimilated but tables often are more thorough because detailed notes
can be added.
Advantages of Hierarchical Task Analysis:
Hierarchical Task Analysis is an economical method of gathering and organizing
information since the hierarchical description needs only to be developed up to the point
where it is needed for the purposes of the analysis.
The hierarchical structure of Hierarchical Task Analysis enables the analyst to focus on
crucial aspects of the task which can have an impact on plant safety.
When used as an input to design, Hierarchical Task Analysis allows functional objectives
to be specified at the higher levels of the analysis prior to final decisions being made
about the hardware. This is important when allocating functions between personnel and
automatic systems.
Hierarchical Task Analysis is best developed as a collaboration between the task analyst
and people involved in operations. Thus, the analyst develops the description of the task
in accordance with the perceptions of line personnel who are responsible for effective
operation of the system.
Hierarchical Task Analysis can be used as a starting point for using various error analysis
methods to examine the error potential in the performance of the required operations.
Disadvantages of Hierarchical Task Analysis:
o The analyst needs to develop a measure of skill in order to analyze the task effectively
since the technique is not a simple procedure that can be applied immediately. However,
the necessary skills can be acquired reasonably quickly through practice.
o Because Hierarchical Task Analysis has to be carried out in collaboration with workers,
supervisors and engineers, it entails commitment of time and effort from busy people
Operator Action Event Trees. Are tree-like diagrams which represent the sequence of various
decisions and actions that the operating team is expected to perform when confronted with a
particular process event. Any omissions of such decisions and actions can also be modeled
together with their consequences for plant safety.
Each task in the sequence is represented by a node in the tree structure. The possible outcomes of
the task are depicted as success or failure paths leading out of the node. This method of task
representation does not consider how alternative actions (errors of commission) could give rise
to other critical situations. To overcome such problems, separate OAETs must be constructed to
model each particular error of commission.
By visual inspection of an Operator Action Event Trees it is possible to identify the elements of a
task which are critical in responding to an initiating event. An important issue in the construction
of Operator Action Event Trees is the level of task breakdown. If the overall task is redescribed
to very small sub-tasks it might be difficult to gain insights from the Operator Action Event
Trees because it can become relatively unwieldy.
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Care should also be taken in the use of recovery factors, because these can exert a significant
effect. In general, recovery paths are appropriate where there is a specific mechanism to aid error
recovery i.e. an alarm, a supervising check, a routine walk round inspection and so on. While
Operator Action Event Trees are best used for the qualitative insights that are gained, they can
also be used as a basis for the quantitative assessment of human reliability. By assigning error
probabilities to each node of the event tree and then multiplying these probabilities, the
probability of each event state can be evaluated.
Advantages of Operator Action Event Trees:
The Operator Action Event Trees is a logical method of structuring information
concerning operator actions resulting from a particular initiating event.
Operator Action Event Trees help to identify those tasks which are important in
responding to particular initiating events.
Disadvantages of Operator Action Event Trees:
o The approach is not a satisfactory method of identifying mistaken intentions or diagnostic
errors.
o Operator Action Event Trees are best suited to represent errors of omission. The
important errors of commission (i.e. alternative actions which may be performed) are
difficult to include satisfactorily.
o No assistance is provided to guarantee that the data used in the modeling process is
complete and accurate. Therefore, the comprehensiveness of the final Operator Action
Event Trees will be a function of experience of the analyst (This criticism applies to all
HRA techniques).
o The Operator Action Event Trees approach does not address error reduction or make any
attempt to discover the root causes of the human errors represented.
Decision/action flow diagrams. These are flow charts which show the sequence of action steps
and questions to be considered in complex tasks which involve decision-making.
Decision/Action Flow Diagrams are similar to the flow charts used in computer program
development. Both charts are based on binary choice decisions and intervening operations. In
general, the binary decision logic in Decision/Action charts expedites communications through
the use of simple conventions and provides for easy translation of Decision/Action charts into
logic flow charts for computerized sections of the system.
Decision/Action charts can be learned easily and workers usually find them useful in formulating
for the analyst their mental plans which may involve decision-making, time-sharing, or complex
conditions and contingencies.
Decision/Action charts have only a single level of task description, and when complex tasks are
analyzed the diagrams become unwieldy and difficult to follow. Also, it is possible to lose sight
of the main objectives of the task. To this extent, HTA is more appropriate because the task can
be represented in varying degrees of detail and the analyst can get a useful overview of the main
objectives to be achieved during the performance of the task.
Although little training is required to learn the technique, Decision/Action charts should be
verified by different operators to ensure that a representative view of the decision task is
obtained.
Advantages of flow diagrams:
Decision/Action charts can be used to represent tasks which involve decision-making,
time-sharing, or complex conditions and contingencies.
Workers find it easy to express their work methods in terms of flow diagrams. This
representation can then provide input to other Task Analysis methods.
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They can be used to identify critical checks that the workers have to carry out to
complete a process control task.
For fault-diagnostic tasks, they can help the analyst to identify whether new staff
members make effective use of plant information.
Disadvantages of flow diagrams
o Decision/Action charts are linear descriptions of the task, and provide no information on
the hierarchy of goals and objectives that the worker is trying to achieve.
o For complex tasks, the diagrams can become unwieldy.
o They offer no guidance concerning whether or not a particular operation or decision
should be redescribed in more detail.
6.2.
Cognitive task analysis techniques
The task analysis techniques described in the previous section are mainly oriented towards
observable actions, although Hierarchical Task Analysis allows it to address functional
requirements as well as the specific actions that are required to satisfy these requirements.
Cognitive task analysis techniques attempt to address the underlying mental processes that give
rise to errors rather than the purely surface forms of the errors. This is particularly important
where the analysis is concerned with higher level mental functions such as diagnosis and
problem solving.
As plants become more automated, the job of the process plant worker is increasingly concerned
with these functions and it is therefore necessary to develop analytical methods that can address
these aspects of plant control. For example, the worker is often required to deal with abnormal
plant states which have not been anticipated by the designer. In the worst case, the worker may
be required to diagnose the nature of a problem under considerable time stress and develop a
strategy to handle the situation. It is clearly desirable in these situations to provide appropriate
decision support systems and training to improve the likelihood of successful intervention. It is
also necessary to be able to predict the types of decision errors that are likely to occur, in order to
assess the consequences of these failures for the safety of the plant. In all of these areas, task
analysis techniques which address the covert thinking processes, as opposed to observable
actions, are necessary.
The problems associated with the analysis of cognitive processes are much greater than with
action oriented task analysis methods. The causes of cognitive errors are less well understood
than action errors, and there is obviously very little observable activity involved in decision
making or problem solving. These difficulties have meant that very few formal methods of
cognitive task analysis are available.
Despite these difficulties, the issue of cognitive errors is sufficiently important that we will
describe some of the approaches that have been applied to systems. These techniques can be
used in both proactive and retrospective modes, to predict possible cognitive errors during
predictive risk assessments, or as part of an incident investigation.
Critical Action and Decision Evaluation Technique (CADET). This method is based on the
Rasmussen step ladder model. The basic units of CADET are the critical actions or decisions
(CADs) that need to be made by the operator usually in response to some developing abnormal
state of the plant. A CAD is defined in terms of its consequences. If a CAD fails, it will have a
significant effect on safety, production or availability.
The following approach is then used to analyze each CAD. The first stage consists of identifying
the CADs in the context of significant changes of state in the system being analyzed. The
approach differs from the OAET in that it does not confine itself to the required actions in
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response to critical system states, but is also concerned with the decision making which precedes
these actions.
Having identified the CADs that are likely to be associated with the situation being analyzed,
each CAD is then considered from the point of view of its constituent decision/action elements.
CADET can be used both to evaluate and to support human performance in terms of training
exercises.
The CADET technique can be applied both proactively and retrospectively. In its proactive
mode, it can be used to identify potential cognitive errors, which can then be used to help
generate failure scenarios arising from mistakes as well as slips. Errors arising from
misdiagnosis can be particularly serious, in that they are unlikely to be recovered. They also have
the potential to give rise to unplanned operator interventions based on a misunderstanding of the
situation. The technique can also be applied retrospectively to identify any cognitive errors
implicated in accidents.
The Influence Modelling and Assessment Systems (IMAS). Reference has already been made to
the difficulty of accessing the mental processes involved diagnosis and decision-making. We
can, however, be certain that success in these activities is likely to be dependent on the worker
having a correct understanding of the dynamics of what is likely to happen as an abnormal
situation develops. This is sometimes referred to as the workers mental model of the situation.
Knowledge of the mental model possessed by the operator can be extremely useful in predicting
possible diagnostic failures.
The IMAS technique is used to elicit Subjective Cause-Consequence Models (SCCM) of process
abnormalities from personnel, a SCCM is a graphical representation of the perceptions of the
operating team regarding:
The various alternative causes that could have given rise to the disturbance
The various consequences which could arise from the situation
Indications such as VDU displays, meters and chart recorders available in the control
room or on the plant that are associated with the various causes and consequences
A specific example of the Subjective Cause-Consequence Model derived by this approach is
given follows. This was developed for a process plant in which powders are transferred by a
rotary valve to a slurry mix vessel. Because of the flammable nature of the powders, they are
covered with a blanket of nitrogen. Any ingress of air into the system can give rise to a potential
fire hazard, and hence an oxygen analyzer is connected to the alarm system.
Because the system can only be entered wearing breathing apparatus, it is monitored via closed
circuit television (CCTV) cameras. The situation under consideration occurs when there is a
failure to transfer powder and the model represents the various causes of this situation and some
of the possible consequences. Any node in the network can be either a cause or a consequence,
depending on where it occurs in the causal chain. It can be seen that the various indicators (given
in square boxes) are associated with some, of the events that could occur in the situation.
The SCCM may be developed using the expertise of an individual or several workers in a team.
In developing the SCCM, the analyst begins at a specific point in a process disturbance (e.g. an
increase of pressure in a line), and asks the worker what the event stems from, leads to, or is
indicated by. Repeated applications of these questions produce a network of the mental model
of the operating team or the individual process worker. As can be seen, an event can stem from
more than one alternative cause, and lead to more than one outcome. The task of the worker is to
identify which of the alternative causes gave rise to the pattern of observed indicators.
Application of IMAS. One of the major problems in training personnel to acquire diagnostic skills
is the difficulty of knowing whether or not their understanding of process disturbances is
sufficiently comprehensive in terms of alternative causes and possible consequences. Elicitation
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of the SCCM at various stages of training enables the trainer to evaluate the development and
accuracy of the workers mental models of a range of process disturbances. A set of SCCMs
developed using experienced operational teams can be used as standards to define the knowledge
requirements to handle critical plant disturbances. Comparison of the trainees mental models
with these SCCMs will indicate where further training is required.
Since the SCCM explicitly identifies the information needed to identify the causes of
disturbances (and to distinguish between alternative causes), it can be used to specify the critical
variables that need to be readily available to the process controller at the interface.
This information can be used as an input to the design and upgrading of interfaces, particularly
when new technology is being installed.
6.3.
Evaluation of Task Analysis Methods
The Task Analysis methods described so far can be evaluated in terms of their focus on different
aspects of the human-machine interaction. To facilitate the process of selection of appropriate
Task Analysis methods for particular research interests, Figure 6.1 describes ten criteria for
method evaluation.
In general, HTA and CADET fulfill most of the ten criteria hence they can be used jointly as a
framework for carrying out both action and cognitive task analysis. Another way of classifying
the various Task Analysis methods is in terms of the application areas in which they might be
seen as most useful. Figure 6.2 provides such a classification in terms of seven human factors
applications.
It is worth pointing out that Figures 6.1 and 6.2 present only a broad qualitative classification
along a number of criteria. It is conceivable that some methods may fulfill a criterion to a greater
extent than others.
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Figure 6.1. Criteria for evaluating the sustainability of various Task Analysis methods
Figure 6.2. How to use various Task Analysis in Human Factors Applications
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7. Vigilence, checking errors and error recovery
7.1.
The error making process
Individual errors are errors which are made by individuals. That is, an individual alone makes
an error without the participation of any other team member. Individual errors may be further
sub-divided into independent errors and dependent errors. Independent errors occur when all
information available to the perpetrator is essentially correct. In dependent errors, however, some
part of this information is inappropriate, absent or incorrect so that the person makes an error
unsuitable for a certain situation.
Shared errors - are errors which are shared by some or all of the team members, regardless of
whether or not they were in direct communication. Like individual errors, shared errors may also
be sub-divided into two categories: independent and dependent.
Figure 7.1. Team error process
7.2.
The error recovery process
The error recovery process may fall into any one of three stages: detection, indication and
correction.
1. Failure to detect the first step in recovering errors is to detect their occurrence. If the
remainders of the team do not notice errors, they will have no chance to correct them. Actions
based on those errors will be executed.
2. Failure to indicate once detected, the recovery of an error will depend upon whether team
members bring it to the attention of the remainder. This is the second barrier to team error
making. An error that is detected but not indicated will not necessarily be recovered and the
actions based on those errors are likely to be executed.
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3. Failure to correct the last barrier is the actual correction of errors. Even if the remainder
of the team notices and indicates the errors, the people who made the errors may not change
their minds. If they do not correct the errors, the actions based on those errors will go
unchecked.
7.3.
Team errors and Performance Shaping Factors (PSFs)
Performance Shaping Factors and their estimation. The next question is why team errors are
made. An error is usually the result of some influencing factors which are called Performance
Shaping Factors.
Generally, there are two kinds of Performance Shaping Factors: External Performance Shaping
Factors and Internal Performance Shaping Factors. These to kinds are probably enough to
discuss why individuals made human errors. However, as described before, most human work is
performed by teams rather than individuals. Especially when the remainder of a team failed to
indicate or correct individual or shared errors in spite of their notices, there must have been
influences of human relations between them. For that, has identified three classes of Performance
Shaping Factors: external, internal and team performance shaping factors.
External Performance Shaping Factors are, for example, darkness, high temperature, excessive
humidity, high work requirement. These factors are shared by people working within the same
working environment.
Internal Performance Shaping Factors include high stress, excessive fatigue, deficiencies in
knowledge, skills and experience. There are ideas that the internal Performance Shaping Factors
are results of external Performance Shaping Factors. Although internal Performance Shaping
Factors are not necessarily independent of external Performance Shaping Factors, the adverse
impact of an external Performance Shaping Factors depends, in part, upon the individual.
Team Performance Shaping Factors are defines as factors arising from a group of people
working together on a common project or task. They include lack of communication,
inappropriate task allocation, excessive authority gradient, over-trusting and others. It could be
argued that team Performance Shaping Factors is a subset of internal Performance Shaping
Factors. However, it is believed that the purposes of this study are better served by treating them
as separate categories.
Relations between Performance Shaping Factors and Team Errors. In order to identify why
teams make team errors, it is probably best to see the relation to the categories defined earlier. As
describe above, the data have biases so that some categories are largely unrepresented.
Accordingly, we will focus upon the relations between Performance Shaping Factors and
individual errors, shared errors, failures to detect or failure to indicate and correct combined.
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7.4.
Shared errors and Performance Shaping Factors
External
Performance
Shaping Factors
Seriousness
Deficiency
in
human
machine interface
High workload
Deficiency in procedures
Deficiency in training
High level activity
Routine task
Regulation
Time pressure
Insufficient visibility
Others
Shared errors
Individual errors
21
24
20
16
9
9
6
6
3
3
3
4
7
19
8
7
4
0
0
4
2
24
Total
100(%)
100(%)
Table 7.1. . External Performance Shaping Factors observed in the shared and individual errors
Table 7.1 shows the external Performance Shaping Factors associated with shared errors and
individual errors. Major differences were not found between the external Performance Shaping
Factors provoking the shared and the individual errors. This table suggests that deficiencies in
the human machine interface exert a larger influence upon shared errors.
Shared errors and internal Performance Shaping Factors. Table 7.2 shows the internal
Performance Shaping Factors associated with shared errors and individual errors. Low
situational awareness, low task awareness and excessive adherence (on their own ideas, opinion,
decisions, actions)/over-reliance (on indicators, warnings) are observed more frequently in the
shared errors than in the individual errors.
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Internal Performance Shaping
Factors
Deficiency
in
knowledge/experience
High arousal
Low situational awareness
Low task awareness
Excessive
adherence/overreliance
Inadequate attitude
Low confidence
Others
Shared errors
Individual errors
22
21
20
16
17
22
6
8
13
3
3
2
4
18
6
19
Total
100(%)
100(%)
Table 7.2. Internal Performance Shaping Factors observed in the shared and individual errors
Shared errors and team Performance Shaping Factors
Team PSFs
Deficiency
in
communication
Excessive belief
Excessive professional
courtesy
Excessive
authority
gradient
Friendship
Deficiency
in
resource/task
management
Organizational factors
Subtotal
TOTAL
External PSFs
Seriousness
Deficiency in human
machine interface
High workload
Deficiency
in
procedures
Deficiency in training
High level activity
Routine task
Regulation
Time pressure
Insufficient visibility
Others
Subtotal
%
9
Internal PSFs
High arousal
7
Deficiency
in
6
knowledge/
7
experience
4
6
Low
situation
awareness
2
4
Low
task
2
awareness
4
Excessive
2
adherence/over2
2
reliance
1
1
Inadequate
1
attitude
1
Low confidence
1
Others
24
38
Subtotal
100%
Table 7.3. Team Performance Shaping Factors in the shared errors
%
9
9
7
6
4
1
1
1
38
Table 7.3. shows Performance Shaping Factors observed in the shared errors. Earlier, we argued
that shared errors are defined as errors shared by some or all members, regardless of whether or
not they were in direct communication. Therefore, we expected that the influences of team
Performance Shaping Factors observed in the shared errors are very small. Deficiencies in
communication and excessive belief have the equivalent percentages to some external and
internal Performance Shaping Factors.
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7.5.
Failures to detect and Performance Shaping Factors
External
%
Performance
Shaping Factors
Seriousness
8
High workload
5
Distance
4
Duty hours
4
Deficiency
in
training
1
Internal
Performance
Shaping Factors
High arousal
Low
task
awareness
Deficiency
in
knowledge/
experience
Team Performance %
Shaping Factors
11
Deficiency
in
communication
Excessive belief
Deficiency
in
resource/
task
management
Excessive authority
gradient
Excessive
professional courtesy
Over-trusting
Air of confidence
Friendship
Organizational
factors
Subtotal
14
9
9
6
5
5
4
2
1
Subtotal
22 Subtotal
23
55
TOTAL
100 %
Table 7.4. External, Internal and Team Performance Shaping Factors observed in team errors
with failure to detect
Table 7.4 lists observed Performance Shaping Factors surrounding the remainder of teams who
failed to detect errors. In most cases, the remainder of a team was in the common situation where
the people made errors. The analysis found some external and internal Performance Shaping
Factors which were found in shared and individual errors as well. The most common team PSF is
deficiency in communication.
7.6.
Failures to indicate/correct and Performance Shaping Factors
Table 7.5 lists the observed Performance Shaping Factors surrounding the remainder of teams
who detected errors but failed to indicate or correct them. This table does not show major
differences in external Performance Shaping Factors. Important differences in internal
Performance Shaping Factors were observed in this table. Low task awareness and low
situational awareness disappeared in the failures to indicate/correct and the ratio of high arousal
increased. This table suggests that arousal levels and low confidence make significant
contributions to the indication and correction of errors.
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External
%
Performance
Shaping Factors
Seriousness
15
Distance
5
Deficiency
in
training
5
Time pressure
5
High workload
2
Deficiency
in
procedures
2
Internal
Performance
Shaping Factors
High arousal
Low confidence
Team Performance Shaping %

Factors
9
2
Excessive authority gradient

Excessive
professional
courtesy
Deficiency in communication
Deficiency in resource/ task
management
Excessive belief
Air of confidence
Antipathy
24
9
9
7
2
2
2
Subtotal
34 Subtotal
11 Subtotal
55
TOTAL
100 %
Table 7.5. External, Internal and Team Performance Shaping Factors observed in team errors
with failures to indicate/correct
7.7.
Summary on Team Errors and Performance Shaping Factors
Figure 7.2. Team Errors and Performance Shaping Factors
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Figure 7.2. summarizes the relations between team errors and Performance Shaping Factors.
Shared errors are influenced by deficiencies in the human-machine interface, low task
awareness, low situational awareness and excessive adherence or over-reliance. Failures to detect
are influenced by deficiencies in communication, resource/task management, excessive authority
gradient and excessive belief. Failure to indicate/correct is influenced by excessive authority
gradient, excessive professional courtesy and deficiency in resource/task management.
Given the incomplete nature of the source material, it was not always possible to identify all
relevant factors. This analysis has revealed some interesting patterns, both with regard to the
nature of the errors that occur in teams and their recovery. It has established some relationships
between error types and performance shaping factors.
Working together creates many problems such as deficiencies in communication, resource/task
management, excessive authority gradient and excessive belief. Many of these problems have
their origins in deficiencies of responsibility. Understanding what is ones own responsibility and
what needs to be done may overcome other obstacles such as excessive authority gradient,
excessive professional courtesy and the like.
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8. Fatigue and workload
In a recent human factors study, the US Office of Marine Safety, Security and Environmental
Protection and the Office of Navigation Safety and Waterway Services found that fatigue was
among the top three causes of marine accidents.
In an Australian report that analyzes reporting methodologies and the relationship between
sleep, fatigue, and accidents in Incident at Sea Reports was found that 86% of the reports
analyzed made some reference to sleep, although many of these references described sleep loss
as a way of life onboard ships rather than as a direct causal factor. Thirty-nine per cent of the
reports considered sleeping or sleepiness as a contributing causal factor. The report noted
that accident investigators were able to identify sleep loss as a critical factor in cases where
there was a "frank-sleep" episode (e.g. watchstander fell asleep) but had a harder time
identifying the more subtle deficiencies in cognition and judgment that resulted from
fragmented or deficient sleep. In the same study was developed a diagram to describe the
relationship between fatigue, sleep and accidents and recommended additional study to "identify
and quantify the manifestations of fatigue other than that of reduced alertness."
Although there is an emerging recognition that neurobiologically based sleepiness or fatigue
contributes to human error as a root cause of many accidents in industrialized, technologyrich societies, the concept of fatigue does not have a clear definition. Thus, prevalence data
are always dependent on the particular definition used.
The International Maritime Organization has, however, formulated a definition of fatigue in
which fatigue is conceptualized as a 'reduction in physical and/or mental capacity as the result
of physical, mental, or emotional exertion which may impair nearly all physical abilities
including: strength, speed, reaction time, coordination, decision making or balance'. The
International Maritime Organization thus acknowledges the relation between fatigue and
human error as indicated above.
Fatigue can be divided into categories in many different ways. However, systematic studies
seem to find between three and five dimensions, including general fatigue (tired, bushed,
exhausted), mental fatigue (cognitive impairment), physical fatigue, and sleepiness (tendency
to fall asleep), and sometimes motivation or lack of activity.
The distinction between acute fatigue and cumulative or chronic fatigue may be an
interesting one with regard to prevention. Acute fatigue is limited to the effects of a single
duty period, such as a 9 to 5 hours working day, which may result in a micro sleep (just
being away for a split second) or actually falling asleep. Cumulative fatigue occurs when
there is inadequate recovery between these duty periods. Thus, cumulative fatigue usually
presents a picture of day-to-day changes for the worse. It is clear that causal factors as well as
preventive measures may be very different, dependent on the type of fatigue. In order to
actually fall asleep, one often is chronically fatigued and has accumulated a sleep deficit
over time. Chronic fatigue therefore, is considered to be a precursor of acute fatigue, but
environmental factors may additionally be important. Falling asleep will occur sooner when
the tasks and working conditions are dull, monotonous, and when the temperature is high.
On the other hand, it is unlikely to fall asleep in a hectic environment, and when a lot of
activity takes place. Ergonomic equipment, machines and software that is designed according
to ergonomic standards may also limit negative consequences when the seafarers behavior is
impaired due to fatigue.
The situation of managing chronic fatigue is quite different from that of managing acute
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fatigue. Having a wide set of risk factors like long working hours, working at night, high
job demands, the noise on board or in the cabin, and social relations at work, managing or
reducing risks by managing work-related risks may be one solution. Additionally personal
characteristics and life may have its impact on the individual resulting in fatigue. Particularly
Chronic fatigue may not only result from quite a different set of predictors, but may result in
quite a different set of preventive measures as well. Preventing the accumulation of fatigue
over time can deal with working schedules, the quality of the sleeping cabins, the social
relations on board, the demands (e.g. number of tasks) imposed upon a person and the
autonomy to handle these demands, as well as with procedures on how to deal with alcohol
(consumption) on board or with other kinds of organizational measures.
The operational impact of seafarers on their circadian rhythm, which also is an important
ingredient of fatigue, particularly where it is not aligned with the day-night cycle of these
seafarers, may have an important effect on both their acute and chronic fatigue. Its effects are
familiar to anyone who has suffered jet lag.
The model used to look at fatigue in this study distinguishes three levels of fatigue (see also
Figure 8.1):
Work load: the factors causing fatigue at work of seafarers/nautical personnel.
Consequences for the coping capacity, life style, sleep quality and fatigue.
Effects on performance, behavior, human error collisions and groundings.
Within these three levels the relation between work load and coping capacity (of the
individual) constitutes an important role. The relation between work load and coping
capacity determines how heavy the job is, and the risk of chronic fatigue to occur.
With respect to the work load it is important to distinguish between four work load areas:
physical load, the environmental load, mental load and perceptual load (Figure 8.1).
Task demands
Health consequence

Physical
Environmental
Mental
Perceptual
Coping capacity
Health problems
Life style
Concentration
problems
Fatigue
Effect on
performance/behavior
Mistakes
Fires
Occupational
accidents
Collisions/
groundings
Figure 8.1. The three level model of fatigue
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Every work load area distinguishes several work load aspects. In total 27 different aspects are
discriminated (as is stated in Table 8.1).
Physical load
Environmental load
Mental load
Perceptual load
Energetic load
Lifting
Carrying
Pushing
Pulling
Static load
Repetitive
movements
Skin
Smell, type of material
Sensation temperature
Hearing damage, noise
Vibration
protective,
clothing, safety means
Aggression
Tension
Human suffering
Time pressure
Irregular/continuous work
Uncomplete job
Short cycled tasks
Decision latitude/
autonomy
Opportunities for contact
Alertness
Perception
Concentration
Assessment
Reaction time
Table 8.1. Four work load areas with different aspects
Causes of fatigue. According to a report published in 2004, the causes of collisions and
groundings can be classified into three categories:
Watch keeping: no proper Look Out, or sailing too speedy.
Navigation: improper preparation of the journey, improper organization at the
bridge.
The manning system: No Look Out, fatigue.
With respect to the causes of fatigue, the International Maritime Organization adopts a much
broader view, and states that: It must be recognized that the seafarer is a captive of the work
environment. Firstly, the average seafarer spends between three to six months working and
living away from home, on a moving vessel that is subject to unpredictable environment
factors (i.e. weather conditions). Secondly, while serving on board the vessel, there is no
clear separation between work and recreation. Thirdly, todays crew is composed of
seafarers from various nationalities and backgrounds who are expected to work and live
together for long periods of time. All these aspects present a unique combination of potential
causes of fatigue.
Additionally, the majority of ships now spend less than 24 hours in port. Time in port was
traditionally a time for crews to rest ashore prior to leaving port. In many cases crews are
now expected to unload/load a vessel, prepare the vessel to sail and then sail the vessel from
port all within a very short time frame. Demands for quick turnaround times for ships in port,
combined with inadequate crew levels, clearly have the potential to present a significant
fatigue risk for crews, particularly those who have been engaged in loading and unloading
duties.
In a recent study was stated that in comparison to other freight transportation modes, merchant
shipping is characterized by longer than average working weeks, non-standard 'work days',
extensive night operations, and periods of intense effort, pre- ceded by periods of relative
inactivity. They arrange the causes of fatigue in this trade into:
Organizational factors (relating to how ships are managed, crew continuity, work
rules, paperwork etc.).
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Voyage and scheduling factors (e.g. dependent on the frequency of port calls).
Ship-design factors (e.g. level of automation).
Physical environment (this factor mainly deals with the weather conditions).
Quite concrete contributing causes to fatigue increase they reported are:
Inflexible work-rules creating imbalanced workloads/work-rules requiring
unnecessary time on duty.
Lack of port-relief crews and/or incompetent relief.
Lack of understanding procedures and tasks requiring retraining during voyage.
Burdensome and unnecessary paperwork.
Officers with poor people management skills, and tolerance for unfit personnel,
which is an encouragement of interpersonal conflict.
Tolerance of substitute-abuse problems.
Poor morale. High personnel turnover; with new personnel, resulting in a lot of
training on sea seems.
The schedules, often with short stay for rest at harbours (<24 hours), its
unpredictability, long working times.
Long periods of duty involving personnel with cargo operations.
Low level of automation of the system, resulting in all kinds of additional problems.
Additionally, the Dutch Shipping Inspectorate indicates that the administrative burden on
board has increased, despite the fact that some procedures are intended to increase safety on
board (e.g. ISM-code, and the ISPS-code). This results in increased audits, mainly by other
organization than the Shipping Inspectorate. Examples of organizations that increasingly
audit are vetting companies, ports & harbours and certifying organization. Increased audits
results in increased workload, more working hours, and less time for sleep. All this may
consequently result in increased fatigue.
The Maritime Accidents Investigation Branch Bridge Watching Study has reviewed in detail
the evidence of 66 collisions, near collisions, groundings and contacts for a period of 10
years (who met special selection criteria) that were investigated by the Branch. It concluded
that minimal manning, consisting of a master and a chief officer as the only two
watchkeeping officers on vessels operating around the UK coastline, leads to watchkeeper
fatigue and the inability of the master to fulfill his duties, which, in turn, frequently lead to
accidents. It was also found that standards of lookout in general are poor, and late detection or
failure to detect small vessels is a factor in many collisions. The study concludes that the
current provisions of STCW 95 in respect of safe manning, hours of work and lookout are
not effective.
The situation as reported in the studies above all results in the common causes of fatigue
known to seafarers, which are lack of sleep, poor quality of rest, stress and excessive
workload.
Little is known about the direct or intermediate consequences of these causes of fatigue in
relation to sleeping problems of seafarers. A study commissioned by the Health and Safety
Executive (HSE) in the United Kingdom on sleeping problems compared seafarers (555
persons), installation workers in the offshore (385 persons) and onshore workers (68 persons).
There were some differences between the seafarers and installations workers, but more than
50% of the seafarers and 44% of the offshore installation said they needed 2-3 days to adjust
after their work period. Over 50% of the installation workers feel the amount of sleep they
obtain offshore to be less than adequate. Perhaps most interestingly, the proportion of
seafarers reporting dissatisfaction related to insufficient sleep is lower than in either the other
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two groups (i.e. offshore installation workers and onshore workers), particularly as they are
more likely to experience split sleep. Seafarers do, however report least to have adequate rest
(29%) and adequate sleep (78%; as opposed to 54% and 85% in the offshore installation
workers, and 56% and 90% in the onshore workers respectively).
Fatigue role in maritime accidents. According with a Dutch study made on a period of 9 years,
studied in total a number of 191 collisions and groundings, results a number of 43 cases produced
by fatigues. A selection was made of cases: took place at short sea (excluding accidents with
fishing and passenger vessels); were related to human factors, and were classified as a collision
or grounding (so no fires or occupational accidents on board were included).
In 13 of these 43 cases (30%) fatigue was identified as (sometimes one of the) casual factor. For all
43 cases the type of shift system could only be identified in 53% of the cases. In three of these
cases different shift systems were used at sea as compared to the harbor situation. In the latter
case a three-shift system (4-hours-on-8-hours-off) was the case when at sea, whereas a twoshift system (6-hours-on-6-hours-off) was the case in the harbor (see Table 8.2).
In those cases where it was clear what shift system was used the two and three-shift
systems occurred almost equally often (Table 8.2). In those cases where fatigue (or fallen
asleep) was reported as one of the cause of the accident, and when it was clear which shift
system was used, 5 (out of 13) cases were related to fatigue in the two-shift system, whereas
only 2 cases were related to fatigue in the three-shift system. Although these findings appear
to favor the three-shift system above the two-shift system on fatigue related to collisions and
groundings, the differences as found on these shift systems is based on too few cases to be
significant.
Total number of Groundings

and
groundings and collisions
where
collisions
fatigue is perceived
to be a cause
13
5
15
2
Two-shift system
Three-shift system
Differences of shift system according to job at
sea-versus-in harbor
3
Shift system unknown
12
6
Total
43
13
Table 8.2. An overview of the two and three shift system and the attribution
of fatigue as a cause of the maritime accidents
Issues that came forward in those 13 cases where fatigue played a role were no mandatory
look-out, falling asleep/being absent for a while, no watch alarm was set, and no proper
navigation. Alcohol was involved on several of these occasions as well.
Other aspects that played a (causal) part in the collisions and groundings studied were:
no proper preparation of the voyage;
no proper manning of the bridge;
no proper outlook;
not a proper navigation;
insufficient communication with other ships;
too high speed at restricted view.
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In some of the above mentioned cases a pilot was on board of one of the ships. In these cases it
is often the bridge organization that was the problem like unclear agreement as to the division
of tasks and the route to follow, the master/crew who put too much confidence in the pilot and
left the pilot on his own, no communication with other ships and harbor control, and a wrong
assessment of the situation by the pilot.
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9. Social factors organizational and group level
9.1.
People, technology, environment and organizational factors
The maritime system is a people system (Figure 9.1). People interact with technology, the
environment, and organizational factors. Sometimes the weak link is with the people
themselves; but more often the weak link is the way that technological, environmental, or
organizational factors influence the way people perform. Lets look at each of these factors.
Environment
Technology
Organization
Figure 9.1. The Maritime System is a People System
First, the people. In the maritime system this could include the ships crew, pilots, dock
workers, Vessel Traffic Service operators, and others. The performance of these people will be
dependent on many traits, both innate and learned (Figure 9.2).
As human beings, we all have certain abilities and limitations. For example, human beings are
great at pattern discrimination and recognition. There isnt a machine in the world that can
interpret a radar screen as well as a trained human being can. On the other hand, we are fairly
limited in our memory capacity and in our ability to calculate numbers quickly and accurately-machines can do a much better job. In addition to these inborn characteristics, human
performance is also influenced by the knowledge and skills we have acquired, as well as by
internal regulators such as motivation and alertness.
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K n o w le d g e
S k ills
A b ilitie s
M e m o ry
M o tiv a tio n
A le r tn e s s
Figure 9.2. The Maritime System: People
The design of technology can have a big impact on how people perform (Figure 9.3). For
example, people come in certain sizes and have limited strength. So when a piece of equipment
meant to be used outside is designed with data entry keys that are too small and too close
together to be operated by a gloved hand, or if a cutoff valve is positioned out of easy reach,
these designs will have a detrimental effect on performance. Automation is often designed
without much thought to the information that the user needs to access. Critical information is
sometimes either not displayed at all or else displayed in a manner which is not easy to interpret.
Such designs can lead to inadequate comprehension of the state of the system and to poor
decision making.
Anthropometry
Reach, strength, agility
Equipment layout
Perception &
comprehension
Information display
Decision-making
Maintenance
Safety & performance
Figure 9.3. The Maritime System: Effect of Technology on People
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The environment affects performance, too (Figure 9.4). By environment we are including not
only weather and other aspects of the physical work environment (such as lighting, noise, and
temperature), but also the regulatory and economic climates. The physical work environment
directly affects ones ability to perform. For example, the human body performs best in a fairly
restricted temperature range. Performance will be degraded at temperatures outside that range,
and fail altogether in extreme temperatures. High sea states and ship vibrations can affect
locomotion and manual dexterity, as well as cause stress and fatigue. Tight economic conditions
can increase the probability of risk-taking (e.g., making schedule at all costs).
Temperature, noise
Sea state, vibration
Regulations
Economics
Physical and mental

performance
Fatigue
Risk-taking
Figure 9.4. The Maritime System: Effect of Environment on People
Finally, organizational factors, both crew organization and company policies, affect human
performance (Figure 9.5). Crew size and training decisions directly affect crew workload and
their capabilities to perform safely and effectively. A strict hierarchical command structure can
inhibit effective teamwork, whereas free, interactive communications can enhance it. Work
schedules which do not provide the individual with regular and sufficient sleep time produce
fatigue. Company policies with respect to meeting schedules and working safely will directly
influence the degree of risk-taking behavior and operational safety.
As you can see, while human errors are all too often blamed on inattention or mistakes on
the part of the operator, more often than not they are symptomatic of deeper and more
complicated problems in the total maritime system. Human errors are generally caused by
technologies, environments, and organizations which are incompatible in some way with optimal
human performance. These incompatible factors set up the human operator to make mistakes.
So what is to be done to solve this problem? Traditionally, management has tried either to cajole
or threaten its personnel into not making errors, as though proper motivation could somehow
overcome inborn human limitations. In other words, the human has been expected to adapt to
the system. This does not work. Instead, what needs to be done is to adapt the system to the
human.
The discipline of human factors is devoted to understanding human capabilities and limitations,
and to applying this information to design equipment, work environments, procedures, and
policies that are compatible with human abilities. In this way we can design technology,
environments, and organizations which will work with people to enhance their performance,
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instead of working against people and degrading their performance. This kind of humancentered approach (that is, adapting the system to the human) has many benefits, including
increased efficiency and effectiveness, decreased errors and accidents, decreased training costs,
decreased personnel injuries and lost time, and increased morale.
W o rk s c h e d u le s
F a tig u e
C re w c o m p le m e n t
K n o w le d g e & s k ills
T ra in in g
W o rk p ra c tic e s
C o m m u n ic a tio n
T e a m w o rk
S a fe ty c u ltu re
R is k -ta k in g
Figure 9.5. The Maritime System: Effect of Organization on People
9.2.
Human factors issues in the marine industry
What are some of the most important human factors challenges facing the maritime industry
today? A study by the United States Coast Guard found many areas where the industry can
improve safety and performance through the application of human factors principles. The three
largest problems were fatigue, inadequate communication and coordination between pilot and
bridge crew, and inadequate technical knowledge (especially of radar). Below are summaries of
these and other human factors areas that need to be improved in order to prevent casualties.
Fatigue. Fatigue has been cited as the number one concern of mariners in two different
studies. A new study has objectively substantiated these anecdotal fears: in a study of critical
vessel casualties and personnel injuries, it was found that fatigue contributed to 16% of the
vessel casualties and 33% of the injuries. More information on fatigue and how to prevent or
reduce it can be found in subsequent chapters in this book.
Inadequate Communications. Another area for improvement is communications between
shipmates, between masters and pilots, ship-to-ship, and ship-to-VTS. Is stated that 70% of
major marine collisions and allisions occurred while a State or federal pilot was directing one or
both vessels. Better procedures and training can be designed to promote better communications
and coordination on and between vessels. Bridge Resource Management (BRM) is a first step
towards improvement.
Inadequate General Technical Knowledge. In one study, this problem was responsible for 35%
of casualties. The main contributor to this category was a lack of knowledge of the proper use of
technology, such as radar. Mariners often do not understand how the automation works or under
what set of operating conditions it was designed to work effectively. The unfortunate result is
that mariners sometimes make errors in using the equipment or depend on a piece of equipment
when they should be getting information from alternate sources.
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Inadequate Knowledge of Own Ship Systems. A frequent contributing factor to marine
casualties is inadequate knowledge of own ship operations and equipment. Several studies and
casualty reports have warned of the difficulties encountered by crews and pilots who are
constantly working on ships of different sizes, with different equipment, and carrying different
cargoes. The lack of ship-specific knowledge was cited as a problem by 78% of the mariners
surveyed. A combination of better training, standardized equipment design, and an overhaul of
the present method of assigning crew to ships can help solve this problem.
Poor Design of Automation. One challenge is to improve the design of shipboard automation.
Poor design pervades almost all shipboard automation, leading to collisions from
misinterpretation of radar displays, oil spills from poorly designed overfill devices, and allisions
due to poor design of bow thrusters. Poor equipment design was cited as a causal factor in onethird of major marine casualties. The fix is relatively simple: equipment designers need to
consider how a given piece of equipment will support the mariners task and how that piece of
equipment will fit into the entire equipment suite used by the mariner. Human factors
engineering methods and principles are in routine use in other industries to ensure humancentered equipment design and evaluation. The maritime industry needs to follow suit. This
topic is discussed further in a subsequent chapter.
Decisions Based on Inadequate Information. Mariners are charged with making navigation
decisions based on all available information. Too often, we have a tendency to rely on either a
favored piece of equipment or our memory. Many casualties result from the failure to consult
available information (such as that from radar or an echo-sounder). In other cases, critical
information may be lacking or incorrect, leading to navigation errors (for example, bridge
supports often are not marked, or buoys may be off-station).
Faulty standards, policies, or practices. This is an oft-cited category and covers a variety of
problems. Included in this category is the lack of available, precise, written, and comprehensible
operational procedures aboard ship (if something goes wrong, and if a well-written manual is not
immediately available, a correct and timely response is much less likely). Other problems in this
category include management policies which encourage risk-taking (like pressure to meet
schedules at all costs) and the lack of consistent traffic rules from port to port.
Poor maintenance. Published reports and survey results expressed concern regarding the poor
maintenance of ships. Poor maintenance can result in a dangerous work environment, lack of
working backup systems, and crew fatigue from the need to make emergency repairs. Poor
maintenance is also a leading cause of fires and explosions.
Hazardous natural environment. The marine environment is not a forgiving one. Currents,
winds, and fog make for treacherous working conditions. When we fail to incorporate these
factors into the design of our ships and equipment, and when we fail to adjust our operations
based on hazardous environmental conditions, we are at greater risk for casualties.
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10. Safety culture and situational awareness
10.1.
Safety culture
Since organizational errors and failures are cited as important components of human factors,
prevention measures that seek to improve both individual and organizational attitudes and
policies toward safety are considered an important component of spill prevention. The term
safety culture has been used to describe an organizational environment that promotes selfregulation by ensuring that each individual within the organization takes responsibility for
actions to improve safety and performance. This requires active support and encouragement at
all levels of an organization, from the very top management levels down to the equipment
operators.
A major initiative, known as Prevention through people, has been implemented to address
human factors in oil spills and accidents and promote a safety culture within companies and
across the industry. According to the United Stated Coast Guard, Prevention through people is
a people - focused approach to marine safety and environmental protection that
systematically addresses the root cause of most accidents: the human element.
This approach recognizes that safe and profitable operations require the constant and balanced
interaction between the management, the work environment, the behavior of people, and the
appropriate technology. People through people itself promotes a cultural change within a
company to improve their safety posture.
Importance of management and organizational factors. In a study of safety culture and
accidents the authors consider the relative importance of accident prevention measures that
influence individual behavior vs. organizational culture and find that improvements to the safety
culture at the organizational level lead to more significant reductions in accident occurrence
rates and severity.
In order to counter the phenomenon of iron men, organizations must be attuned to the
attitudes onboard vessels, which can be difficult due to physical distance and separation.
Informal reward systems for safe behavior and negative consequences for risk-taking can help to
overcome at least part of the iron men culture. Social approval or disapproval of peers is a
powerful contributor to human behavior; however, it requires significant and ongoing efforts on
the part of organizations to affect such an informal rewards system.
A safety culture can be enhanced if management reacts to accidents by considering the
organizational policies, both overt and implied, that may have contributed to the operator errors.
Similarly, when management sets time or budget constraints, they must consider whether
operators may be inadvertently encouraged to cut corners or violate safety policies in order to
meet those constraints. Productivity and safety often conflict in the short term; therefore,
organizations should offer active incentives that back up stated safety policies.
In the study of organizational safety across industries, researchers have considered high
reliability organizations, which are defined as organizations that are involved in dangerous
operations, such that failure in the operation results in severe consequences. High reliability
organizations have, over long periods of time, had very few accidents.
Five attributes have been identified that characterize high reliability organizations: process
auditing; appropriate reward systems; high standards of quality; appropriate risk perception; and
command and control functions. These principals generally align with the findings regarding
safety cultures.
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In order for organizations to improve safety, they must learn from past mistakes. This can
be accomplished through several channels, such as describing past accidents in safety bulletins
and at safety meetings, and highlighting safety recommendations from past incidents. New
employees should be exposed to reports from past incidents, and the company should maintain
readily accessible data regarding accident investigation data from past incidents.
Interventions at the individual and group levels. The major human factors that influence
accidents within the marine industry at the individual level are fatigue and inadequate
knowledge. At the group level, communications among group members and group dynamics
tend to influence human errors and influence accident causes. Interventions that target these
problems can be challenging to design, implement, and audit.
One challenge in predicting and managing human performance is that, when time or
performance constraints are particularly tight, people tend to cut corners in ways that are
difficult to predict. Tight production schedules or quotas may lead people to circumvent or
improvise safety procedures, or to take high-risk short cuts. In some cases, the people taking
these actions are unaware of the potential short or long-term impacts to overall safety.
Individual behavior can be influenced through organizational and group-level safety policies
that involve operators in risk assessment processes and that explicitly address cutting corners
and other short cuts. Specific directives (e.g. instructions from a supervisor) have been
shown to have a more significant effect on human performance than general policies.
To prevent accidents caused by inadequate knowledge, organizations must either ensure that
their operators have a sufficient knowledge base to solve problems effectively, or provide
sufficient procedural guidance and oversight to prevent errors or lapses in judgment. Some
contributors offer that, The trade-off between productivity and safety can be managed either by
extremely competent employees who are given wide latitude, or by less experienced people and
strict rules and regulations. The problem with the latter is that rules and regulations
rarely foresee all possible consequences; therefore, it is important to build in sufficient
oversight to ensure that operators of complex systems are adhering to the rules and regulations.
Regulatory requirements for manning, qualifications, and licensing are useful to ensure a
minimum skill set and knowledge base for individuals filling a particular crew position. In a
human factors study, the USCG found a general need for procedures to ensure adequate training
and manning levels on ships. Inadequate knowledge can often be a function of too many job
tasks for one crewmember, which is a byproduct of insufficient manning. The USCG
recommends regular testing, training, evaluation programs, and a task-based approach to work
requirements for determining manning levels and safe operation.
Significant effort has been made to develop programs and policies that address the major
individual human factor fatigue. At its 20th session, the IMO Assembly adopted a resolution
outlining the human element vision, principles and goals for the organization. The resolution
included a component that addressed fatigue factors in manning and safety. The fatigue factor
initiative aimed at increasing awareness of the complexity of fatigue and encourages all parties
involved in ship operations to take these factors into account when making operational decisions.
Crew endurance management seeks to improve work and rest environments onboard ships to
maximize the amount and quality of restorative sleep that crewmembers receive and to integrate
other lifestyle factors, such as good diet and nutrition and adequate air quality, which has been
found to significantly influence fatigue. However, the major contributor to crew fatigue on
vessels is the watchstanding schedule. Typical watches on many vessels run 6-on, 6-off, which
means that two watchstanders alternate every six-hour period. The problem with this schedule is
that the 6-off period rarely involves uninterrupted sleep, as crew members have other aggregate
duties to address, as well as eating, relaxing, and taking care of personal business. The actual
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amount of sleep realized by most crewmembers on a 6-on, 6-off schedule may be significantly
less than needed.
The People through people program recommends that 7-7-5-5 or, preferably, 8-8-4-4 watch
systems be used to promote better rest patterns for watchstanders. Under these systems,
watchstanders have one long (7 or 8 hours) and one short (5 or 4 hours) watch, separated by one
long (7 or 8 hours) and one short (5 or 4 hours) rest period, which allows more time for crew
members to rest within each 24-hour period. Vessels that have experimented with the 8-8-4-4
system report generally positive feedback from crewmembers and improved alertness among
watchstanders.
In the marine industry (and in aviation), group factors are often addressed through crew
resource management programs, which address the interactions between crewmembers as they
impact safety systems. These programs focus on the interactions among crewmembers on the
flight deck or ships bridge, to improve communications and teamwork.
In aviation industry studies conducted in the 1970s, crew factors found to affect safety
performance include the attitudes of the team toward communication and coordination,
command responsibility, and recognition of stressor effects. Members of crews with low
accident occurrences were found to have a clear understanding not only of their own roles and
responsibilities but also those of other team members. Crews with low accident rates tend to
promote a climate of openness where junior crewmembers are able to assert their opinions and
challenge poor decisions on the part of the captain.
An United States Coast Guard human factors study found that communications systems were
critical to addressing human factors at
the group level. The study recommends that
improvements in person-to-person and equipment-to- person communications will reduce
confusion and reduce other documented problems on vessels, such as overcrowding on radio
channels.
Regular and ongoing emergency training is also essential to accident prevention. Likewise, a
clear chain of authority is critical during an emergency, and it must be clear to all employees
when a switch to crisis mode from day-to-day operations is necessitated.
10.2.
Situational awareness
The simple view about situational awareness is that it basically involves paying attention to your
surroundings. Commentators on the subject suggest that having good situational awareness
allows us to respond faster to changing circumstances, by knowing what is going on around us
and predicting how things will change.
From the maritime perspective, can define situational awareness as:
the accurate perception of the factors and conditions affecting the safe operation of the ship,
now and in the future.
Developing situational awareness. To develop situational awareness throughout a task, involved
personnel must:
Start off with a full and accurate knowledge of the situation and the environmental status;
Consider what they intend to do, and in particular, how appropriate that is in the given
circumstances;
Think about how what they intend to do will affect or change the environment and other
personnel working around.
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Maintaining situational awareness. Once you have an adequate level of situational awareness,
the challenge is to maintain it. We maintain our situational awareness through constantly
comparing the facts with our understanding. Effective communication allows for the continual
update of understanding and the ability to check this understanding against up-to-date
information. It is also the best tool to check individuals understanding against that of others, an
essential for identifying degraded situational awareness (between individuals and teams).
When something going wrong, must act immediately, like:
Stop and review your actions
Think about how your actions may be affecting the current system status (for yourself
and others around you);
Consider the possible adverse consequences of continuing.
Loss of, or degraded, situational awareness has been a major factor in many incidents and
accidents. How do you know when your situational awareness is degraded? Here are some
common clues:
Ambiguity or confusion
Narrowing of task focus
Reduced frequency of, or poor, communication
Feeling rushed
Unexpected results
Increasing anxiety
Use of undocumented procedures
Violations.
Distractions, unexpected events, and schedule pressure are all factors that reduce situational
awareness. Unfortunately, these are commonplace factors in maritime activities.
Recovering from a loss of situational awareness. Recovery from a loss of, or degraded,
situational awareness is vital to maintaining a safe operating environment. Recovering situational
awareness is a deliberate process involving checking and seeking information from other team
members, or someone independent of the task.
To recover from a degradation or breakdown in situational awareness, consider the following
strategies:
Communicate communicate the elements of confusion or discrepancy with others in the
team, or your immediate supervisor;
Request assistance this can be essential when conformation bias has greatly decreased
the ability to review the situation accurately;
Stop, and review your steps discussion should centre on the value of retracing steps to a
known good state of situational awareness. It can be
difficult to update your understanding while trying to
the task;
Debrief/discuss what happened lessons learnt provide valuable information to prevent
others from repeating the mistakes.
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11. Human decision making
Group decision-making (also known as collaborative decision-making) is a situation faced

when individuals collectively make a choice from the alternatives before them. The decision is
then no longer attributable to any single individual who is a member of the group. This is
because all the individuals and social group processes such as social influence contribute to the
outcome. The decisions made by groups are often different from those made by individuals.
Group polarization is one clear example: groups tend to make decisions that are more extreme
than those of its individual members, in the direction of the individual inclinations.
There is much debate as to whether this difference results in decisions that are better or worse.
According to the idea of synergy, decisions made collectively tend to be more effective than
decisions made by a single individual.
Factors that impact other social group behaviours also affect group decisions. For example,
groups high in cohesion, in combination with other antecedent conditions (e.g. ideological
homogeneity and insulation from dissenting opinions) have been noted to have a negative effect
on group decision-making and hence on group effectiveness. Moreover, when individuals make
decisions as part of a group, there is a tendency to exhibit a bias towards discussing shared
information (i.e. shared information bias), as opposed to unshared information.
Consensus decision-making. Tries to avoid "winners" and "losers". Consensus requires that a
majority approve a given course of action, but that the minority agree to go along with the course
of action. In other words, if the minority opposes the course of action, consensus requires that the
course of action be modified to remove objectionable features.
Consensus decision-making is a group decision-making process that seeks the consent of all
participants. Consensus may be defined professionally as an acceptable resolution, one that can
be supported, even if not the "favourite" of each individual. Consensus is defined as, first,
general agreement, and second, group solidarity of belief or sentiment. It has its origin in the
Latin word cnsnsus (agreement), which is from cnsenti meaning literally feel together. It is
used to describe both the decision and the process of reaching a decision. Consensus decisionmaking is thus concerned with the process of deliberating and finalizing a decision, and the
social and political effects of using this process.
As a decision-making process, consensus decision-making aims to be:
Agreement Seeking: A consensus decision making process attempts to help everyone get
what they need.
Collaborative: Participants contribute to a shared proposal and shape it into a decision
that meets the concerns of all group members as much as possible.
Cooperative: Participants in an effective consensus process should strive to reach the best
possible decision for the group and all of its members, rather than competing for personal
preferences.
Egalitarian: All members of a consensus decision-making body should be afforded, as
much as possible, equal input into the process. All members have the opportunity to
present, and amend proposals.
Inclusive: As many stakeholders as possible should be involved in the consensus
decision-making process.
Participatory: The consensus process should actively solicit the input and participation of
all decision-makers.
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Consensus decision making is an alternative to commonly practised adversarial decision making
processes. Proponents claim that outcomes of the consensus process include:
Better decisions: Through including the input of all stakeholders the resulting proposals
may better address all potential concerns.
Better implementation: A process that includes and respects all parties, and generates as
much agreement as possible sets the stage for greater cooperation in implementing the
resulting decisions.
Better group relationships: A cooperative, collaborative group atmosphere can foster
greater group cohesion and interpersonal connection.
The level of agreement necessary to finalize a decision is known as a decision rule. Possible
decision rules for consensus vary within the following range:
Unanimous agreement
Unanimous consent (See agreement vs consent below)
Unanimous agreement minus one vote or two votes
Unanimous consent minus one vote or two votes
Super majority thresholds (90%, 80%, 75%, two-thirds, and 60% are common).
Simple Majority
Executive committee decides
Person-in-charge decides
In groups that require unanimous agreement or consent (unanimity) to approve group decisions,
if any participant objects, they can block consensus according to the guidelines described below.
These groups use the term consensus to denote both the discussion process and the decision rule.
Other groups use a consensus process to generate as much agreement as possible, but allow
participants to finalize decisions with a decision rule that does not require unanimity. In this
case, someone who has a 'block' or strong objection must live with the decision.
Agreement vs. consent. Giving consent does not necessarily mean that the proposal being
considered is ones first choice. Group members can vote their consent to a proposal because
they choose to cooperate with the direction of the group, rather than insist on their personal
preference. Sometimes the vote on a proposal is framed, Is this proposal something you can live
with? This relaxed threshold for a yes vote can achieve full consent. This full consent, however,
does not mean that everyone is in full agreement. Consent must be 'genuine and cannot be
obtained by force, duress or fraud'.
Near-unanimous consensus. Healthy consensus decision-making processes usually encourage
and out dissent early, maximizing the chance of accommodating the views of all minorities.
Since unanimity may be difficult to achieve, especially in large groups, or unanimity may be the
result of coercion, fear, undue persuasive power or eloquence, inability to comprehend
alternatives, or plain impatience with the process of debate, consensus decision making bodies
may use an alternative benchmark of consensus. These include the following:
Unanimity minus one - requires all delegates but one to support the decision. The
individual dissenter cannot block the decision although he or she may be able to prolong
debate. The dissenter may be the ongoing monitor of the implications of the decision, and
their opinion of the outcome of the decision may be solicited at some future time.
Unanimity minus two - does not permit two individual delegates to block a decision and
tends to curtail debate with a lone dissenter more quickly. Dissenting pairs can present
alternate views of what is wrong with the decision under consideration. Pairs of delegates
can be empowered to find common ground that enables them to convince a third,
decision-blocking, decision-maker to join them. If the pair can't convince a third party to
join them, typically within a set time, their arguments are deemed unconvincing.
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Unanimity minus three - and other such systems recognize the ability of four or more
delegates to actively block a decision. Unanimity minus three and lesser degrees of
unanimity are usually lumped in with statistical measures of agreement, such as: 80%,
mean plus one sigma, two-thirds, or majority levels of agreement. Such measures usually
do not fit within the definition of consensus.
Consensus blocking and other forms of dissent. Groups that require unanimity allow individual
participants the option of blocking a group decision. This provision motivates a group to make
sure that all group members consent to any new proposal before it is adopted. Proper guidelines
for the use of this option, however, are important. The ethics of consensus decision making
encourage participants to place the good of the whole group above their own individual
preferences. When there is potential for a block to a group decision, both the group and
dissenters in the group are encouraged to collaborate until agreement can be reached. Simply
vetoing a decision is not considered a responsible use of consensus blocking. Some common
guidelines for the use of consensus blocking include:
Limiting the option to block consensus to issues that are fundamental to the groups
mission or potentially disastrous to the group.
Providing an option for those who do not support a proposal to stand aside rather than
block.
Requiring a block from two or more people to put a proposal aside.
Requiring the blocking party to supply an alternative proposal or a process for generating
one.
Limiting each persons option to block consensus to a handful of times in ones life.
Dissent options. When a participant does not support a proposal, he or she does not necessarily
need to block it. When a call for consensus on a motion is made, a dissenting delegate has one of
three options:
o Declare reservations: Group members who are willing to let a motion pass but desire to
register their concerns with the group may choose "declare reservations." If there are
significant reservations about a motion, the decision-making body may choose to modify
or re-word the proposal.
o Stand aside: A "stand aside" may be registered by a group member who has a "serious
personal disagreement" with a proposal, but is willing to let the motion pass. Although
stand asides do not halt a motion, it is often regarded as a strong "nay vote" and the
concerns of group members standing aside are usually addressed by modifications to the
proposal. Stand asides may also be registered by users who feel they are incapable of
adequately understanding or participating in the proposal.
o Block: Any group member may "block" a proposal. In most models, a single block is
sufficient to stop a proposal, although some measures of consensus may require more
than one block (see previous section, "Decision rules"). Blocks are generally considered
an extreme measureonly used when a member feels a proposal endanger[s] the
organization or its participants, or violate[s] the mission of the organization (i.e., a
principled objection). In some consensus models, a group member opposing a proposal
must work with its proponents to find a solution that works for everyone.
Consensus process. There are multiple stepwise models of how to make decisions by consensus.
They vary in the amount of detail the steps describe. They also vary depending on how decisions
are finalized. The basic model involves:
collaboratively generating a proposal,
identifying unsatisfied concerns, and then
modifying the proposal to generate as much agreement as possible.
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After a concerted attempt at generating full agreement, the group can then apply its final decision
rule to determine if the existing level of agreement is sufficient to finalize a decision.
Decision-making in social settings. Decision-making in groups is sometimes examined
separately as process and outcome. Process refers to the group interactions. Some relevant ideas
include coalitions among participants as well as influence and persuasion. The use of politics is
often judged negatively, but it is a useful way to approach problems when preferences among
actors are in conflict, when dependencies exist that cannot be avoided, when there are no superordinate authorities, and when the technical or scientific merit of the options is ambiguous.
In addition to the different processes involved in making decisions, group-decision support
systems (GDSSs) may have different decision rules. A decision rule is the GDSS protocol a
group uses to choose among scenario planning alternatives.
Gathering. Involves all participants acknowledging each other's needs and opinions and tends
towards a problem solving approach in which as many needs and opinions as possible can be
satisfied. It allows for multiple outcomes and does not require agreement from some for others to
act.
Sub-committee. Involves assigning responsibility for evaluation of a decision to a sub-set of a
larger group, which then comes back to the larger group with recommendations for action.
Sometimes a sub-committee includes those individuals most affected by a decision, although at
other times it is useful for the larger group to have a sub-committee that involves more neutral
participants.
Participatory. Each participant has a say that is directly proportional to the degree that particular
decision would affect him or her. Those not affected by a decision would have no say and those
exclusively affected by a decision would have full say. Likewise, those most affected would
have the most say while those least affected would have the least say.
Plurality and dictatorship are less desirable as decision rules because they do not require the
involvement of the broader group to determine a choice. Thus, they do not engender
commitment to the course of action chosen. An absence of commitment from individuals in the
group can be problematic during the implementation phase of a decision.
There are no perfect decision-making rules. Depending on how the rules are implemented in
practice and the situation, all of these can lead to situations where either no decision is made, or
to situations where decisions made are inconsistent with one another over time.
Social decision schemes. Sometimes, groups may have established and clearly defined standards
for making decisions, such as bylaws and statutes. However, it is often the case that the decisionmaking process is less formal, and might even be implicitly accepted. Social decision schemes
are the methods used by a group to combine individual responses to come up with a single group
decision. There are a number of these schemes, but the following are the most common:
Delegation. An individual, subgroup or external party makes the decision on behalf of the group.
For instance, in an "authority scheme", the leader makes the decision or, in an oligarchy, a
coalition of leading figures makes the decision.
Averaging. Each group member makes their own private and independent decision and all are
later "averaged" to produce a decision.
Plurality. Group members vote on their preferences, either privately or publicly. These votes are
then used to select a decision, either by simple majority, supermajority or other more or less
complicated voting system.
Unanimity. A consensus scheme whereby the group discusses the issue until it reaches a
unanimous agreement. This decision rule is what dictates the decision-making for most juries.
Random. The group leaves the choice to chance.
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There are strengths and weaknesses to each of these social decision schemes. Delegation saves
time and is a good method for less important decisions, but ignored members might react
negatively. Averaging responses will cancel out extreme opinions, but the final decision might
disappoint many members. Plurality is the most consistent scheme when superior decisions are
being made, and it involves the least amount of effort. Voting, however, may lead to members
feeling alienated when they lose a close vote, or to internal politics, or to conformity to other
opinions. Consensus schemes involve members more deeply, and tend to lead to high levels of
commitment. But, it might be difficult for the group to reach such decisions.
Normative model of decision-making. Groups have many advantages and disadvantages when
making decisions. Groups, by definition, are composed of two or more people, and for this
reason naturally have access to more information and have a greater capacity to process this
information. However, they also present a number of liabilities to decision-making, such as
requiring more time to make choices and by consequence rushing to a low quality agreement in
order to be timely. Some issues are also so simple that a group decision-making process leads to
too many cooks in the kitchen: for such trivial issues, having a group make the decision is
overkill and can lead to failure.
Decide. The leader of the group uses other group members as sources of information, but makes
the final decision independently and does not explain to group members why s/he required that
information.
Consult (individual). The leader talks to each group member alone and never consults a group
meeting. S/he then makes the final decision in light of the information obtained in this manner.
Consult (group). The group and the leader meet and s/he consults the entire group at once,
asking for opinions and information, then comes to a decision.
Facilitate. The leader takes on a cooperative holistic approach, collaborating with the group as a
whole as they work toward a unified and consensual decision. The leader is non-directive and
never imposes a particular solution on the group. In this case, the final decision is one made by
the group, not by the leader.
Delegate. The leader takes a backseat approach, passing the problem over to the group. The
leader is supportive, but allows the group to come to a decision without their direct collaboration.
Cognitive limitations and subsequent error. Individuals in a group decision-making setting are
often functioning under substantial cognitive demands. As a result, cognitive and motivational
biases can often affect group decision-making adversely. There are three categories of potential
biases that a group can fall victim to when engaging in decision-making:
Sins of commission. The misuse, abuse and/or inappropriate use of information. Thise can
include:
Belief perseverance - a group utilises information in their decision-making that has
already been deemed inaccurate.
Sunk cost bias - a group remains committed to a given plan primarily due to the
investment already made in that plan, regardless of how inefficient and/or ineffective it
may have become.
Extra-evidentiary bias - a group choosing to use some information despite having been
told it should be ignored.
Hindsight bias - group members falsely over-estimate the accuracy of and/or the
relevance of their past knowledge of a given outcome.
Sins of omission. Overlooking useful information. This can include:
Base rate bias - group members ignore applicable information they have concerning basic
trends/tendencies.
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Fundamental attribution error - group members base their decisions on inaccurate
appraisals of individuals' behaviour.
Sins of imprecision. Relying too heavily on heuristics that over-simplify complex decisions. This
can include:
Availability heuristic - group members rely on information that is readily available.
Conjunctive bias - when groups are not aware that the probability of a given event
occurring is the least upper bound on the probability of that event and any other given
event occurring together; thus if the probability of the second event is less than one, the
occurrence of the pair will always be less likely than the first event alone.
Representativeness heuristic - group members rely too heavily on decision-making
factors that seem meaningful but are, in fact, more or less misleading.
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12. Command styles and leadership
There is well-established research both in the maritime and other hazardous industries that
confirms the huge impact of leadership on the safety of operations. Whilst the International
Safety Management (ISM) code has been a major step forward in improving safety standards, its
effectiveness depends heavily on how leaders approach its implementation, and this in turn
depends heavily on the skills and qualities of leaders both at sea, at the ship-shore interface,
and on-shore.
Virtually all maritime leaders want to do their best for safety, this is not in doubt. But sometimes
real life makes things difficult time pressures, economic constraints and everyday
circumstances sometimes seem to conspire against good safety leadership.
12.1. The ten core safety leadership qualities
A.
Confidence and Authority
1. Instill respect and command authority
2. Lead the team by example
3. Draw on knowledge and experience
4. Remain calm in a crisis
B.
Empathy and Understanding
5. Practise tough empathy
6. Be sensitive to different cultures
7. Recognise the crews limitations
C.
Motivation and Commitment
8. Motivate and create a sense of community
9. Place the safety of crew and passengers above everything
D.
Openness and Clarity
10. Communicate and listen clearly
Instill respect and command authority. The ability to instill respect from, and command
authority over, the crew is probably the first thing that comes to mind when people think of
leadership.
In many ways it happens on its own when you get everything else right.
Leaders get respect and command authority when crews believe that you:
Are willing to exercise the power vested in your position
Possess the necessary knowledge and competence
Understand their situation and care about their welfare
Are able to communicate clearly
Are prepared to act confidently and decisively.
Without authority and respect it is difficult for leaders to influence the behaviour of their crews,
including safety-related behaviour. Crews may establish their own individual or group values,
attitudes and behaviours, or else follow other de-facto leaders lower down in the hierarchy. This
can lead to poor compliance with standards and excessive risk-taking.
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Research shows that some Masters feel that their authority is being undermined by increasing
governance from shore-based managers under ISM (e.g. through the Designated Person Ashore
requirements). Also, some Masters feel that the increase in the volume of management standards
and procedures is undermining their authority. These areas are important to address.
Leaders need to tailor leadership style to fit their individual personalities, but there are some
common features:
Things that tend to work
Have confidence in your decisions and stick to them
Admit mistakes when you are sure you are wrong
Demonstrate staff care and respect through everyday actions
Earn respect through your actions
Try to achieve better mutual ship-shore management understanding (e.g. through
meetings, informal contacts or job rotation).
Things that tend not to work
Demanding respect from subordinates
Using the power vested in your position as a threat
Refusing to listen when challenged
Acting unnecessarily tough when there is no justification
Ignoring shore-based management
Blaming shore-based management for the consequences of decisions
Shore-managers being too prescriptive with Masters.
Lead the team by example. Leading the team by example is the combination of two things:
being seen to be practicing what you preach, and pulling your weight as a key part of the team.
It is well-known that people are less likely to follow any rule or practice if you do not follow it
yourself this is especially true for safety rules.
Traditionally, Masters may have regarded themselves more as authorities to be obeyed rather
than team players. However, with increasing safety requirements and fluid labour markets,
sometimes with high crew turnover, it is increasingly important to use leadership styles that
demonstrate shared safety values through actions, not just words.
Always be seen to follow simple, visible safety rules during everyday activities
Be seen to be playing an active role, not just behind the scenes
Occasionally be seen to assist in subordinates tasks where necessary.
Applying hard discipline for non-compliance whilst flouting rules yourself
Avoiding getting your hands dirty with subordinates tasks.
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Draw on knowledge and experience. It is self-evident that adequate knowledge and experience
are prerequisites for effective leadership. In the context of safety leadership this means in
particular:
Good knowledge of safety-related regulations, codes and standards
Experience and skills not only in technical and operational issues but also in people
management.
Without factual safety knowledge, leaders cannot convince their crews that they are on top of
safety issues and take it seriously themselves. Without people management skills, effective
implementation of written safety regulations, codes and standards is very difficult. Research
indicates that people management is an area for further improvement in the maritime industry.
There is little dedicated formal training in this area at present.
Ensure that you are up-to-speed on safety requirements
Consider your own strengths and weaknesses in people skills such as communication,
motivation, team working, conflict resolution, crisis management, coaching and
appraisal, discipline
You cant be an expert in everything so be prepared to acknowledge your own
knowledge gaps and seek advice when you need to.
Concentrating only on technical safety knowledge without considering people skills.
Remain calm in a crisis. People need strong, clear leadership in a crisis and rely more on their
leaders than would otherwise be the case. Calmness in a crisis situation is a core requirement and
will rely on many of the other leadership qualities described in this booklet including
commanding authority and drawing on knowledge and experience. In particular, it is important
to have confidence and trust in the crews abilities and emergency preparedness. Attendance at
safety training and at response drilling is essential for all crew.
Calmness in a crisis is particularly important in view of the additional complications of different
languages and nationalities that make up the crew. These complications tend to be emphasised
during emergencies.
Develop excellent knowledge of, and confidence in, the crews abilities
Implement a firm policy on compulsory attendance at emergency safety training and
response drills.
Infrequent or inconsistent emergency drills
Failure to address language issues in emergency planning.
Practise tough empathy. Empathy is all about identification with and understanding of
anothers situation, feelings, and motives. It requires the capacity to put yourself in anothers
place, and the cultivation of good listening skills. Good leaders empathise realistically with
employees and care intensely about the work they do but this doesnt mean that they always
agree with them or join in with concerns and grumbles. Instead they practise tough empathy,
which means giving people what they need, rather than necessarily what they want. Another way
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of looking at this is care with detachment. An example is providing staff with safety footwear
that is comfortable and safe, rather than spending more money to provide a more fashionable
style.
Tough empathy is important in order both to convey to your crew that you understand their
situation, feelings and motives, and to enable you as a leader to take the right courses of action
which take due account of these desires, feelings and concerns whilst focusing on achieving
appropriate overall objectives. In a safety context, this is especially important for encouraging
compliance with safety rules by the crew.
Encourage crew to provide feedback on their situation, feelings and motives, both in
everyday situations and formally in prearranged communication sessions
Be prepared to acknowledge, mirror or summarise feedback to demonstrate
understanding, then to explain your conclusions and intended course of action. If this is
significantly different to what people have said they want, take the time to explain the
case and illustrate why you are adopting this course of action
Making a point of listening to what people say, but then taking a different decision
without any clear demonstration that you have heard and understood, or explanation of
your rationale
Over emphasising listening at the expense of decision-making this can lead to loss
of respect and authority
Be sensitive to different cultures. Good leaders are sensitive to differences in the social and
behavioural norms of national cultures, yet at the same time value all crew members equally
irrespective of their nationality. They know how to interpret different behavioural signals, and
how best to react in order to exert the strongest influence.
Crews of mixed nationalities are the norm. It has been clearly demonstrated that different
national cultures may have different values and attitudes towards safety for example in terms
of fatalism, following rules, risk-taking etc. These values and attitudes can certainly be adapted,
but sensitivity is needed to understand how best to proceed.
In some cases, mixed nationalities can lead to splitting into different social groups, often on the
basis of language. This can be a serious barrier towards effective and consistent implementation
of safety-related requirements, and social wellbeing of the crew as a whole. In emergency
situations, language is of course also a potential risk area.
Ensure as far as possible that one working language is used even in social situations,
and that crew have adequate training in this language
Try to avoid a large critical mass of one nationality developing, where possible
Learn the key features of typical behavioural signals exhibited by the nationalities
represented on board training in this is available
Consciously seek to build trust, familiarity and integration of disparate social groups
through organised or semi-organised social activities on-board.
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Ingrained value judgements about different nationalities
Overdoing political correctness in terms of dealing with different nationalities, so that
relations become forced and unnatural.
Recognise the crews limitations. Good leaders have a clear understanding of how operational
and other demands can be realistically met by the crew, and are able to judge whether fatigue
levels are such that action should be taken.
Commercial pressures continue to be intense in the maritime industry.
Minimum manning levels and increased demands for reporting and paperwork mean that
working hours are long and fatigue is a key issue. It has been shown that excessive fatigue and
stress has an adverse effect on safety, and is one of the key causal factors of human error and
poor decision-making.
Monitor and be aware of the signs of excessive fatigue in crew members
Ensure that working hours are adequately supervised and recorded
In the case of recurrent problems, discuss possible solutions with shore management
Be able to decide when it is necessary to slow or halt operations temporarily
Relying on crew members to tell you if they are suffering from excess fatigue
Accepting that high levels of fatigue are an acceptable norm
Create motivation and a sense of community. Research has shown that people in work are
typically motivated by satisfaction or pride in completing a good job, and the feeling of being
part of a team not just money. Leaders have an important role to play in creating the conditions
to encourage and maintain these healthy motivators. Demonstrating respect for staff is often a
key part of this.
Meeting someones basic needs is often the key to keeping their motivation high.
Team spirit and pride in ones work are primary contributors to the morale of a team. Morale has
been shown to have an adverse impact on error and violation rates, hence attention to these
aspects is an important part of safety leadership.
Involve staff in aspects of management, for example development of detailed working and
operational practices
Ensure that feedback is always given on staff suggestions or questions
Demonstrate interest in, and care for, crew welfare issues
Take part in and encourage social activities involving the staff
One off staff morale-boosting initiatives or reward schemes that could be perceived as
condescending or trivial
Involving staff in theory, but in practice taking little note of their inputs
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Place the safety of crew and passengers above everything. It is universally accepted that
commitment from the leader is an absolute essential for good safety. Leaders need to
demonstrate this commitment clearly to their staff through their actions, rather than just through
formal declarations or policy statements. In practice this means showing that the safety of crew
and passengers is placed above everything else nothing we do is worth getting hurt for.
The commitment of the Master is vital to ensuring that operational pressures do not compromise
safety. Clear demonstration of commitment is also essential to reinforce the shared values of the
team with regard to safety and to help embed safety issues into everyday actions rather than
being seen as an additional chore.
Make it clear to both superiors and subordinates that you are empowered to act according to
your own judgement on safety matters, without sanction from others
Ensure that safety issues are integrated into other everyday operational activities, including
walkabouts, meetings and one to one discussions.
Declaring that safety is your highest priority, then contradicting this in your subsequent actions
(e.g. by compromising safety in response to operational pressures).
Communicate and listen clearly. The ability to communicate clearly is important at all levels in
an organisation. For a Master, the key issue is most often how to encourage better two-way
rather than one-way communication, balancing authority and approachability. Being open to
criticism is a part of this.
Clear two-way communication and openness is necessary to achieve a just culture. A just
culture is one in which individuals feel free to speak up about problems or mistakes without
being blamed. In a just culture, safety incidents are not automatically blamed on individuals
however for repeated violations there is a transparent and well-defined progressive discipline
policy. Without the openness inherent in this just culture, safety incidents and near-misses may
be suppressed and unnecessary risks taken.
Hold safety tours and informal discussions with all levels
Ensure that your listening skills are adequate. If necessary obtain training or coaching in
effective listening
Implement an open door policy for crew members who wish to see you
Ensure that there are no barriers preventing the open reporting of safety incidents and
near-misses. If necessary consider using a confidential reporting system
Give positive feedback on what lessons have been learned through reporting of incidents
and near-misses without apportioning blame, and demonstrate commitment to addressing
root causes
Cultivate an atmosphere of openness through your own personal management style and
everyday interactions
Holding safety tours which become primarily an excuse to check up on crew and chastise
them
Declaring a no-blame policy without acknowledging the need for discipline.
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13. Organizational issues
Organizational behavior is a misnomer. It is not the study of how organizations behave, but
rather the study of individual behavior in an organizational setting. This includes the study of
how individuals behave alone, as well as how individuals behave in groups.
The purpose of organizational behavior is to gain a greater understanding of those factors that
influence individual and group dynamics in an organizational setting so that individuals and the
groups and organizations to which they belong may become more efficient and effective. The
field also includes the analysis of organizational factors that may have an influence upon
individual and group behavior. Much of organizational behavior research is ultimately aimed at
providing human resource management professionals with the information and tools they need to
select, train, and retain employees in a fashion that yields maximum benefit for the individual
employee as well as for the organization.
Organizational behavior is a relatively new, interdisciplinary field of study. Although it draws
most heavily from the psychological and sociological sciences, it also looks to other scientific
fields of study for insights. One of the main reasons for this interdisciplinary approach is because
the field of organizational behavior involves multiple levels of analysis, which are necessary to
understand behavior within organizations because people do not act in isolation. That is, workers
influence their environment and are also influenced by their environment.
Individual level of analysis. At the individual level of analysis, organizational behavior
involves the study of learning, perception, creativity, motivation, personality, turnover, task
performance, cooperative behavior, deviant behavior, ethics, and cognition. At this level of
analysis, organizational behavior draws heavily upon psychology, engineering, and medicine.
Group level of analysis. At the group level of analysis, organizational behavior involves the
study of group dynamics, intra- and intergroup conflict and cohesion, leadership, power, norms,
interpersonal communication, networks, and roles. At this level of analysis, organizational
behavior draws upon the sociological and socio-psychological sciences.
Organization level of analysis. At the organization level of analysis, organizational behavior
involves the study of topics such as organizational culture, organizational structure, cultural
diversity, inter-organizational cooperation and conflict, change, technology, and external
environmental forces. At this level of analysis, organizational behavior draws upon anthropology
and political science.
Other fields of study that are of interest to organizational behavior are ergonomics, statistics, and
psychometrics.
A number of important trends in the study of organizational behavior are the focus of research
efforts. First, a variety of research studies have examined topics at the group level of analysis
rather than exclusively at the individual level of analysis. For example, while empowerment has
largely been investigated as an individual-level motivation construct, researchers have begun to
study team empowerment as a means of understanding differences in group performance. Similar
research has focused on elevating the level of analysis for personality characteristics and
cooperative behavior from the individual level to the group level.
Another research trend is an increasing focus on personality as a factor in individual- and grouplevel performance. This stems from the movement toward more organic organization designs,
increased supervisory span of control, and more autonomous work designs. All of these factors
serve to increase the role that personality plays as a determinant of outcomes such as stress,
cooperative or deviant behavior, and performance.
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Personality traits that are related to flexibility, stress hardiness, and personal initiative are also
the subject of research. Examples of these personality traits include a tendency toward
individualism or collectivism, self-monitoring, openness to experience, and a proactive
personality. Forms of behavior that are constructive and change-oriented in nature are also
studied. These forms of behavior are proactive in nature and act to improve situations for the
individual, group, or organization. Examples of these behaviors include issue selling, taking
initiative, constructive change-oriented communication, innovation, and proactive socialization.
Organizational behavior is the study of individuals and their actions within the context of the
organization in a workplace setting. It is an interdisciplinary field that includes sociology,
psychology, communication, and management; and it complements the academic studies of
organizational theory (which is more macro-level) and human resource studies (which is more
applied and business-related). It may also be referred to as organizational studies or
organizational science. The field has its roots in industrial and organizational psychology.
Organizational studies encompass the study of organizations from multiple viewpoints, methods,
and levels of analysis. For instance, one textbook divides these multiple viewpoints into three
perspectives: modern, symbolic, and postmodern. Another traditional distinction, present
especially in American academia, is between the study of "micro" organizational behaviour
which refers to individual and group dynamics in an organizational setting and "macro"
strategic management and organizational theory which studies whole organizations and
industries, how they adapt, and the strategies, structures and contingencies that guide them. To
this distinction, some scholars have added an interest in "meso" scale structures - power, culture,
and the networks of individuals and i.e. ronit units in organizations and "field" level analysis
which study how whole populations of organizations interact.
Whenever people interact in organizations, many factors come into play. Modern organizational
studies attempt to understand and model these factors. Like all modernist social sciences,
organizational studies seek to control, predict, and explain. There is some controversy over the
ethics of controlling workers' behavior, as well as the manner in which workers are treated. As
such, organizational behaviour or OB (and its cousin, Industrial psychology) have at times been
accused of being the scientific tool of the powerful. Those accusations notwithstanding, OB can
play a major role in organizational development, enhancing organizational performance, as well
as individual and group performance/satisfaction/commitment.
One of the main goals of organizational theorists is "to revitalize organizational theory and
develop a better conceptualization of organizational life." An organizational theorist should
carefully consider levels assumptions being made in theory, and is concerned to help managers
and administrators.
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14. Organizational change
Today, teams and organizations face rapid change like never before. Globalization has increased
the markets and opportunities for more growth and revenue. However, increasingly diverse
markets have a wide variety of needs and expectations that must be understood if they are to
become strong customers and collaborators. Concurrently, scrutiny of stakeholders has increased
as some executives have been convicted of illegal actions in their companies, and the
compensation of executives seems to be increasing while wages of others seems to be decreasing
or leveling off. Thus, the ability to manage change, while continuing to meet the needs of
stakeholders, is a very important skill required by today's leaders and managers.
Significant organizational change occurs, for example, when an organization changes its overall
strategy for success, adds or removes a major section or practice, and/or wants to change the
very nature by which it operates. It also occurs when an organization evolves through various
life cycles, just like people must successfully evolve through life cycles. For organizations to
develop, they often must undergo significant change at various points in their development.
That's why the topic of organizational change and development has become widespread in
communications about business, organizations, leadership and management.
Leaders and managers continually make efforts to accomplish successful and significant change
-- it's inherent in their jobs. Some are very good at this effort (probably more than we realize),
while others continually struggle and fail. That's often the difference between people who thrive
in their roles and those that get shuttled around from job to job, ultimately settling into a role
where they're frustrated and ineffective. There are many schools with educational programs
about organizations, business, leadership and management. Unfortunately, there still are not
enough schools with programs about how to analyze organizations, identify critically important
priorities to address (such as systemic problems or exciting visions for change) and then
undertake successful and significant change to address those priorities.
Organizational change is undertaken to improve the performance of the organization or a part of
the organization, for example, a process or team.
To really understand organizational change and begin guiding successful change efforts, the
change agent should have at least a broad understanding of the context of the change effort. This
includes understanding the basic systems and structures in organizations, including their typical
terms and roles. This requirement applies to the understanding of leadership and management of
the organizations, as well.
Organizational change should not be conducted for the sake of change. Organizational change
efforts should be geared to improve the performance of organizations and the people in those
organizations. Therefore, it's useful to have some understanding of what is meant by
"performance" and the various methods to manage performance in organizations.
The past few decades have seen an explosion in the number of very useful tools to help change
agents to effectively explore, understand and communicate about organizations, as well as to
guide successful change in those organizations. Tools from systems theory and systems thinking
especially are a major breakthrough. Even if the change agent is not an expert about systems
theory and thinking, even a basic understanding can cultivate an entire new way of working.
The field of Organization Development is focused on improving the effectiveness of
organizations and the people in those organizations. Organization Development has a rich history
of research and practice regarding change in organizations. Why not learn from that history?
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Your nature and the way you choose to work have significant impact on your client's
organization, whether you know it or not. You cannot separate yourself from your client's
organization, as if you are some kind of detached observer. You quickly become part of your
client's system -- the way the people and processes in the organization work with each other on a
recurring basis. Thus, it is critical that you have a good understanding of yourself, including your
biases (we all have them), how you manage feedback and conflict, how you like to make
decisions and solve problems, how you naturally view organizations, your skills as a consultant,
etc.
Nowadays, with the complex challenges faced by organizations and the broad diversity of
values, perspectives and opinions among the members of those organizations, it's vital that
change agents work from a strong set of principles to ensure they operate in a highly effective
and ethical manner.
There are several phrases regarding organizational change and development that look and sound
a lot alike, but have different meanings. As a result of the prominence of the topic, there seems to
be increasingly different interpretations of some of these phrases, while others are used
interchangeably. Without at least some sense of the differences between these phrases,
communications about organizational change and development can be increasingly vague,
confusing and frustrating.
There are different overall types of organizational change, including planned versus unplanned,
organization-wide versus change primarily to one part of the organization, incremental (slow,
gradual change) versus transformational (radical, fundamental), etc.. Knowing which types of
change you are doing helps all participants to retain scope and perspective during the many
complexities and frequent frustrations during change.
Successful change efforts often include several key roles, including the initiator, champion,
change agent, sponsor and leaders.
Appreciative Inquiry is a recent and powerful breakthrough in organizational change and
development. It's based on the philosophy that "problems" are often caused as much by our
perception of them as problems as by other influencing factors. The philosophy has spawned a
strong movement that, in turn, has generated an increasing number of models, tools and tips,
most of which seem to build from the positive perceptions (visions, fantasies, wishes and stories)
of those involved in the change effort.
There are numerous well-organized approaches (or models) from which to manage a change
effort. Some of the approaches have been around for many years -- we just haven't thought of
them as such. For example, many organizations undertake strategic planning. The
implementation of strategic planning, when done in a systematic, cyclical and explicit approach,
is strategic management. Strategic management is also one model for ensuring the success of a
change effort. The following links provide more perspectives on approaches to managing
change. (Note that, with the maturation of the field of Organization Development, there are now
more strong opinions about which are change management approaches and which are not -- there
seems to be no standard interpretation yet.)
A typical planned, systemic (and systematic) organizational development process often follows
an overall action research approach (as described below). There are many variations of the action
research approach, including by combining its various phases and/or splitting some into more
phases. This section provides resources that are organized into one variation of the action
research approach. Note that the more collaborative you are in working with members of the
organization during the following process, the more likely the success of your overall change
effort.
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Phase 1: Start-Up. This phase is sometimes called the "Contracting" and/or "Entry" phase. This
phase is usually where the relationship between you (the initial change agent) and your client
starts, whether you are an external or internal consultant. Experts assert that this phase is one of
the most - if not the most - important phases in the organizational change process. Activities
during this stage form the foundation for successful organizational change. The quality of how
this phase is carried out usually is a strong indicator of how the project will go.
Phase 2: Joint discovery to identify priorities for change. The more collaborative the change
agent is in working with members of the client's organization, the more likely that the change
effort will be successful. Your client might not have the resources to fully participate in all
aspects of this discovery activity -- the more participation they can muster, the better off your
project will be.
Whether you are an external or internal change agent in this project, you and your client will
work together during this phase to understand more about the overall priority of the change effort
and how you all can effectively address it. It might be a major problem in the organization or an
exciting vision to achieve. Together, you will collect information, analyze it to identify findings
and conclusions, and then make recommendations from that information. Sometimes the datacollection effort is very quick, for example, facilitating a large planning meeting. Other times,
the effort is more extensive, for example, evaluating an entire organization and developing a
complete plan for change. The nature of discovery also depends on the philosophy of the change
agent and client. For example, subscribers to the philosophy of Appreciative Inquiry (referenced
above) might conduct discovery, not by digging into the number and causes of problems in the
organization, but by conducting interviews to discover the visions and wishes of people in the
organization.
Sometimes, people minimize the importance of - or altogether skip - this critical discovery
phase, and start change management by articulating an ambitious and comprehensive vision for
change. Many would argue that it is unethical to initiate a project for organizational change
without fully examining (or discovering) the current situation in the client's organization.
Focusing most of the change efforts on achieving a robust vision, without at least some careful
discovery, often can be harmful to your client's organization because your project can end up
dealing with symptoms of any current issues, rather than the root causes. Also, the project could
end up pushing an exciting vision that, while initially inspiring and motivating to many, could be
completely unrealistic to achieve -- especially if the organization already has many current,
major issues to address. Therefore, when working to guide change in an organization that already
is facing several significant issues, you are usually better off to start from where your client is at
-- that usually means conducting an effective discovery to identify priorities for change.
One of the most powerful means to cultivate collaboration is by working with a project team.
Besides, no change agent sees all aspects of the situation in the organization -- team members
help to see more of those various aspects.
Phase 3: Joint planning of Organizational Development activities to address priorities. In the
previous phase about discovery, you and your client conducted research, discovered various
priorities that needed attention, generated recommendations to address those priorities, and
shared your information with others, for example, in a feedback meeting. Part of that meeting
included discussions - and, hopefully, decisions - about the overall mutual recommendations that
your client should follow to in order address the priorities that were identified by you and your
client during your discovery. This phase is focused on further clarifying those recommendations,
along with developing them into various action plans. The various plans are sometimes
integrated into an overall change management plan. Thus, the early activities in this phase often
overlap with, and are a continuation of, the activities near the end of the earlier discovery phase.
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This is true whether you are an external or internal consultant. Action plans together can now
provide a clear and realistic vision for change. They provide the "roadmap" for managing the
transition from the present state to the desired future state.
Development of the various action plans is often an enlightening experience for your client as
members of their organization begin to realize a more systematic approach to their planning and
day-to-day activities. As with other activities during change management, plans can vary widely
in how they are developed. Some plans are very comprehensive and systematic (often the best
form used for successful change). Others are comprised of diverse sections that are expected to
somehow integrate with each other. Subscribers to the philosophy of Appreciative Inquiry
(referenced above) might do planning by building on past positive outcomes and on the strengths
of members of the organization.
Phase 4: Change management and joint evaluation. During this phase, emphasis is on
sustaining and evaluating the change effort, including by addressing resistance that arises from
members of the organization -- and sometimes in the change agent, as well.
Evaluation occurs both to the quality of implementation of plans so far during the project and
also regarding the extent of achievement of desired results from the project. Results might be
whether certain indicators of success have been achieved, all issues have been addressed, a
vision of success has been achieved, action plans have been implemented and/or leaders in the
organization agree the project has been successful.
As part of the final evaluation, you might redo some of the assessments that you used during the
discovery phase in order to measure the difference made by the project.
The field of Organization Development uses a variety of processes, approaches, methods,
techniques, applications, etc., (these are often termed "interventions") to address organizational
issues and goals in order to increase performance. The following types of interventions are often
highly integrated with each other during a project for change.
How people choose Organizational Development activities. There are no standard activities
that always successfully address certain types of issues in organizations. Many times, the success
of a project lies not with having selected the perfect choice of activities, but rather with how
honest and participative people were during the project, how much they learned and how open
they were to changing their plans for change.
However, there are some basic considerations that most people make when selecting from
among the many choices for organizational development, or capacity building, activities.
Considerations include:
First, does the change-management method (if one was used) suggest what organizational
development activities to use now, for example, the method of strategic management
might suggest that a SWOT analysis be done, strategic goals be established along with
action plans for each goal, and then implementation of the action plans be closely
monitored.
Is the activity most likely to address the findings from the discovery, that is, to solve the
problems or achieve the goals? To find out, review any research about use of the activity,
discuss the potential outcomes with experts and also with members of the organization.
Consider posing your questions in online groups of experts about change.
Does the nature of the activity match the culture of the organization? The best way to
find out is to discuss the activity with members of the organization.
Does the change agent and key members of the organization have the ability to conduct
the activity? For example, techno-structural and strategic interventions sometimes require
technical skills that are not common to many people.
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Does the activity require more time to conduct than the time available in which to address
the problem or goal? For example, a cash crisis requires immediate attention, so while a
comprehensive strategic planning process might ultimately be useful, the four to five
months to do that planning is impractical.
Does the client's organization have the resources that are necessary to conduct the
activity, considering resources such as funding, attention and time from people and
facilities.
Before you and your client select types of interventions for the project, be aware of your strong
biases about how you view organizations. Without recognizing those biases, you might favor
certain types of interventions primarily because those are the only ones you can readily see and
understand, even if other types of interventions might be much more effective in your project.
Human Process Interventions (Group and Individual Human Relations). With today's
strong emphasis on humanistic values, the following interventions are getting a great deal of
attention and emphasis during efforts for change. They focus on helping members of the
organization to enhance themselves, each other and the ways in which they work together in
order to enhance their overall organization. Although the types of interventions selected for a
project depend on a variety of considerations and the interventions in a project often are highly
integrated with each other, the following human process interventions might be particularly
helpful during change projects in organizations where there is some combination of the
following: many new employees, different cultures working together, many complaints among
organizational members, many conflicts, low morale, high turnover, ineffective teams, etc.
Techno-structural Interventions (Structures, Technologies, Positions, etc.). The following
are examples of activities that focus on improving the performance of organizations primarily by
modifying structures, technologies, operations, procedures and roles/positions in the
organization. Although the types of interventions selected for a project depend on a variety of
considerations and the interventions in a project often are highly integrated with each other, the
following technostructural interventions might be particularly helpful in the following kinds of
situations: rapid growth but few internal systems to sustain that growth, much confusion about
roles, a new major technology or process has been introduced, many complaints from customers,
etc. These interventions might also be useful in new organizations where internal operational
systems must be developed and implemented.
Human Resource Management interventions (Individual and Group Performance
Management). The following activities aim to enhance overall organizational performance by
improving the performance of individuals and groups within the organization. Performance is in
regard to setting goals, monitoring progress to the goals, sharing feedback, reinforcing activities
to achieve goals and dissuading those that don't. Performance also is in regard to developing
employees, including by enhancing their overall sense of well-being. Although the types of
interventions selected for a project depend on a variety of considerations and the interventions in
a project often are highly integrated, the following human resource interventions might be
particularly helpful in the following kinds of situations: new organizational goals have been
established, a major new system or technology must be implemented in a timely fashion, many
new employees, plans don't seem to get implemented, productivity is low, ineffective teams, etc.
Strategic Interventions (Organization and Its External Environment). The following
activities focus especially on the organization and its interactions with its external environment,
and often involve changes to many aspects of the organization, including employees, groups,
technologies, products and services, etc. Although the types of interventions selected for a
project depend on a variety of considerations and the interventions in a project often are highly
integrated, the following strategic interventions might be particularly helpful in the following
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kinds of situations: rapid changes in the external environment, rapid or stagnant sales,
significantly increased competition, rapid expansion of markets, mergers and acquisitions, the
need for quick and comprehensive change throughout the organization, etc.
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