In this part, we examine the “Making Mistakes” section of “The Human Element” and break down the most relevant information.

Dirk Gregory and Paul Shanahan  of the UK Maritime and Coastguard Agency developed the guide “The Human Element – A Guide to Human Behavior in the Shipping Industry”. It helps to understand how and why human based accidents and errors occur and are still the leading cause of disasters in the shipping and offshore industry.

The Human Element – Making Mistakes in the Shipping Industry

Making mistakes is the one thing which allows us to develop skills and to learn something – by simply working with the notion that real outcomes and desired outcomes are equal. Therefore, making mistakes is not the problem; the true problem is the serious results that can develop from mistakes due to the nature of our business.

There are three main types of mistakes:

• Skill-based mistakes
• Rule-based mistakes
• Knowledge-based mistakes

If we forget to give way for a vessel or wrongly assume that a give-way-vessel will always give way then it is a rule-based mistake. These events help us to categorize mistakes and therefore actively work towards mistake avoidance. However, there are a number of factors which can make any of these mistakes more likely.

On an individual basis:

• Stress and inadequate resting
• Insufficient training
• Bad communication

On an organizational basis:

• Inadequate time allotted for tasks
• Poor equipment design
• Bad safety culture

Unfortunately, these factors can also transform a normal mistake into a disastrous one as they additionally affect the ability to recover from a mistake or stop it before it becomes dangerous. Exhaustive research about how human mistakes occur shows that the combination of several adverse circumstances create catastrophic events. This raises the interesting question of how we can prevent mistakes from becoming disasters.

Mistakes: traditional and modern interpretation

Nowadays there are two main approaches, each based on a different interpretation of the source of mistakes. The traditional interpretation dictates that mistakes are governed by cause and effect. Therefore, rules and standing orders are introduced to avoid possible causes. Over time, and as new accidents happen these rule sets become bigger and bigger.

This approach leads to counter-actions as companies and crews value efficiency higher than rules, which are therefore often broken or bent. Another problem is that mistakes tend to be invisible when they happen and as long as they do not lead to disasters or prompt us to take action, only history can tell us if it was a mistake.

A newer approach to interpret how mistakes happen is to consider them taking place within a complex, unpredictable system – a world of circular interactions and complex behavior. This brings up a number of points. First, humans create safety and no system is perfect, hence humans need a degree of freedom in their decision-making to cope with upcoming threats. Second, organizations are a living entity and safety is influenced by a number of outside and inside factors (even politics).

The main problem is that changes arising in one department can influence the safety and chance of failure within another one. Last but not least in “The Human Element – A Guide to Human Behavior in the Shipping Industry” it is pointed out that organizations are responsible for creating the behavior of their employees and so they can have no complaint about such behavior.

How to protect against the results of mistakes?

• Expertise must be protected and exploited: Many masters today try to find shore-based jobs as the likelihood of criminal charges has increased significantly.
• The fault lines within an organization are a real risk to safety-critical operations: E.g. ship owners and crew, manager and operators or differences between training and practice.
• The players of the shipping industry should make decisions on a system-based approach: All members influence each other; therefore finding solutions that suit one party but ignore the needs of others endangers all.

The article continues with the advantages of implementing a just culture vs a typical blame culture.

• Increased reporting of unsafe incidents
• Increased trust between all levels of the workforce
• Decreased numbers of incidents and accidents
• Decreased operational costs – due to safer behavior, higher workforce motivation and morale

Link: UK MCA

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