Doc. dr. sc. Pero VidanFaculty of Maritime Studies Split

E-mail: pvidan@pfst.hr

Gdynia, 13 May 2014

At 10 a.m., March 17, 1978, the super-tanker Amoco Cadiz broke in two, releasing its entire cargo of 1.6 million barrels (250,000 m3)

Ecuadorean-registered ship Jessica, spilled 175,000 gallons of diesel and bunker oil into the sea off the Galapagos Islands

57 %, 71%

10%

33%, 19%

Management errors

Outside control of crew:

Lack of skills:

Crew management errors:

Preoccupation with minor (technical) problemsFailure to delegate tasks and responsibilitiesFailure to set prioritiesInadequate monitoring Failure to utilize available dataFailure to communicate intent and plansFailure to detect and challenge deviations from SOP’s, rules and safe actions

(Source: NTSB, DNV)

The balance

Safety is often a trade-off between optimising Production or Safety

P

S

An orgnisation must know where it stands in order to make informed decisions

Adapted from Reason

Reason’s Swiss Cheese Model

Holes caused by actions

Holes caused by ”latent problems-pathogens”

Stress factors:• Danger

• Hostile environment (temperature,

motions, etc.)

• Time pressure

• Workload

• Distractions

• Performance pressure

• Social interaction

Human weaknesses

Consequences:

• Decision errors

• Restricted attention

• Distorted time-perception

• Weakened short-term memory

• Frequent change of problem

solving strategies

Fatigue:• Inadequate rest

• Disturbance of

biological rhythm

• Heavy cognitive work

• Physical work

Human weaknesses

Consequences:• Slower reactions

• Less capable of creative

problem solving

• Difficulties to remember data

• Denial of negative messages

Hazardous attitude:

•”I know best”

• ”I am not good enough”

Consequences:• Captain failing to listen to First Officer

• Third Eng. failing to provide critical info

Human weaknesses

Culture

Culture is …“The way we do things around here and why we do them.”

Carroll & Quijada (2004).

http://www.safetycenter.navy.mil/photo/archive/

Personality

Behavior

Values

CRM/MCRMtraining

Social environment:• Family• Schools• National culture• Professional culture• Organizational culture• Safety culture

Knowledge,experiences

Attitudes

Skills(SOP’s, etc.)

• Good situational awareness - anticipated next condition

• Cognitive resources free - secured time to think

• Relevant information early - during time of low workload

• Built a shared mental model - a common understanding

• Conservative strategies - kept options open

• Decisions were sensitive to constraints. Resources & Environment

• Explicit task allocation - clear action commands and delegation

• Monitored progress. Verbalised stratagies

NASA - Good Teams

Dr. Judith Orasano

Focus on willingness to :

Manage Trade-offs

Follow Rules & procedures

Avoid violations

Inter-personal relations & communication

Team work

Understand human error and manage it !

Some solutions from CRM

Can be divided into two groups:• Physical• Mental

• Physical:• Sleep disorder• Fatigue• Motivation• Seasickness• Speed and walking• Drugs and alcohol• Hunger and thirst• Physical discomfort and pain• Disease and infection

Mental•Current and situational stress•Change in time perception•Perception impossibility•Concern and anger•Loss of memory•Motivation

Seasickness can be dangerous for seamen because it causes attention deficit.

Prevention: walking restriction, nicotin, alcohol, caffeine and salt avoidance. Do not talk to the person who has seasickness.

“Stress is basically a physical and psychological mechanism that starts working when we are exposed to strain of any kind - physical, psychological or social to make it possible for us to cope with whatever caused the strain - it prepares the organism to cope with the new situation…..”

Good Stress

Bad Stress

Your own personality

Your family

Your working surroundings

The actual situation

On a ship environmental stressincludes:

• Excessive noise• Heat• Vibration• Low humidity

Physical disabilities

Clumsiness Disorientation Anxiety

Cognitive disability

Poor leadership High workload

Tiredness Time zone change Time of the day Temperature Uncomfortable

environment

Physical and mental fitness Experience Training received Crew composition training received

Degree of influence depends on:

Personality:TraitsAttitudesNeedsExperience

Environment:Situational factorsWorkloadCockpit environmentetc...

Assessment

Amount of stress

Coping?

“Panic” amygdala hijack

Long term effects

Increased StressNo

Increased stress tolerance

Solution

Yes

highhigh

1. Experienced/skilled1. Experienced/skilled 2. Low 2. Low experience / skillexperience / skill

ActivationActivationlowlow

PPeerrffoorrmmaannccee ActivationActivation

lowlow highhigh

PPeerrffoorrmmaannccee

How does stress influence human performance?

Brain Activity level

Time

Brain activity level

Time

Stress is the product of a whole lifestyle. It is not just the product of an occasional crisis!

BUT a crisis can accelerate the effects! Leading to IQ dump

Consequently each person must learn to monitor personal internal stress-levels (and symptoms) and find ways to relieve such conditions!

Insomnia Interrupted sleep Nightmares Excessive sleeping Lack of energy Fatigue Hyperactivity Mood changes Worry Depression Stress reduces the effect of work and prevents

judgement

Them affects: Physical rhythm Human clock allows vigilance through the day and good

sleep or lack of attention at night Problems on board Adaptation to night work or early morning job Day and night changing during shifts Biological rhythm of most people is updated 1-2 hours

per day The human body is the most sensitive to light around

5:00 a.m Shifts in the clockwise direction: Morning ⇒ Afternoon It is easier to get used to the night shift than mixed ones

Medical care Loss of productivity Loss of material Administration cost Costs of social help and of life quality

improving

Sweden categorized the risk of life on: Decks:1. Embroidery2. Hatches handling3. Working at height Machine:1. Tools handling in a limited place2. Handling with big machines and tools3. Carrying scales and ladders Hotel: bif1. Slippery floor2. hot or sharp objects due to the rolling of the

shipOpći problemi:3. Ladders4. Slippery or uneven deck floor

Danish research shows that 50% of injuries are related to work on the deck

Other critical activities are walking and working in the engine room

Suggestions for improvements: Terms of walking on the deck, scales, climbing a

ladder Gangway and access to the ship-shore Assessment of safety equipment for embroidery Lashing Access Safety Wheelhouse: enough handles and avoidance of

sharp edges

Fatigue is one of the most dangerous phenomena on board.

It is cause of the false judgments, management and operations.

Fatigue often occurs due to improper organization of work on the ship, but ship's specific environment as well, etc.

Fatigue is considered undesirable physical and mental state of crew members. It is a frequent cause of human errors that results in distress (Figures 1 and 2) as it reduces the ability of perception and thinking.

The most common causes of collisions

0 5 10 15 20 25 30

poor use of radar

failure of communication devices

poor communication between crew

unexperience

fatigue

poor familiarisation

poor training

poor looking

wrong decission

COLREG violation

Izvor: http://www.brighthub.com/engineering/marine/articles/106516.aspx?image=151636

The most common causes of stranding

0 2 4 6 8 10 12 14

failure of devices

poor use of ECDIS

poor visibility

tiredness

wrong percepction of…

wrong passage plan

igmorance areas

poor use of radar

poor communication

unexperiance

fatigue

poor decission

broj pojava u vremenskom razdoblju

The growth of technology standards of construction and equipment of ships and maritime competitiveness of the market has led to the emergence of saving the human workforce and reducing costs at the expense of the crew. Reducing these costs included the emergence of hiring cheaper crews from the east. These crews are often less educated.

0

20

40

Phillippines Russia Ukraine Poland China Greek Croatia

(%)

Crew nationality

Percentegeof crew

Another phenomenon that follows global maritime industry is to reduce the number of crew to "minimum safety" given by the legislature of the state of the vessel (Minimum Manning Document).

Fatigue is a phenomenon that accompanies human activity, reduces operating efficiency and adversely affects the attitude towards work. If one looks through the production, fatigue is defined by reducing the performance over time.

Crews often do more contracts for small amounts of money. Time longer contracts of seamen mean increased fatigue arising from such relationships and lifestyle.

Studies have shown that the speed of doing business increases with shorter working day. During a long day of work worker fights fatigue actively by frequent and longer breaks and a slower pace of work. Lengthening of working time significantly increases the negative effects of fatigue.

Figure 4. Average of daily working and overtime hours according to the workplace

deck crew

engine crew

cattering

deck officers

engine officers

Chief mate

Chief Engineer

Master

0 2 4 6 8 10 12 14

Figure 5. Dependence on night’s sleep and composure

Time of sleep previous night

Full awareness

Medium awareness

Low awareness

Total sleepiness

Figure 6. Dependence on night’s sleep and composure

Izvor: http://ajitvadakayil.blogspot.com/2010/12/fatigue-on-chemical-tankers-capt-ajit.htm

Full awareness

Medium awareness

Leve

l of

awar

enes

s

Total sleepiness

Low awareness

Consecutive days of reduce sleeping

The ILO and the ITF do not allow exceeding the scheduled number of hours of overtime because of the level of safety. Therefore shipper and administration regulate by the contract of seaman the by collective agreement for seafarers number of overtime hours. The overtime hours include hours outside of working hours, which include:

maneuver of the ship periodic maintenance and repair of the ship stay in the port enhanced marine guard because of the conditions

(low visibility, bad weather, etc.) unadjusted schedule of stays in port and navigation time zone changes other hours outside of working hours.

Research have shown that except insomnia other factors affect the fatigue;lightnoisevibrationsventilationtemperature and ship movement.

Figure 7. The effect of the employee during the day

Izvor: http://ajitvadakayil.blogspot.com/2010/12/fatigue-on-chemical-tankers-capt-ajit.htm

Working hours

Per

fom

ance

Fatigue has a negative impact on safe work. It increases human error. Errors occur as a result of lack of mental function. The immediate effects of human fatigue are: error in the judge loss of productivity errors in decisions injury at work.

In the ship's organization fatigue effects the occurrence of human errors, which often manifests by: accident collision damage to the ship or cargo by environmental pollution. Fatigue can be divided into five categories: physical discomfort loss of energy loss of motivation sleepiness.

Fatigue affects the health of the seamen and causes:

cardiovascular diseases hypertension diabetes stomach problems insomnia.

In addition, fatigue affects the social aspect of the seamen and the organizing crew and causes: problems with family reduces workperformance increases the number of errors increases sleepiness reduces teamwork reduces motivationincreases physical effort.

The intensity of fatigue is not manifested at all crew members the same, but it depends on: age lifestyles rhythm of life anamnesis weight previous working experience and habit.

Insomnia causes a decrease in energy, increase of fatigue and exhaustion. Fatigue caused in the history some of the greatest maritime accidents:

Stranding the Exxon Valdez (1989) The fire in the cargo holds Kometik (2006) Stranding Algomarine (2008).

Fatigue can be prevented by proper organization of activities on board. Assessment of human capabilities for performing the tasks is of crucial importance. Therefore, an officer during the organization of work on board must be familiar with: culture of crew members age of crew members nationality work experiencephysical fitness training programmes

Officers are trained for work organization through special programs: Psychosociology, human resources management of the bridge (Bridge Resource Management-BRM) and engine room (Engine Management team-ETM), etc. They are explained individual, national and cultural differences of multinational crew, their advantages and defects. In addition, officers are taught the proper work organization, avoiding stressful situations, behavior in crisis situations, etc.

Facts:The relaxation time of the organism Reducing of metabolism Pressure, pulse and respiration declineThe muscle tension reliefResting in a dream is more intense at the beginning and lower at the end. If we wake up before time, rest is not complete.

Rest periods for adults are on average 7 hours and 23 minutes on working days and one hour longer on non-working days (weekend)

Stages of sleepPhase 1: Transition from vigilance to sleepPhase 2: Sleeping with relaxing in smaller extentPhase 3 i 4: Sleeping with bigger relaxing, vigilance is harderREM phase = we are dreaming, brain is active. REM is not important for short-term

but for long- term memory.

Non-sleeping:OverworkLong vigilancePossible disorders the day earlierNightwork

Morning workSleep interrupts clock in the final stage of sleep The period of sleep is often 5 hours Increased sleepiness in the day, especially in the afternoon. Increased risk of accidents

Evening workNo sleepiness and work is safer Problem can be if you start earlier next week (shift change)

Other factorsLong working shift (longer than 10 hours) Short rest periods (less than 11 hours) Monotonous, hard, stressful work Drug use (abuse) Sleeping problems occur in the 45 year of life

AntimeasuresSleep will be compensated by increased sleep.Missed night of sleep can be replaced by another Break of 30 minutes is required, especially if there are messy shifts

Schedule techniquesNight shift should not be longer than four repeatedlyRotation in a clockwise direction Maximum of 8 hours, 11 hours of rest

If you work the night shift Have peace of sleeping Plan your sleep Slumber before shift Avoid heavy meals, especially carbo hydrates and fiber foodAvoid taking fluids before sleeping

Measures against fatigueChange your workSit in uncomfortable positionStand upTake a walkBreath fresh air Expose to noiseAmplify the lightTalk to your colleaguesCoffeeSongThese anti measures give short-term performance, the best anti measure is rest.

Caffeine stimulates alertness (Coca-Cola, tea contains 1/3 the caffeine of regular coffee). The normal dose of coffee gives vigilance. The effect lasts 6 hours, and the maximum effect gives the first cup.

Nicotine is a stimulant. Smokers are worse sleepers than non-smokers.

Alcohol increases sleepiness. Sleeping and anti-seasickness pills increase

sleepiness. The suppression of deep sleep has a

negative impact.

Exon Valdez Estonia

3 truths:Sea is dangerousYou cannot change the rules of natureMen can go wrong

The Master does not use proper human resources, only one man on the bridge.

It is important to have it, so the following should be considered:Time (past or required)PositionSpeedAutomatismResourcesPersonality, health, attitude

Frequent questions

Take information-What is happening? Answer- What does it mean for you and

the ship? Foresight- What can happen? Examples: noone is navigating the ship,

veering of the ship, information quality, susceptibility

Thank you! Questions???