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HUMAN ERROR

DEFINITIONEN zum "HUMAN ERROR" findet man u.a. in /30/ :

 

 

RIGBY (1970) :
“A human action is to be evaluated as an error if, as a result of it, the requirements established by the system are not met or are not met adequately.”

SWAIN (1992) :
“The term ‘human error’ covers all activities or omissions by a person that either cause something undiserable or that have the possibility of causing something undiserable.
…. This definition of the human error is taken in the context of the system, even though the main factors that contribute to an error, for example, can be due to absence of ergonomic design, procedures, training, or a combination of the above. This is why no guilt should be connected with the term ‘human error’”.

REASON (1990) :
„A human error is construed as a generic term that covers all occasions in which a planned sequence of mental or physical activities can fail to achieve an intended result and where this failure cannot be blamed on the intervention of an accidental triggering source.”

/ 30 / Sträter, O. : Evaluation of Human Reliability on the Basis of Operational Experience. – Dissertaion.- Gesellschaft für Anlagen- und Reaktorsicherheit (GRS) mbH.- August 2000. GRS – 170. ISBN 3-931995-37-2


Die US Coast Guard bezieht den „Human Error“ auf menschliche Handlungen oder Unterlassungen außerhalb einer durch ein System eingeführten Toleranz, selbst wenn sich keine ernsthaften Konsequenzen ergeben :

The term "human error" refers to human actions or inactions outside the tolerances established by a system, even if no immediate consequences occur. Systems within every industry are almost always subject to failure as a result of human error. 30)

30)http://www.uscg.mil/hq/gm/risk/e-guidelines(html/vol4/Volume4/Gen_Rec/ HumanErr.htm

Der “human error” umfasst :

- das Personal folgt nicht den vorgeschriebenen Verfahren oder hält Routinen nicht ein;
- unpassendes oder ungenügendes Training der Arbeiter oder der Mannschaft;
- Fehler in schriftlichen Betriebsanweisungen;
- Geräte- oder Systemgestaltung, Konstruktion oder Installationsfehler;
- ungeeignete oder ungenügende Inspektion, Prüfung oder Reparatur der Ausrüstung;
- mangelhafte Managementübersicht.
 

Der “human error” schließt keine beabsichtigten Handlungen ein, die im Zusammenhang mit schädlichen Absichten (z.B. Sabotage) auftreten.

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HINWEIS auf :

 

MCA RP545: Development of guidance for the mitigation of human error in automated shipborne maritime systems

Ian Rowley

This document is supplied by QinetiQ for the Maritime and Coastguard Agency Contract No. RP545 MSA/10/9/210. - QINETIQ/06/00037. - April 2006

Executive Summary

Background
As with other high hazard domains, the use of automation is increasing within maritimesystems. Although automation can be beneficial to operators of complex systems in terms ofa reduction in workload or the release of resources to perform other on-board duties, it canalso be detrimental to system control if errors are introduced through its use. In the maritimearea, human errors related to the use of automated ship-borne maritime systems have beenidentified as possible contributory factors to accidents and incidents at sea.This report is produced in response to the Maritime and Coastguard Agency’s (MCA)contract MSA 10/9/210. The MCA has a requirement for a research programme aimed atdeveloping guidance for the mitigation of human error in automated ship-borne maritimesystems. It is envisaged that this guidance material will be used by industry to assist inunderstanding how complex automated systems should be used on-board ships.

Maritime automation issues identified
A review of maritime incidents, accidents and related literature identified the following human element issues:

• Over-reliance on automation
• Lack of in-depth understanding
• Sub-optimal ergonomic design
• Sub-optimal Human-Computer Interface design
• Inherent system latency interfering with error recovery efforts
• Lack of awareness of automation failsafe modes
• Maintenance and calibration errors
• Poor support to development and maintenance of situation awareness
• Information overload issues
• Display inconsistencies between different manufacturers
• Poor appreciation of automation characteristics and limitations by operators
• Automation not designed around operators’ abilities and limitations
• Standardisation
• Human Factors
• Training
• Subsequent changes made to original automated system designs

The current taxonomy adopted for grouping maritime incidents may mean there are furthercases involving automation that cannot be retrieved with a standard search of the databases.



List of contents

1 Introduction
1.1 Background
1.2 Requirement

1.3 Structure of report

2 Identification of automation issues in commercial shipping and other high-hazard industries
2.1 Review of accidents, incidents and near misses in commercial shipping
2.2 Case Studies involving accidents, incidents and near misses in the commercial shipping industry
2.3 Other automation issues identified from maritime literature review
2.4 Automation issues identified from other industries
2.5 Summary of automation issues identified
3 Standards and guidance for addressing automation issues
3.1 Human Factors Integration plan
3.2 Standards and guidance from other high-hazard industries
3.3 Standards and guidance from the general human factors and ergonomics field
4 Training requirements to address automation issues
4.1 Training in the aviation industry
4.2 Development of Maritime Resource Management (MRM) training
4.3 Pedagogical Issues in MRM training
4.4 Current MRM courses
4.5 Comparison of Syllabi
4.6 Improving MRM Training
4.7 Suggested MRM Training curriculum
5 Guidance for automated maritime systems
5.1 Guidance for shore-based company management
5.2 Guidance for shipboard management
5.3 Guidance for automation users (e.g. Seafarers)
5.4 Guidance for automated marine systems
6 Conclusions
6.1 Maritime automation issues
6.2 Standards and guidelines for addressing the effects of automation issues
6.3 Training requirements to address automation issues
6.4 Guidance for automated maritime systems
7 Recommendations
7.1 Recommendations for further research
8 References

A Appendix A – Review of existing MAIB accident and incident reports that cite automation as a causal factor
B Appendix B – IMO Safety of Life At Sea (SOLAS) Chapter V Regulation 15
C Appendix C - IMO Specification of minimum standard of competency in crises management and human behaviour
D Appendix D - STCW Guidance on keeping a navigational watch
E Appendix E - STCW Guidance on keeping an engineering watch [proposed]
F Appendix F - IMO Model courses relevant to the mitigation of human error in automated ship-borne maritime systems.


                                                                       *** 

 

Vergleich zwischen einem aktuellen Bridge Resource Management Manual
und der Ausarbeitung des MARITIME SAFETY COMMITTEE , 88th session; Agenda item 16 / MSC 88/16/1, 20 August 2010 zur ROLE OF HUMAN ELEMENT / Just Culture – Essential for Safety, Submitted by the United Kingdom


Diethard Kersandt, 2014

Ziel des Vergleiches ist der Versuch der Einordnung eines anonymisierten BRM in eine Richtlinie der IMO zu Problemen des menschlichen Elements. Es soll die Frage beantwortet werden, ob die Hinweise aus dem BRM in ausreichender Weise Anforderungen an die ganzheitliche Systemgestaltung und Prozessführung erfüllen können, wie sie in dem aktuellen IMO – Dokument aufgeführt sind.
Durch eine kritische Betrachtungsweise des BRM-Manual sollen Reserven aufgedeckt werden und die grundsätzliche Betrachtungsweise des Problems (die „Philosophie“) um die Sichtweise der IMO zu erweitern. Der Verfasser unterstreicht die Analyse der IMO zum „human element“. Er weist auf seine Lösungsvorschläge (NTM - Nautical Task Manager für die Erhöhung der VERLÄSSLICHKEIT des ganzheitlichen Systems Schiffsführung hin.

The comments result from a comparison of the two documents. The aim of the comparison is an attempt to implement the BRM in a directive of the IMO problems of the human element. It should to answer the question whether the instructions in the BRM can fulfill requirements for the complete system design and process management in a sufficient manner, as in the current IMO - document are listed. By a critical approach of the BRM Manual reserves to be uncovered. The "philosophy" is to be extended by means of view IMO. The author emphasizes the analysis of the IMO "human element". He points to his proposed solutions (NTM - Nautical task management) towards the increase in the RELIABILITY of the holistic system ship operation.


IMO MSC 88/16/1 (20 August 2010) :

HOW IS THE WORLD DIFFERENT NOW?

 Recent developments in our increasingly globalized world – such as the world of shipping – emphasize the need to see it more as a complex system of interacting, circular relationships rather than a linear sequence of causes and effects.
What developments have produced this changed view?

 Rapid technological change – Technology is changing too fast for managers and engineers to keep up. This is affecting all parts of the maritime industry, e.g., bridge automation and navigation systems, real-time global tracking and management of vessels by their land-based owners, and high-tech vessel design and operation (e.g., LNG tankers).

 New ways to fail – Digital technologies create new kinds of failure and new kinds of accident. The traditional safety engineering approach of using redundancy to minimize risks does not work with (e.g.,) computer systems where redundancy adds complexity and thereby actually increases risk.

 Bigger disasters – The scale and expense of modern systems means that the human and financial harm resulting from accidents is becoming less acceptable. Learning from experience is not tolerable, and the emphasis must be on preventing even a single accident.


 More complexity – The development of highly complex systems frequently means that no one person understands the whole system or has complete control of it. Furthermore, the circumstances of their use can never be completely specified and the resulting variability of performance is unavoidable.

 More serious knock-on effects – Systems are increasingly tightly linked. This means a disturbance in one part of the system can have rapid, far-ranging and unpredictable ripple effects. It also means that many adverse events cannot be attributed to breakdown of compo-nents, but may be the result of unexpected combinations of performance variability that is essentially normal. In this view, adverse events are simply the other side of the coin from equally unexpected but beneficial events.


Bridge Resource Management Manual :

1. Philosophy of Bridge Resource Management

The ….. outlines our commitment to protecting the health, safety and security of our passengers, guests, employees and all others working on behalf of the Company and our commitment to protect the environment.
Bridge operations are directly related to the safety and environmental aspects of this policy. We recognize that proper implementation of Bridge Resource Management practices is the most effective way to mitigate the risk of having a navigational incident, thereby enhancing the safety of our passengers and crew and minimizing the risk of damage to property and the environment.

KE: Die Einführung der BRM - Praktiken allein reicht nicht ! Der effektivste Weg sieht anders aus. Grundproblem : der Mensch wird der Technik angepasst; eine gemeinsame Mensch- Maschine-Lösung gehört nicht zur "Philosophie" !

The introduction of BRM - practices alone is not enough! The most effective way is different. Basic problem: the man is adapted to the technology, a common human-machine solution is not a part of the "philosophy"!

Human error is inevitable. When errors are made, they must be detected, managed, analyzed and shared, not hidden, to provide learning experiences.

KE : Das ist zwar richtig, doch wer bemerkt den Fehler vor Eintritt einer schädlichen Folge ? Der Mensch findet seine Erfüllung in der Rückschau auf Gelungenes. Dadurch wird er in der Gegenwart unkritischer und versucht, Fehler zu verdecken !

KE : While this is true, but who noticed the error prior to the occurrence of a harmful consequence? Man finds its fulfillment in retrospect to Successful. Thus he is in the presence of non-critical and tries to hide error !

IMO MSC 88/16/1 (20 August 2010) :
Almost all accidents and incidents are attributable to the "human element", either through:


a) direct human error in the course of operations;

b) by failing to deal effectively with incidents once they arise; and

c) or latent human element issues – problems hidden within the overall system, often resulting from actions and decisions taken many years previously, e.g., design of equipment, weaknesses in the Safety Management System(SMS), inadequate training, recruitment and manning or policies and practices designed to meet certain commercial requirements.

IMO MSC 88/16/1 (20 August 2010) :
Decisions based on wrong interpretations of complicated or ambiguous information are usually the result of insufficient training or experience, or bad communications.


KE: This statement expresses in a single sentence the entire error of BRM - "philosophy." For shipowners and manufacturers, it is an argument that technical solutions do not adapt to the possibilities of man, but to concentrate all efforts on the people alone.

…... embrace a ‘Just Culture’ philosophy (Ref MSC 88/16/1, Just Culture Essential for Safety) that is strongly supported by relevant HR and safety policies. A ‘Just Culture’ is one that accepts error as a natural part of human behaviour and does not punish honest mistakes but still treats recklessness and negligence appropriately.
Integration of training programs, operating procedures and proactive safety analysis from lessons
learned further reduces the risk of an accident.

KE : Das setzt voraus, dass man qualitative Prozesszustandsverläufe messen, aufzeichnen und analysieren kann. Gegenwärtig gibt es dafür keine Werkzeuge. Die "black box" ist es nicht, da sie nicht bewertet.

KE : This requires that you can measure, record and analyze qualitative process state gradients. Currently, there are no tools for it. The "black box" it is not because the system can not rate the data.

Management endorses a philosophy of continuous improvement, under which Masters and officers should strive to promote and actively seek new ideas to improve their respective areas of operation and, consequently, the operation of the entire fleet.

KE : Was soll man wie verbessern, wenn die Zustände nicht messbar sind ? Die gesamte Philosophie bleibt ein Appell.
Das BRM allein ist in dieser Weise ein Beruhigungsmittel für Reederei und Öffentlichkeit.

KE : What should you do better and how you can do it, if the states are not measurable? The overall philosophy remains an appeal. The BRM alone in this way is a sedative for shipping company and the public.

Bridge Resource Management

The effective use and coordination of all resources available to the bridge team:
• human
• technical
• procedures

KE :Ist es möglich, an dieser Stelle die Bedeutung der Ressourcen "Daten" bzw. "Information" hervorzuheben, um auf den besonderen Charakter der Schiffsführung und ihrer notwendigen Weiterentwicklung hinzuweisen ?

KE : Is it possible at this point to emphasize the importance of resources "data" or information" in order to draw attention to the specific character of the ship operation and their necessary development?

 

IMO MSC 88/16/1 (20 August 2010) :

inadequate design – poor design of equipment, user controls and interfaces, or work procedures, increases workload, response times, fatigue and stress levels. It may also promote the invention and use of dangerous short-cuts;

KE: This fact should be mentioned at least on the BRM philosophy to increase the critical attention of the crew.

Bridge Status Board

A notice board which contains up to date information on the status of the ship (e.g. weather, permits to work in force, bridge manning level, equipment defects and if swimming pools are empty or full). The purpose of the status board is to give the bridge team an opportunity to quickly become familiar with the status of the ship by having the information in one place. (See example in Appendix I).

KE : Das ist ein hervorragender Ansatz ! Allerdings ist er hier eindeutig auf rein technische Abbildungen zugeschnitten.
Ergänzt werden muss die Abbildung der Qualität von Prozesszuständen in den partiellen Aufgaben der Schiffsführung.
Das bedeutet den Schritt von der reinen Signal- bzw. Datendarstellung zur Angabe ihrer Bedeutung zu gehen !
Das wäre ein außerordentlich wichtiger Beitrag zur kognitiven Modellbildung !

KE : This is an excellent approach ! However, he is clearly tailored here to purely technical illustrations. The picture of the quality of process states in the partial tasks of navigation must be complement. This means to go the step from pure signal or data representation to the state of their meaning! That would be an extremely important contribution to cognitive modeling!

IMO MSC 88/16/1 (20 August 2010) :

The real problem in safety-critical industries like seafaring is that some mistakes have such serious consequences that they need to be caught before they have a chance to develop into disasters.

IMO MSC 88/16/1 (20 August 2010) :

for example, a design flaw in an instrument panel made years before might combine with an engineer's tiredness, their preoccupation over difficult personal circumstances, and their insufficient training with the panel to produce the selection of the wrong setting, or an incorrect reading at a critical moment.

KE : In the BRM philosophy must necessarily be made aware of this relationship!

Charge


The officer in charge of a navigational watch, “the charge”, has overall responsibility for the safe navigation of the vessel. The charge is to be held by the most senior ranking member of the operational bridge team at any point in time. A pilot can never have the charge. The charge has to be formally taken/handed over in order to transfer this responsibility. Having the “charge” is not the same as having the Conn. The officer with the charge only has the Conn if s/he is also acting as Navigator.
If the officer with ‘charge of the ship’ wishes to assume the Conn, s/he must clearly state “I have the Conn”, so all members of the Bridge Team are aware of the transfer of responsibility. Urgent situations may arise, which require the officer with the “charge” to immediately take the Conn without completing the normal takeover procedure. In this case the officer with the “charge” can override the officer with the “Conn” by giving a countermanding order. Where possible this action should be preceded by clearly stating “I have the Conn”.

KE : Diese Festlegungen können sehr leicht durch die Berechnung des Prozess-zustandes und seiner zukünftigen Entwicklung unterstützt werden.

KE : These definitions can be easily supported by the calculation of the process state and its future development.

IMO MSC 88/16/1 (20 August 2010) :

How can we stop mistakes from becoming disasters?
There are two distinct approaches to this question:

a) one is traditional and assumes that the things that happen are in principle predictable and are due to cause and effect; and

b) the other has become much more important recently and assumes that many of the things that happen emerge unpredictably from the behaviour of complex systems.

KE : Yes, and so we have to work on the improvement of the system in its entirety: Increasing the reliability in an integrated man-machine system.

Procedure
A procedure exists in order to specify five things:
1. What the task is.
2. When the task is to be conducted.
3. By whom the task is to be conducted.
4. How the task is to be done and what actions need to be taken.
5. What the sequence of actions is to be.

KE : Ein Assistenzsystem (NTM) kann an dieser Stelle wertvolle Handlungsimpulse geben.

KE : An assistance system (NTM) can give at this point valuable impulses to act.

Thinking Aloud
A means of sharing verbally a mental model of the current situation and future intentions.

KE : Das halte ich für noch weitgehend ungeklärt. Würde man so verfahren, wäre die Gefahr des "Wettstreites" der individuellen mentalen Modelle und daraus resultierender Handlungen sehr groß.
Auch hier muss sich jedes individuelle Modell mit dem subjektiven Bild guter Seemannschaft messen. Was passiert, wenn eines davon falsch ist ? Aber : die Differenz zwischen IST und SOLL (hier nur subjektiv möglich) ist der Motor der Handlungsregulation !

KE : I think this is still largely unknown. If one were to proceed, the danger of "rivalry" of the individual mental models and resulting actions would be very large. Again, each individual model must measure with the subjective image of good seamanship. What happens if one of them is wrong? But the difference between ACTUAL and TARGET (only subjectively possible here) is the engine of action regulation!

Closed Bridge Condition
To ensure that the bridge team is not distracted from its duties, the bridge must be designated to be “closed” during Red Manning or at any time when it is considered necessary for the safe operation of the ship. When in effect, access to the bridge is limited to the Master, Second in Command and other personnel with operational functions.

KE : Die Zustände, die diese Maßnahmen erfordern, sind berechenbar. Der Verfasser hat ein Beispiel dafür vorgelegt.

KE : The states that require these measures can be calculated. The author has presented an example of this.

4. Functional Positions

KE : Ist das die einzige Chance des Reeders, Ordnung in das System zu bringen ?
Wie werden diese Dinge trainiert ?
Was passiert bei Personalwechsel ?
Hat man überhaupt soviel qualifiziertes
Personal (einheitliches Bildungs- und Erfahrungsniveau) ?
Wie sichert der Reeder den Zugriff auf das Signal- und Datenangebot technisch ab ?

KE : Is that the only chance of the shipowner to bring order into the system? How to train these things? What happens when personnel changes? If one has ever so much qualified Personnel (uniform education and experience level)? How can the shipowner realize the access to the signal and data offer?

6. Bridge Manning Levels and Functions

Policy

The Master will ensure that the manning level on the bridge is appropriate for both the current and anticipated risks and workload.

KE : Das kann er gegenwärtig nur nach seinem Gefühl entscheiden.
Auf welche Weise kann er Risiken und Arbeitsbelastung voraussehen ?
Lösung : Reiseplanung unter Zuhilfenahme von Verfahren zur Gefahrenberechnung.
Diese Richtlinie ist ein Entschuldigungszettel für den Reeder und ein unlösbare Verpflichtung für den Kapitän !

KE : He can currently only decide according to his feeling. In what way he can foresee risks and workload? Solution: Travel planning with the aid of methods for risk calculation. This Directive is an excuse note for the shipowner and a non- detachable obligation for the captain!


When setting or changing the bridge manning level, every effort shall be made to anticipate the need for resources as the risk or workload increases rather than waiting until the situation may exceed the capabilities of the existing bridge manning level. In an effort to remove hierarchical barriers and enhance teamwork and communication, the traditional rank based system is replaced by a function based bridge organization. The function based bridge organization introduces organizational countermeasures to detect and manage human error.

KE : Ein frommer Wunsch ! Mehr nicht !!!

KE : A pious hope! Nothing more!

The function based bridge organization does not diminish the authority of the Master. The Master assigns functions based on watch keeper competence and experience with the upcoming operation, making it a very adaptable system.
In an emergency situation, the Master is not bound by the specified manning levels, but shall instead establish manning levels that are most appropriate to ensure the safety of the vessel.

Procedure

What is the task?
Assign the appropriate bridge manning level and functions.

When?
Every effort shall be made to anticipate the need for resources as the risk or workload increases
rather than waiting until the situation may exceed the capabilities of the original manning level.

By whom?
The Master will identify required bridge manning levels and ensure that they are displayed on the
passage plan.

KE : Na dann viel Erfolg !
Diese Festlegung endet genau dort, wo sie nach einem Unfall immer endet : auf dem grünen Tisch der Untersuchungsorgane.
Dort weiß man ganz genau, wann was wie hätte gemacht werden können und müssen.

KE : Well, then good luck! This definition ends exactly where it always ends after an accident: on the green table by the investigative bodies. There one knows exactly when and what how could have been done and need.

Should conditions change, the officer who has the charge can at any time increase the manning level, in which event s/he must immediately notify the Master, or decrease the manning level, but only after consultation with the Master.

How?

When the bridge manning level is set or changed, the below risk factors table must be consulted to determine the proper manning level.
The “Bridge Manning Level” structure of Green, Yellow and Red Manning is provided as a tool to help determine the appropriate manning level on the bridge. It is structured to assist in ensuring that adequate personnel are on the bridge with full situational awareness before they are actually
needed. Additionally, the Master is to provide the bridge officers with clear criteria to assist them in determining when the manning level should change and the type and level of resources required to meet the specific manning level.
In determining bridge manning level, all relevant factors should be considered. These factors include but are not limited to:

• Vessel speed (planned and actual)
• Traffic
• Visibility
• Under keel clearance
• Distance to safety contour
• Time to grounding line
• Skill and experience of the watch keepers
• Equipment limitations
• Workload and distractions
• Significant whale activity
• Adverse weather conditions
• Watch keeper familiarity with cruising area
• Proximity of navigational hazards
• Zone of Confidence of ENCs

KE : Kann man diese Vollkommenheit von einem Menschen verlangen oder sollte er technisch unterstützt werden ?
Die Forderung ist unerfüllbar und durch die Praxis längst widerlegt (Unfälle).
Sie bedeutet : alle Signale, Daten aufnehmen, selektieren, ..., bewerten, Zusam-menhänge herstellen; Prioritäten festlegen.

KE : Can you ask for this perfection of a human or he should be technically supported? The requirement is impracticable and long since been refuted by the practice (accidents). It means that all signals receive data select, ..., evaluate, establish correlations; establish priorities.


The following tables are guides to assist the Master in determining the criteria for changes in the bridge manning level. They are structured to ensure that adequate personnel are on the bridge with full situational awareness before they are actually needed.
The Risk Factors Table defines the low, medium and high risk categories for waters, traffic and visibility. Based on the factors involved, bridge officers should use the Risk Analysis and Bridge Manning Table to determine the appropriate bridge manning level for the present or anticipated conditions. The Required Functions at Each Bridge Manning Level Table then defines the functions required for each bridge manning level.

KE : Der Verfasser dieser Kommentare hat dazu eine Lösung unterbreitet und sie der Reederei angeboten.

KE : The author of these comments has also put forward a solution and offered that to the shipping company.

7. Communication

Policy

Effective communication is vital for team situational awareness, team co‐ordination, leadership and decision making.

KE : Was ist "team situational awareness"?
Jedes Individuum nimmt eine Situation individuell war und bewertet Signale, Daten, Informationen nach seinen eigenen Vorstellungen. Die individuelle kognitive Modellbildung ist eine wichtige Voraussetzung für die Kommunikationsfähigkeit ! Die Forderungen sind sicher nicht falsch, doch wer entscheidet, was eine "essential ... conversation" ist ?

KE : What is "team situational awareness"? Each individual perceives a situation individually and evaluates signals, data, information on his own terms. The individual cognitive modeling is an important precondition for the ability to communicate! The demands are certainly not wrong, but who decides what an "essential ... conversation" is?

KE : Insgesamt ist diese "Richtschnur" viel zu schwach und trifft den Schwerpunkt moderner Informationsverarbeitung und Kommunikation in einem Prozessleitsystem mit vielen technischen Einheiten, hoher Dynamik, Komplexität und Zufälligkeit nicht.
Moderne Mensch-Maschine-Schnittstellen verkörpern mehr als die Kommunikation zwischen Individuen !

KE : Overall, this "guide" is much too weak and does not meet the focal point of modern information processing and communication in a process control system with many technical units, high dynamics, complexity and randomness. Modern man- machine interfaces embody more than the communication between individuals!



7.2 Thinking Aloud

Policy

Wrong decisions are often caused by a lack of situational awareness. The intent of thinking aloud is to develop a shared mental model of the current situation and future intentions in order to prevent the development of a possible human error.
Thinking aloud is a tool to enhance the situational awareness of the bridge team.

KE : Das laute Denken verhindert nicht den Unterschied zwischen Realität und technisch abgebildetem Modell. Wird diese Abbildung durch Erwartungen und Routine, durch Ablenkung und Fehlinterpretation ergänzt, mindert das die Qualität des Vergleichsprozesses zwischen wahrgenommener Abbildung und innerem Modell einer "guten Seemannschaft" als "SOLL" / PLAN.
Mit diesen Mängeln behaftet, kann das formale laute Denken zwar nach Vorschrift ablaufen, jedoch auch total am Ziel vorbeilaufen (Illusuion) :
Es wird zwar laut gedacht; das Ergebnis aber ist falsch !

KE : The thinking aloud does not prevent the difference between reality and technically pictured model. If this image accompanied by expectations and routine, through distraction and misinterpretation, that reduces the quality of the matching process between perceived image and inner model of "good seamanship" as "TARGET" / PLAN. Fraught with these shortcomings, can indeed run the formal thinking aloud to rule, but also totally to miss the mark run (Illusuion): Although it is thought aloud, but the result is wrong!
...

Procedure

What is the task?
To challenge a navigational decision.

When should it be done?
• When a deviation from the plan is made by the person with the Conn without properly explaining intentions in advance.
• When a bridge team member is not sure that the correct decision has been made.

By whom?
A challenge can be made by any bridge team member who does not have the Conn. If the Conn is kept by a person more senior in rank, s/he must ensure that the more junior officers understand that they are expected to challenge any navigational decision raising a concern.

 

How?
In any case of challenging navigational orders, questionable acts or omissions, the PACE process should be used. This acronym, widely used in aviation, is applicable to the marine industry. It has been determined to be the best means for a bridge team member to address questionable acts or omissions with minimal likelihood of adverse confrontation or embarrassment.


P (probing for better understanding) Would you explain...?
A (alert to anomalies) It appears to me that if..., then...(will happen).
C (challenge) This course of action places our ship in danger.
E (emergency) response to immediate danger. If you do not immediately...

KE : Meine Lösung : eindeutige qualitative Beschreibung / Berechnung des Prozess- Status mit der Positionierung in Betriebsbereiche als Grundlage der Handlungsregulation und Vorausberechnung der Entwicklung für die nächsten 9 Minuten.

KE : My (author's) solution: clear qualitative description / calculation of the process status with the positioning in operating areas as the basis of action regulation and prediction of the development for the next 9 minutes.

When responding to a challenge, remember that it is not the person who is being challenged but the navigational decision. When responding to a challenge, it is important to ensure that the person making the challenge will feel s/he can do so again. In this way, a “safety net” is created around the bridge operation.

 

Example
If the Navigator’s intention is unclear to the bridge team, they should challenge the Navigator’s understanding of the situation. If the Co‐Navigator does not agree with the Navigator’s intention following the challenge and if agreement is not reached, the Co‐Navigator is to call the Master.

KE : Siehe Beitrag von Hederström, Kersandt, Müller im "Journal of Navigation"

KE : see Article by Hederström, Kersandt, Müller "Journal of Navigation"

...

7.4 Briefings

Policy
A briefing is an important management tool to prepare the team for the operation ahead by developing a shared mental model of the operation.

KE : Das ist ein Problem der Risikoplanung mit angenommenen Prozessindikatoren.
Der Unterschied zu gegenwärtigen Lösungen : man kann den Gefahrenzustand eindeutig einordnen, muss keine Vermutungen anstellen und kann Parameter so verändern, dass die Gefahr als Prozesskenngröße "greifbar" und gestaltbar wird.

KE : This is a problem of risk planning process by means of assumed indicators. The difference with current solutions: one can classify the hazardous condition clearly, must not speculate and can change parameters so that the risk as a process characteristic is "tangible" and can be designed.

The team is created at the briefing. Crewmembers bring with them not only their knowledge and skills, but also their expectations, hopes and worries. The person performing the briefing should use it as an opportu-nity to build team cohesiveness and keep the team informed about expected conditions and possible problems. The person performing the briefing must emphasize to team members that their ideas and inputs are valued.
To create a safety net around the operation, a briefing must end by emphasizing that challenges are expected and welcomed whenever there is any doubt or when there is a deviation from the agreed plan.
Briefings must not interfere with the navigational watch.

...

7.5 Debriefing
7.5.1 Successful Evolution

Policy
The purpose of a debriefing is to learn from experience in order to make improvements. The
Master shall conduct a debriefing after every arrival and departure and after any other event for
which s/he deems a debriefing to be appropriate.

KE : Eine ganz große Chance !
Die Verfügbarkeit über Daten und ihre fachgerechte Aufbereitung verkörpern die eigentliche Macht über das Wissen als zukunftsorientierte Geschäftsgrundlage.
Das setzt voraus, dass man Gefahrenkurven berechnen und aufzeichnen, abrufen und hinsichtlich ihrer Ursachen auswerten kann
(Grundlage für Systementwicklung, Kompetenzbewertung und Simulation).

KE : A very big opportunity! The availability of data and their professional preparation embody the actual power about the knowledge as a future-oriented basis for business. This requires that you calculate and record hazard curves, retrieve, and can evaluate their causes (Basis for system development, competency assessment and simulation).

Even if there were no issues during the operation, there will still be things to consider. For example, another member of the bridge team may have observed something that the Master did not notice. If given the opportunity, this team member may be instrumental in bringing about improvements. The more junior team members should first be given the opportunity to share their views.
Debriefings must not interfere with the navigational watch.


7.5.2 Significant Learning Experience

Policy
If a situation has occurred where safety was compromised, the Master must lead a debriefing.
Involved officers will be expected to participate fully. Debriefing is an excellent method of learning from experience. Failure to learn from experience increases the likelihood of repeating mistakes.

KE : Dazu muss er auf die aufgezeichneten Gefahrenkurven zurückgreifen können, aus denen die Schwerpunkte (Spitzen) mit ihren Ursachen erkennbar sind.

KE : To this end, he must have access to the recorded hazard curves from which the focal points (peaks) can be identified with their causes.


Procedure

What is the task?
Debrief the team after a nautical learning event.

When?
• As soon as possible after an operation, while it is fresh in everyone’s mind.
• Allow adequate time.
• Consider using VDR and/or INS replay functionalities.

KE : Das ist natürlich deshalb sinnlos, weil zwar die Daten abrufbar sind, aber jede Bewertung vermissen lassen. Eine nachträgliche Bewertung und Ursachenforschung trägt immer den Mangel der Subjektivität und gegebenenfalls der Rechtfertigung.

KE : This of course is therefore pointless because, although the data are available, but lack any review. A posteriori evaluation and root cause analysis always bears the lack of subjectivity and, where appropriate justification.


By whom?
1. The Master starts the debriefing by pointing out some positive aspects.
2. The Master next deals with his/her shortcomings. The Master must show that s/he is taking full responsibility for the outcome.
3. After examining his/her own role, the Master should facilitate discussion by the bridge team members involved in the event.
Once the Master has opened the door to discussing personal shortcomings, the officers will be ready to bring up their own for discussion. They will at least be more inclined to accept the Master asking questions about their performance.

Points to Consider
• Critique of errors must be corrective in a positive sense and directed toward behavior and not the individual.

KE : Natürlich ! Genau hier haben wir das soeben angesprochene Problem.

KE : Of course! Right here we have the just described problem.


It should be treated as a learning experience. No blame should be attached.
• Problems should be dealt with as team issues rather than focusing on individuals.
• Action plans must be developed based on the debriefing. If appropriate, suggestions for amending checklists, policies or procedures should be made.
• Good debriefings develop cohesion within teams.
• A debriefing should end on a positive note.
...

7.6 Situation Report (SITREP)

KE : Das kann sicher in Zusammenhang mit einem FOC gesehen werden.
Hier eröffnet sich die große Chance der Verallgemeinerung von Erfahrungen.
Das geht aber nur, wenn man gleiche Bewertungskriterien für die Qualitätsberechnung verwendet.

KE : Which can be seen in the context of a FOC. This opens up a great opportunity the generalization of experience. This will only work if you use the same evaluation criteria for the quality calculation of partial tasks in ship operation.

Policy
A SITREP can be requested by any officer in the bridge team and should be conducted by the officer in charge. It should be used to ascertain team situational awareness whenever there is a doubt about this. A SITREP should not be called if it would compromise the immediate navigational duties of the bridge team so as to endanger the safety of the vessel. Examples of when a SITREP should be called include:
• The Master is called to the bridge as a difficult situation has developed.
• The Operations Director feels that one or more team members have lost situational awareness.
• A situation is developing that requires special attention.
...

9. Nautical Meeting

Policy
The purpose of this meeting is to have a process for continuous improvement and professional development of the bridge team. It should serve as a forum for the Master’s ongoing review of best practices with deck officers to continue their coaching and development ‐ probing, questioning, searching for problems and solving them.
It is also a valuable feedback tool for management to understand the possible differences or “gap” between written bridge procedures and onboard practices. If the bridge team identify such a gap,
they should propose an amendment to the written procedure or change their practices in order to close the gap.
...

IMO MSC 88/16/1 (20 August 2010) :

STEPS TOWARDS A "JUST CULTURE"

Address corporate and legal issues
 Need to obtain unambiguous boardroom commitment
 Need to create indemnity for incident reporters against legal proceedings – this may require changes to existing legislation
 Need to separate reporting system staff from disciplinary staff

Design and integrate reporting system
 Need to identify responsibilities and incident report investigators with domain expertise in safety, operations, management and HR
 Need to create a rapid, efficient reporting process that captures and yields useful information at the right level of detail
 Need to create clear, easily-accessible process that will be used and trusted
 Need to decide if new process will be integrated with current incident-reporting procedure
 Need to create investigative and assessment processes for deciding accountabilities and action

Develop, promote and roll out reporting system
 Need to identify and assign development resources
 Need to identify champion(s) and communications strategy
 Need to educate users
 Need to collect feedback from users
 Need to feed back useful results to users at all organizational levels – including impact on production, efficiency, communication and cost benefits

...


Conclusion

The conclusion of the research carried out by the United Kingdom is that a Just Culture is the essential component underpinning safety and business success:

 Business success depends on managing risks effectively
 to manage risks you need an effective safety culture
 to have an effective safety culture you need an effective learning culture
 for an effective learning culture you need an effective reporting culture
 which cannot exist without an effective Just Culture.

...

Here are three reasons with particular relevance for the maritime industry:

a) expertise must be developed, retained and exploited. In the face of pressure for greater efficiencies, people at all organizational levels work hard to understand the routes to failure and to develop alternative strategies, while all the time creating and maintaining whatever safety margins they can. Central to their success is the depth of their expertise. It permits them to read complex situations, project into the future, and to follow timely and effective courses of action. Organizations that fail to invest in developing such expertise, or that fail to protect their experts from the legal and corporate consequences that flow from the decisions they took in good faith, will ultimately fail economically. The experts will leave as soon as they perceive the risk to them is too great. For example, one reason why it has become increasingly common for masters to get shore jobs as soon as they are qualified is to avoid potentially serious criminal charges should they make a mistake;

b) organizations must pay attention to their "fault lines". Assessment of the risks of operational error or adverse events often miss the point that the real risk to safety critical operations is in the interfaces – the natural fault lines – between an organization's different parts. These include the "fault lines" between training and practice; managers and operators; designers and users; shipowners and crews; officers and ratings; efficiency and thoroughness. Focusing on the real risks is one challenge. Another, is knowing how these risks are changing over time and, in particular, how far the organization is drifting towards dangerous levels of behaviour. Many maritime organizations collect data on accidents and near misses.
However, most then analyse this data for "missing" rules rather than to optimize interfaces or detect and correct dangerous drift; and

c) decision making must be based on systems thinking. All safety-critical industries are formed of different organizations which must interface successfully. In the maritime industry, these include shipbuilders, shipowners and managers, Masters and crews, port authorities, flags, insurance clubs and so on. In the absence of applied systems thinking, organizational decisions are taken that are locally optimized (i.e. too narrowly focused on a small part of the problem) at the expense of global effectiveness. There are countless examples of this in the maritime industry – mostly driven by apparent opportunities to save money in the immediate future.


- end of documents -

 

SOLAS Chapter V

 

Auszug

Regulation 15 - Principles relating to bridge design, design and arrangement of navigational systems and equipment and bridge procedures

 

Summary
Requires owners, naval architects, manufacturers and administrations to ensure compliance with specified ergonomic principles.
Requires owners and masters to ensure that bridge procedures are adopted which take ergonomic criteria into consideration

 

Regulation 15
1.
All decisions which are made for the purpose of applying the requirements of regulations 19, 22, 24, 25, 27 and 28 and which affect bridge design, the design and arrangement of navigational systems and equipment on the bridge and bridge procedures* shall be taken with the aim of:
1.1
facilitating the tasks to be performed by the bridge team and the pilot in making full appraisal of the situation and in navigating the ship safely under all operational conditions;
1.2
promoting effective and safe bridge resource management;
1.3
enabling the bridge team and the pilot to have convenient and continuous access to essential information which is presented in a clear and unambiguous manner, using standardized symbols and coding systems for controls and displays;
1.4
indicating the operational status of automated functions and integrated components, systems and/or sub-systems;
1.5
allowing for expeditious, continuous and effective information processing and decision-making by the bridge team and the pilot;
1.6
preventing or minimizing excessive or unnecessary work and any conditions or distractions on the bridge which may cause fatigue or interfere with the vigilance of the bridge team and the pilot; and
1.7
minimizing the risk of human error and detecting such error if it occurs, through monitoring and alarm systems, in time for the bridge team and the pilot to take appropriate action.
* Refer to Guidelines on ergonomic criteria for bridge equipment and layout (MSC/Circ.982) and the Performance standards for IBS (resolution MSC.64(67); annex 1); and for INS (resolution MSC.86(70); annex 3).

MCA Guidance
1.
Regulation 15 applies primarily to companies, ship builders and naval architects. Masters and watchkeepers of all vessels are responsible for ensuring the efficient deployment and use of bridge resources in particular noting the requirements of 15.6.
2.
The Regulation addresses the principles to be followed in the design and layout of ships' bridges and the establishment of bridge procedures using ergonomic criteria. These criteria are detailed in IMO MSC/Circ.982. Where ships are fitted with Integrated Bridge Systems (IBS) or Integrated Navigational Systems (INS) the appropriate IMO Performance Standards should be referred to. (For Performance Standards see also

Regulation 18).
3.
The Regulation specifically covers decisions which are made for the purpose of applying the requirements of Regulations 19 (Navigational Equipment), 22 (Bridge Visibility), 24 (Heading/Track control systems), 25 (Operation of main source of Electrical Power and Steering Gear), 27 (Nautical Charts and Publications) and 28 (Records of Navigational Activities.)
4.
The Regulation addresses designers, manufacturers and shipowners with respect to the bridge design and layout. However, the responsibility for ensuring correct bridge procedures are adopted lies with the Master.
5.
Masters should therefore be familiar with the principles involved to ensure that personnel are fully familiar with the equipment and its layout and that procedures are adopted which optimise the design and layout of the ship's bridge.
6.
Of particular importance to Masters is paragraph 1.6 relating to the prevention or minimisation of unnecessary work or distractions in order to minimise fatigue and maximise the bridge team's vigilance.
7.
The MCA considers that MSC.Circ/982 is intended for guidance and documentation is not required to verify compliance with individual guidelines. However compliance is required with the international standards given in Appendix 3 of MSC.Circ/982. For plan approval of bridge design compliance should be demonstrated with:

 

ISO 8468 (Ships’ Bridge Layout and Associated Equipment – Requirements and Guidelines,) and if applicable
ISO 14642 (Ships and Marine Technology – Ships’ Bridge Layout and associated Equipment – additional requirements.)
Bridge equipment should demonstrate compliance with the ergonomic requirements given in:
IEC 60945 (Maritime Navigation and Radiocommunication Equipment and Systems – General Requirements – Methods of Testing and Required Test Results)


8.
For Integrated Bridges, the MCA requires documentation showing compliance with Resolution MSC.64(67) Annex 1 (Performance Standards for Integrated Bridge Systems) and particularly a documented failure analysis.

                                                            ***                                                             

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