Human Performance

Handbook

Accredited by:
 Human Performance
This handbook is provided as a refresher to the course(s) you attended and
sets out the principal points of human performance and non-technical skills
you need to become an effective leader or manager.

Human Performance is about the relationship between people and how

people interface with complex technology.

Additional ‘tools’ that ‘bond’ this human performance model together

and bring about organisational improvements are:

Understanding Situational Awareness.

The importance of quality Decision Making.

Health Issues – including managing stress and fatigue.

Professional Conduct.

The significance of Nationality, Language and Culture.

The importance of appraisals.

 Contents

Section Page

1. Introduction 1

2. Communication 5

3. Leadership and Management 15

4. Team Skills 30

5. Management Systems 36

6. Professional Conduct 42

7. Appraisals 44

8. Situational Awareness 47

9. Decision Making 53

10. Nationality, Language and Culture 58

11. Health Issues – Stress & fatigue 61

12. Risk Management 70

13. Summary 84

14. Acknowledgements 86

Appendices
Appendix A: Incident Analysis Checklist 88
Appendix B: Incident Investigation Prompt List for
Underlying Causes (Latent Failures
or Latent ‘Pathogens’) 90
 Introduction

WrightWay Training Limited’s Human Performance training courses are

designed to equip people with an understanding of the human issues that may
affect them when designing, building, maintaining and operating within any
organisation. The courses are particularly relevant for those using safety
critical technologies.

The courses highlight the particular importance of high quality leadership,

management, communication and teamwork, to the success of any
undertaking and to the safety and health of its employees, contractors and
customers.

Many blue chip companies recognise that successful business leaders

develop a ‘one team’ approach, where all employees feel part of a single
company team who are enthused, involved, engaged, satisfied, empowered
and therefore motivated. They recognise that this leads to increased
productivity, lower turnover, lower absenteeism, reduced costs and reduced
losses through running a safer and more efficient organisation.

The keys to this change are:

Developing management, leadership and interpersonal skills which are
the so called ‘soft or ‘non technical’ skills.
The development of employee’s skills to enable each individual to
attain his full potential. As well as providing the necessary technical
training, this is done by systematically improving job satisfaction,
flattening hierarchies, empowering people and by introducing self
imposed accountabilities for everyone.
Improving communication in all areas of the business.
Implementing an Integrated Management System where Health,
Safety, Environment, Quality and service & manufacturing excellence
are all managed in one single seamless loss management system.

Technical excellence alone is not sufficient to ensure good performance.

Knowledge and application of non-technical skills is essential to the success
of any enterprise, as high profile loss events can, and have, cost companies
their business. For this reason alone, understanding human performance is
vital to business survival in the 21st century.

The ‘human factor’ plays an important part in both causing and preventing
incidents and there are many examples of disasters where poor human
performance played a key part. Human error is responsible for approximately
70 to 80 per cent of all accidents, of which about three quarters have their
origins within the organisational culture. Learning from past loss events and

Human Performance Handbook 1

high potential ‘learning opportunities’ is vital to avoiding similar disasters in the
future.

The Civil Aviation Authority (CAA) and the Federal Aviation Authority (FAA)
have made human factor training mandatory for all flight crew. Other
industries, notably the nuclear, marine, medical (anaesthetists) and fire
services are now realising the importance of this type of training in the quest
to reduce accidents and incidents.

Human Performance training addresses everyday skills, which some may

think are acquired with common sense. However, common sense is
apparently not very common, since accident investigations often reveal that it
was not applied.

Human Performance training is much more than just an examination of

behavioural errors, since the principles also apply to the ‘design’ of the
equipment and plant and not just to its ‘operation’. Before knowledge of
Human Performance became better understood, the statement often made
was, “The cause was human error”, i.e. blame the captain or operator and
look no further. Unfortunately this approach regularly fails to get to the root of
the problem.

In this handbook the terms ‘loss event’, ‘loss management’ or ‘loss

avoidance’, are generally used instead of ‘health and safety’, because harm to
people, vitally important though this is, is only a part of the picture and use of
the word ‘Safety’ can sometimes ‘turn off’ people’s minds. The British Health
and Safety Executive define it succinctly:

‘An accident is any unplanned event that results in injury or ill health of
people, or damage or loss of property, plant, materials or the environment or a
loss of business opportunity.’

This handbook has been produced to explain:

The vital non technical skills associated with communication,

leadership, management and teamwork.
How and why we behave in certain situations.
How we arrive at the decisions we make.
What affects our understanding of a situation (although we often think
we understand).
What prevents us from doing the task safely and getting it right first
time.

Human Performance Handbook 2

Examples of Human Factor related incidents from a number of
industries (Figure 1.1)

Figure 1.1

Human Factor Date Comments Fatalities / injuries /

related Incident consequence

Barings Bank 27-Feb-95 Bankruptcy of an old Bankruptcy of the

respected bank oldest merchant
through one sole rogue banking company in
trader’s behaviour - England, having
Organisational and been founded in
systems failures 1762 by Sir Francis
Baring

Enron 02-Dec-01 Collapse of a very The largest

large energy trader - bankruptcy in US
Organisational and corporate history
systems failures

Piper Alpha oil 06-Jul-88 Poor shift handover, 167 fatalities

platform permit to work system,
(UK sector of lack of proper
North Sea) emergency planning

Grounding of 24-Mar-89 Spilt entire cargo of oil Environmental

tanker Exxon in Alaska. disaster
Valdez Organisational failures.
Failure in CRM

Tenerife air crash 27-Mar-77 Loss of situational 582 fatalities

awareness. Autocratic
management style.
Organisational failures

Bhopal Chemical 2/3 Dec-84 Maintenance related. 2500 fatalities, many

plant (India) Organisational failures left with poor health

Herald of Free 6th Mar 87 Lack of procedures 187 passengers &

Enterprise crew died

Human Performance Handbook 3

The incidents in Figure 1.1 are just some examples of an error chain being
allowed to develop and then remaining unbroken to the point of disaster, due
to the ‘Human Factor’. It is from these types of loss events that lessons need
to be learnt to avoid further incidents.

To avoid expensive business and safety losses it is also necessary to

proactively carry out the following:

Put in place robust business and safety management systems. (See

section 5)
Carry out business and safety risk assessments (See Section 12).
Create a company culture which ensures that all ‘learning opportunity’
near miss loss events are reported and then priced by potential
outcome.
Ensure systemic organisational changes are made, as and when
necessary, following loss event investigations.

Human Performance Handbook 4

 Communication

COMMUNICATION ???

“I know you believe you understand what you

think I said, but I ’m not sure you realise that
what you heard is not what I meant ”

Effective communications underpins everything contained in this

handbook and is the key to efficient Human Performance.

Most managers devote almost all day to various types of interpersonal

communications.

Research has identified that:

60% of the day is spent in some form of oral communication

(53% face-to-face and 16% on the telephone).
25% is spent writing and handling correspondence.
3% is devoted to problem solving, conceptualising and planning.

Even front line supervisors and middle managers spend up to 80% of the day
communicating with others.

We have all heard the expression "actions speak louder than words: If people
are to trust the things we say, our behaviour must confirm our words. This is
particularly true of the actions observed by others in our non-verbal
communication. Our attitudes and demeanor must be congruent with our
words.

Human Performance Handbook 5

Communication takes place in many different forms and uses various
mediums including radio, telephone, email, video conferencing and the written
word in a range of forms. It is essential, especially within our working
environment, that we get it right.

In achieving efficient communication we are often faced with difficulties such

as, language, cultural aspects, noise distractions and lack of knowledge. The
potential for confusion and misinterpretation are high.

In all communication there must be a transmitter and one or more receivers

and we have to spend time in both roles for it to work effectively. It is vital for
the receiver to have both time and space to be able to think and formulate a
response. In communication it is quality, not quantity that matters.

Personal face to face communication - Verbal and

non-verbal
During a normal, face to face communication we usually transmit and receive
in a combination of three ways. These are:

What is said.
How it is said.
Body Language.

Research has shown that 7% of communication is by words, 38% through the

way we speak (intonation & inflection of our voice), and 55% by the use of our
‘body language’ (conscious or unconscious). See Figure 2.1

Figure 2.1

The words
7%

Body The tone

language 38%
55%

Human Performance Handbook 6

 "It's not what you say it's the way that you say it!"

During periods of high workload, or when stressed, our body language is

usually unnoticed.

Remember! During these times the words we use and the way in which we
say them have greater importance and our ability to listen reduces as our
workload and stress increases.

Figure 2.2

Communication

Workload versus Listening Capability

120

100

80
Workload
60
Listening
40

20

Some key points to understand in verbal communication are:

Communication involves both a transmitter and a receiver – the person
transmitting the message must have the ability to articulate the
message and the receiver needs the willingness and ability to
understand the intended meaning. What we say, how we say it and
when we say it are very important.

If the intended receiver is overloaded there is no point in trying to have

quality communication with them. If the message is extremely important
then the workload needs to be lessened (See Figure 2.2). If the
message is just spoken it is known as ‘broadcasting’ and the
transmitter will be satisfied that he has said what he wanted.
Unfortunately there is no guarantee that the receiver has heard, or that
they will act upon it. If the message is not vital it should be left until a
more appropriate time.

When intending to communicate you should ask yourself if you have

the receiver’s attention. Some, or all, of the message will be lost or

Human Performance Handbook 7

 misunderstood if the recipient is not paying attention. Often positive
attention getting techniques must be employed. These include using a
person’s name and/or touching them on the arm to ensure you gain
their attention.

Hearing and Listening

There is a difference between hearing and listening. Hearing is a mechanical
process involving sound waves being translated by the mechanism in the ear
into something identifiable. Listening is when we actively put logic and context
to the sound.

A conversation or discussion is usually more than just an exchange of

questions and answers. We need to understand how the listening process
works to appreciate that someone may only listen to part of what is said.

Figure 2.3

Attention Loop

Attention Level

Talking
ME

YOU
Listen Plan

Evaluate
Time

A typical exchange would be:

LISTEN - An active process that involves our minds.

EVALUATE - Considering what is being said and asking:

Does it make sense?
Is it in context?
Do we wish to respond?

PLAN - Plan what we are going to say and wait (or not) for an
opening.

We only listen to about one third of what we hear if we are interested. It will
be much less if we are not interested.

Human Performance Handbook 8

Often we go round the Listen / Evaluate / Plan loop a number of times before
speaking. Our tendency is to listen to the early part of any communication as
we are not only evaluating what we have heard but also looking for a place to
break in and speak. One of the first things to suffer is our listening ability and
we may drop out of this attention loop.

Questioning Skills
Questions can be put in many different ways and the way they are put can
control a discussion.

There are several types of question. The five most used, with common
response types, are:

Type Response

Closed - A fact or YES / NO

Open - Invites an extensive reply

Leading - Indicates the required answer

Limiting - Restricts options

Multiple - Confusion

The type of question asked will dictate the reply received. It is necessary to
communicate clearly, concisely and precisely so that misunderstandings are
avoided. This is not always easy but is vital.

Use of the appropriate type of question can reduce the possibility of

misunderstanding and help in the flow of relevant information. From the
Attention Loop diagram, it can be seen that we only listen to part of what we
hear, especially when in a stressful situation or when workload is high. We
should always ensure that there is positive acknowledgement of all vital
messages with closed loop communications.

Having asked the question we must also practice good listening skills.
Listening means you want to hear others and you will subsequently ask
further questions helping people to articulate their responses.

Listening skills include:

Non-verbal signs using body language such as eye contact and
posture.
The use of verbal attends, which are small verbal acknowledgements
during the other person’s transmission.
Not showing impatience to speak.
Replying based on what has been said by the other person.

Human Performance Handbook 9

 Backtracking - summarising what the other person has said. This
includes checking understanding.
Reflecting – feeding back some of the other person’s words. This
demonstrates close listening.

Be aware of information overload in others and yourself. As a team leader, be

conscious that your own behaviour will affect the remainder of the team.

We are always communicating. Even when silent we are communicating and

we may imply any one of a number of emotions or feelings. We should
consider what effect our own personal style can have on others. (Figure 2.4)

Figure 2.4

Communication
How you think and feel

Affects
Affects
how
how you
others
behave
behave

Affects how other person

thinks and feels

Some good practices in oral communication include:

Control of distractions.
Make visual eye contact when possible.
Clearly identify the transmitter and receiver.
Be clear, precise and concise.
Avoid words that could be misinterpreted.
Use phonetics for alpha-numeric information.
Obtain verification from the receiver that the message is understood.
Acknowledge verification (closed loop communication).

Human Performance Handbook 10

 Communication
Listen
carefully to what is said

Respond
to what was said; if necessary
asking for clarification

Act
do something

Emotional Intelligence
What is it?
Knowing one’s emotions: Self-awareness – recognizing a feeling as
it happens is the keystone of emotional intelligence. The ability to
monitor feelings from moment to moment is crucial to psychological
insight and self-understanding. An inability to notice our true feelings
leaves us at the mercy of those feelings. People with certainty about
their feelings are often good pilots of their own lives. They have a surer
sense of how they really feel about personal decisions such as who to
marry or which job to take.

Managing emotions: Handling feelings so they are appropriate is an

ability that builds on self-awareness. This basic emotional skill
concerns the capacity to soothe oneself and to shake off anxiety,
gloom or irritability. People who do not have this ability are often feeling
distressed, while those who can handle this feeling can bounce back
far more quickly from life’s setbacks and upsets.

Motivating oneself: Marshalling emotions in the service of a goal is

essential for paying attention, for self-motivation and mastery, and for
creativity. Emotional self-control – delaying gratification and stifling
impulsiveness underlies accomplishment of every sort. Being able to
get into the “flow” state enables outstanding performance of all kinds.
People who have this skill tend to be highly productive and effective in
whatever they undertake.

Recognizing emotions in others: Empathy, another ability that builds

on emotional self-awareness, is the fundamental “people skill.” This is
about awareness of the roots of empathy, the social cost of being
emotionally “tone-deaf,” and the reasons empathy kindles altruism.
People who are empathic are more attuned to the subtle social signals

Human Performance Handbook 11

 that indicate what others need or want. This makes them more suited
to roles such as the caring professions, teaching, sales and
management.

Handling relationships: The art of relationships is, in large part, skill

in managing emotions in others. It is about social competence and
incompetence, and the specific skills involved. These are the abilities
that underpin popularity, leadership, and interpersonal effectiveness.
People who excel in these skills do well at anything that relies on
interacting smoothly with others; they are social stars.

Developing Emotional Intelligence - Top Ten Suggestions:

1. Label your "I feel impatient." - "This is ridiculous."

feelings, rather than
labelling people or "I feel hurt and - "You are an insensitive
situations. bitter." Versus, fool."

"I feel afraid." - "You are driving like an

Versus, idiot."
2. Distinguish Thoughts: I feel like...& I feel as if.... & I feel that
between thoughts
and feelings. Feelings: I feel: (feeling word)
3. Take more "I feel jealous." - "You are making me
responsibility for jealous.”
your feelings.
4. Use your feelings "How will I feel if I do this?" "How will I feel if I don't?"
to help them make
decisions.
5. Show respect for Ask: "How will you feel if I do this?" "How will you feel if
other people's I don’t?"
feelings.
6. Feel energized, Use what others call "anger" to help feel energised to
not angry. take productive action.
7. Validate other Show empathy, understanding, and acceptance of
people's feelings. other people's feelings.
8. Practice getting a Ask yourself: "How do I feel?" and "What would help
positive value from me feel better?"
their / your
emotions. Ask others: "How do you feel?" and "What would help
you feel better?"
9. Don't advise, Instead, try to just listen with empathy and non-
command, control, judgement.
criticise, judge or
lecture others.
10. Avoid people While this is not always possible, at least try to spend
who invalidate you. less time with them and disallow them psychological
power over you.

Human Performance Handbook 12

Briefings
Briefings need to be conducted prior to any event involving one or more
people. They should contain only about seven main points, so that information
can be retained in a person’s short term memory: (See Section 8).

Briefings should be warm and enthusiastic and not delivered in a lacklustre

manner or with a downbeat voice. Briefings should not be one way and should
use open questions and listening skills to check understanding and
agreement.

Checklist for improving interpersonal communication

Check your self-expression
o Are all the statements you make as clear as they can be?

Use opportunities for feedback

o Do you really listen to what people say when reacting to you?

Improve your non-verbal communication

o Do you closely observe people when you are in conversation
with them so that you can pick up cues that will help to enhance
mutual understanding?
o Are you looking and listening such that you can see things from
their point of view?

Pay attention to your instincts

o How often do you ignore your “gut reaction” and wish afterwards
that you had paid attention?

Be sure of the facts

o Do you ever find yourself trying to explain unsubstantiated
statements you have previously made in the heat of the
moment?

Ask questions to clarify

o Do you always check out mutual understanding when exploring
or trying to reach agreement in difficult situations?

Be objective when it matters

o Have you learned how to control your emotions and to think
before you speak in situations that could rebound later?

Remember! Next to physical survival, the next most important thing for us is
our psychological survival; to be understood, affirmed, validated and
appreciated.

Human Performance Handbook 13

 Summary: The Effect We Have

Our approach Results in

-Empathising with -An open mind; receptive
problems and -Reflective
recognising emotion
-Using ‘open ’ questions
-Using a caring approach
! -In a ‘Learning ’ mode

-Telling - A closed mind; resistant

-Getting angry - Fear and resentment
-Using ‘closed ’ questions
-Using ‘leading ’ questions ! - Concealment
- Aggression

The Braer disaster - This is what can happen as a result

of ineffective communication!

Human Performance Handbook 14

 Leadership and Management

"A good leader inspires others with confidence in them; a great leader
inspires them with confidence in themselves!"

"There is no limit to what can be accomplished if no one cares who gets

the credit!"

Good leaders:
Set clear, realistic objectives, have a shared sense of purpose, make
best use of resources, are open and build on experience.
Possess superior general or technical competence. “Authority flows
from the one that knows”.
Have integrity – people need to trust you. Trust is of central importance
in all relationships. Adherence to values is especially important.
Have enthusiasm – All good leaders have this; warmth – a warm
personality is infectious.
Have calmness – reason and calm judgement.
Have the ability to be tough but fair – demanding with fairness.
Admit to being wrong and comfortable in saying, “I didn’t know that”.
They understand that subordinates view these admissions of fallibility
as strengths not weaknesses.
Understand that effective leadership leads to a high performance team.
Use power intelligently and sensitively.
Understand that leadership is a form of service, with humility as its
hidden badge.
Pass the ball, make the team look good, let team members score the
goals and get the credit. If you give credit away anything is achievable.
Reduce organisational weaknesses by:
o Looking for, and acting upon, problems and information that may
lead to errors.
o Determining fundamental causes of performance problems.
o Monitoring trends in equipment and human performance.
o Reinforcing desired behaviours.

“Leadership: The art of getting people to do things because they want

to”

“Leadership is a way of influencing people beyond routine compliance

with directions and orders”

Human Performance Handbook 15

Leaders need to be ‘trusted’ and this can be achieved by:
Being honest and telling the truth.
Being consistent, open and transparent.
Being fair.
Fulfilling promises and maintaining confidentiality.
Demonstrating confidence.
Giving direction.
Setting an example.
Inspiring.
Motivating.
Influencing the team.
Being a ‘role model’.

There are many ways to motivate people. They include:

Being motivated oneself.
Treating each team member as an individual.
Setting realistic and challenging targets.
Remembering that progress with a task
motivates.
Creating a suitable environment.
Giving recognition.
Giving prompt feedback.

Qualities good leaders have include:

Enthusiasm.
Integrity.
Toughness.
Fairness.
Warmth.
Humility.
Confidence.

Situational leadership
The different skills, attributes and varied experience of individual team
members can add strength and overall effectiveness to the group. However, if
these are to be capitalised upon, individuals will need the particular different
types of leadership in different situations. This is known as ‘situational
leadership’.

The four styles of situational leadership are:

Directing (telling) – The leader provides specific instructions and the
performed task is closely supervised.

This style should be used during critical and/or complex situations or when the
leader is not yet sure of the team member’s competence. Emergencies should
always result in a directing style being used. It is important to direct firmly,
calmly and with sensitivity.

Human Performance Handbook 16

Coaching (persuading) – The leader continues to direct and closely
supervise task accomplishment, but also explains decisions, asks for
suggestions and supports progress. This is a mentoring style, with the leader
offering encouragement to the individual and the team.

Supporting (participating) – The leader supports and facilitates efforts

towards task accomplishment and shares responsibility for decision making
with the individual and the team. This is an extension of coaching.

Delegating – The leader gives responsibility for decision making and problem
solving to the team member and to the team. The leader must know the
competence of, and be confident in, each individual and the team.

For success, flexibility of the leader is the key. Initially someone may need
direction, with coaching and support being appropriate later. Then, if the
person is performing well, he should be allowed to work without interference.
The leader may need to revert to one or both of earlier stages if the person
has a problem or encounters an unknown situation.

There is no single best leadership style; the most appropriate style to use will
depend on the situation and also a range of factors such as:

The competence and commitment of individual team members.

The leader’s knowledge of their capabilities.
Whether the task is of a critical nature.
The time available.

Even then it is not easy! - Different types of ‘difficult’ people:

Tank: Extrovert and task oriented. Managers can often be ‘tanks’ with a
strong need for control and tendency to roll over the opposition.
Analytic: Introvert and task oriented. This person pays attention to detail. He
can be known as a complainer, can snipe from a distance and be sarcastic.
Entertainer: Extrovert and people oriented. Trainers/Lecturers tend to be
entertainers. They have a strong need for adulation from the audience, can be
emotional, not think through ideas and can throw in a ‘grenade’.
Yes Person: Introvert and people oriented. He has a strong need for warmth
and approval, often agrees to everything that is asked for, tends not to assert
his own needs and so can let people down on promises.

Functional Leadership
Leaders have to perform a range of functions within their role. These
include:
Setting objectives which need to be agreed and not just set.
Planning the objectives, the route, and a process for monitoring
progress. The objectives need to be carefully planned to avoid
‘paralysis by analysis’ where thinking and planning ahead can become
an end in itself. Objectives should be SMARTT (Specific, Measurable,

Human Performance Handbook 17

 Achievable, Realistic, Time bound, and Trackable). They should also
be challenging, agreed, written, clear, consistent and worthwhile.
Communicating in several ways, keeping all interested parties
informed.
Organising the team and the individuals. Specific responsibilities
include briefing, delegating, coaching, supporting, supervising and
monitoring.
Monitoring / Evaluating: Reviewing performance and giving helpful
feedback so they can do it better next time. Measures and targets are
needed – if it can’t be measured, it can’t be managed.
Setting team standards by encouraging individual thinking and acting
as a role model.
Decision making taking into account associated risks.

Figure 3.1 shows the different levels of control that a leader can take. There
are advantages to all of the positions on the diagram. Depending on the
different prevailing circumstances of any particular situation, different positions
on the diagram will be more suitable.

At the bottom of the scale, the leader will need to make decisions and act with
authority to achieve the desired result. At the top end, if a leader involves the
individual or the team in decision making, he is more likely to get commitment,
and people giving of their best. Therefore there is much to be said about
decisions being made as high as possible up this model because one of the
first principles of leadership is, “The more an individual or group shares in
making a decision which effects their working lives the more motivated they
will be”.

A good leader makes decisions at different points on the scale and chooses
correctly nine out of ten times.

Figure 3.1

Functional Leadership

Leader defines limits, asks team to make

Area of
decision
authority
for team
members Leader suggests problem, gets suggestion,
makes decision

Leader presents tentative decision subject to

change

Use of Leader presents ideas and invites questions

authority
by leader Leader makes decision and announces it

Human Performance Handbook 18

Action Centred Leadership
Things to be aware of:
Harshness.
Excessive leniency.
Blaming “personality”.
Overlooking problems outside a person’s control.
Letting previous incidents or appraisals cloud judgement.
Giving high appraisal ratings to people who appear to be busy.

Some reasons why people do not succeed:

They don’t really understand what they should do.
They don’t know how to do it.
They are prevented from doing it by the system.
They are punished if they do it.
They see no reward in doing it.
They suffer no losses if they don’t do it.
They can’t do it no matter how hard they try.

Constructive Criticism:
Be specific (failures not failings).
Offer suggestions.
Encourage (express faith in the ability of others).
Give support.

Remember!
You cannot antagonise and influence people at the same time.
Seek first to understand; then seek to be understood.
Diagnose with their help before prescribing.

Leadership and Achievement

The Rules of the game:
The ‘Do’s’:
In applying these rules, act as a role model for others to aspire to.
Be open, honest, approachable, constructive and positive in what you
say or do.
Do as you say you will do!
Do the right work, not just any work right.
Comply with standards and procedures, but challenge these openly if
there is scope for improvement.
Recognise, praise and reward success.
Have a bottom line focus on everything you do.
Admit it quickly if you are wrong or do not know something.

Human Performance Handbook 19

The ‘Don’ts’:
Don’t tolerate or disguise inadequate performance or negligent
behaviour.
Don’t expect people to know what is happening unless they are told.
Don’t over-promise and don’t under-deliver.
Don’t ignore procedures you don’t like. Seek positive improvements.

Effective Delegation
Build up confidence in subordinates and in colleagues.
Have clear lines of authority.
Delegate the end result rather than the method of achieving it.
Involve colleagues in the process of delegation by discussion and
agreement.
Agree priorities and set a date.
Record what has been agreed thus generating mutual understanding.
Delegate the necessary authority and inform other interested parties.

To delegate with confidence, ask yourself:

What can I delegate?
To whom can I delegate it?
How much of it will I delegate?
How much learning and supervision will be needed?
How will I motivate the people to do the task?
How will I effectively supervise and help their learning?
Have I set up a control system?
Have I handed over the task?
Have I told people what I have done and who is now responsible for the
task?
Is delegation a normal part of my management practice?

Remember! You are delegating but not abdicating – this is a shared

responsibility and you are the one who has made the decision to select this
person.

Reasons often given for not delegating - to be avoided:

Speed:
“I can do it quicker than they can”.
“By the time I’ve explained it, I could have done it myself”.
Accuracy:
“They won’t do it exactly the way I want it”.
“They are bound to make mistakes and I’ll only end up correcting it”.
Preference:
“I quite like doing this myself”.
“It is too important for anyone but me to be doing”.
Fear:
“They may do it better than me”.
“I won’t know what is going on anymore”.

Human Performance Handbook 20

Leadership Tips:
The more an individual or group shares in making a decision which
affects their working lives the more motivated they will be.
There is so much power or energy in an organisation if you can locate,
release, harness and direct it.
Really high performance teams need almost invisible leadership.
Top down plans do not work.
Always be on the same level as your men – distance is created
naturally anyway. Show that you are willing to eat the same food, wear
the same clothes and share the same hardships.
You must have people around you who will argue the case, disagree
with you, and courteously oppose you. Avoid yes men.
Great leaders wear 3 hats: leader – colleague – subordinate. Be the
subordinate you would wish for and give credit to gain credit.
Never tell people how to do things, tell them what to do and they will
surprise you with their ingenuity.
You have to be consistent so people know where they are with you.
The art of leadership is to work with the fact that people largely
motivate themselves rather than against it.
The title ‘Leader’ may be given, but it has to be earned before it has
meaning.
If you do not accept anything but the best you will be surprised at how
often you get it.
Be willing to feel and show warmth towards people. If you look after
individuals in this way they will work harder. If you give you will receive
BUT don’t do it with an ulterior motive – it is fatal. Do it because it is the
right thing to do. Caring really matters.
Leadership is not about being popular. It is about respect, which comes
from recognition of the leader’s worth. This can grow into being held in
high esteem.
There is no such thing as instant leadership – it is a plant that grows.

In North Africa, Churchill asked Auchinbech why he did not visit the
troops – “Because familiarity breeds contempt”. Churchill replied, “I find
that without familiarity I cannot breed anything!”

“Leadership is the skill required to motivate members of the team to

construct a plan of action for themselves to ensure ownership, and then
to co-ordinate the efforts of the team in implementing and achieving the
objectives of the plan”

Human Performance Handbook 21

Supervisors, line managers and ship’s officers’ ‘Tool Bag’ of
Skills

THE EFFECTIVE SUPERVISOR

• Is clear about desired results

• Knows the capabilities of the team and
each individual
• Plans in order to meet deadlines
• Understands the importance of
maintaining quality standards
• Knows the limits of personal authority
• Ensures adherence to Health and
Safety requirements
• Operates within the rules of
Employment Legislation
• Gains the respect of the team as their
leader
• Helps others to be the best they can be

What is a supervisor?
“A supervisor controls the activities of others and has the responsibility
of carrying out management’s policies and intentions by leading the
group in their charge. Their task is, in fact, to get things done through
people for whom they are responsible.”

A supervisor’s chief responsibility is to maintain enthusiasm among their

people whose attitude to the company, and the kind of service they give,
depend very much on the way the supervisor behaves towards them.

Supervisors must know what they are responsible and accountable for and
they must have an appreciation of people.

The Effective Working Group

Supervisors’ effectiveness will depend largely on their treatment of people.
They must maintain enthusiasm, win confidence and keep discipline. They
should not regard themselves as superior beings, but as a member of the
group – in fact they are the leaders of their teams.

If you approach your work in this way, as a supervisor it is important to

remember the following:
Be accessible. You will not be able to understand and know the
feelings of the rest of your team unless you are always available.

Human Performance Handbook 22

 Keep people informed of any change in the organisation or system on
any matter that is likely to affect them.
Encourage colleagues to express their opinions and to participate in
any decision affecting their work.
Never ignore any grievance or unrest. Make sure that people come to
you first with any problems or grievances.
Learn to give directions clearly and be understood.
By example, encourage team members to be courteous with each
other and with anyone else in contact with your ship or department.
Keep your manager fully informed of your team members’
requirements, views and reactions to any impending change.
Discuss with your manager any outstandingly good work by a member
of your team, or any shortcomings that may exist. Encourage new
ideas, suggestions and justified criticism.
Hold regular meetings with your team as an additional opportunity for
two-way exchanges.

Reminder to supervisors and ship’s officers:

Supervisors are part of the organisation’s management structure.
If you are in management, you are first and foremost in the people
business.
Management is the achievement of results through other people.
The other people through whom you achieve results are not only those
below you in the organisational structure, they are also those above
you and even more especially, your peers.
Your success will be judged by the success you help others to achieve.
Getting things done through other people requires techniques and skills
such as delegation, communication and motivation.
A supervisor’s calibre is judged by his/her effectiveness rather than
efficiency.
People’s confidence grows with knowledge and experience.
Knowledge on its own is worthless – it requires application.
Experience is learning from mistakes – yours and others.
Twenty years of so-called experience is often one year’s experience
twenty times over!
The livelihood of many people depends on your effectiveness.

Efficiency: Doing things the right way.

Effectiveness: Getting the right things done!

People are a company’s most important and unique asset. They:

Determine the degree of success of a business.
Are individuals, so respect them as such.
Like to feel needed, so show interest.
When involved, become committed and confident.

What do good line managers, supervisors & ship’s officers do?

Offer guidance.
Delegate responsibility.

Human Performance Handbook 23

 Admit errors quickly and openly and do not pretend to have all the
answers.
Empower their teams to produce an output with a value many times
more than the sum of the individuals within the team.

These abilities earn managers the respect of their people.

"A manager's duty is to get people to whistle on their way to work,

rather than on their journey home".

Question: What is the difference between management and leadership?

Answer: Situations are managed. People are lead

Figure 3.2

Leader Manager

The necessity of managing change in modern business, leads to these two

circles overlapping (Figure 3.2). Both are about achieving objectives and
getting results through other people. However, leadership and change are
linked and change requires leaders.

Managers prefer a steady state environment – nothing rocking the boat – but
this is not likely today because the pace of change is accelerating.

A Manager:
Carries out other people’s objectives.
Is not a leader until the appointment is ratified in the hearts and minds
of those with whom they work with.
As a term does not imply inspiration, creating teamwork, or setting an
example. A manager can (and sometimes does) manage people like
things. If inspiration and teamwork do exist then managers may be
leaders, especially if they are the source of the inspiration.
Is necessary, while leaders are essential.
Is called upon to run organisations in a steady state. This is less
common now, as an organisation that is not changing is not an option
in today’s business world. Leadership is needed where change is
essential.

Human Performance Handbook 24

‘Followship’
Any team consists of a leader and followers. Good followers can handle
training, direction, constructive criticism and are open to new ideas and
suggestions and do not become defensive. When required, followers are
flexible and can adapt to changing situations, procedures and programmes.
Followers are active rather than passive. They have the ability to acquire,
evaluate and integrate information necessary to complete a task, and also
have a questioning attitude. Followers are able to contribute to group
discussions, decision making and goal setting and help to achieve those
goals.

“If you are a good leader I am a good follower” Knudsen, 2004

Management Styles
The roles of managers require different ‘skill sets’.

Consideration of the following different ‘styles’ of management can be helpful

when examining your own management and leadership skills.

Figure 3.3

Management Style

Author
ity Gra
dient
The leader ’s Team member ’s
authority assertiveness

The style depends on the ratio between the leader’s

authority and the team’s assertiveness

The type of management style that we adopt depends, to a large extent, on

our personalities and the way we behave naturally. There is an ‘Authority
gradient’ (Figure 3.3) between the Manager and his team and the individuals
within that team. The steepness of this gradient will determine the relationship
between the manager and the others.

Synergistic Management Style (Figure 3.4)

The assertiveness of the individual, or the team, contributes to team synergy.
A synergistic management style, set by the leader, creates the right

Human Performance Handbook 25

environment for all team members to be assertive in a positive manner. In this
management style team members will quickly indicate if their mental model
differs from that of the leader, will not hesitate to question the plan and will
contribute to decision making. Effective communication between all members
of the team is one indicator that this desirable style is being used.

The ‘Synergistic’ style is preferred for most situations. The word synergy is
derived from the medical world where several drugs are mixed in a ‘cocktail’
with the effect that the combination of drugs is many times more than the sum
of each drug acting alone. So 1+1 = a great deal more than 2. It is a style
where people work together in an effective team, the ‘authority gradient’ is
flexible and the team members understand when the gradient needs to alter
and will respond accordingly. With this style there is good co-ordination and
communication between the team members and the leader. The leader may
seek opinions and may discuss the situation with the team when it is the right
thing to do. The climate is such that team members are assertive and feel
able to voice their views.

Figure 3.4

Synergistic
The inclination of the gradient depends on the situation

The leader’s Crew member’s

authority assertiveness

Co-ordination

In a Synergistic workplace there will be:

Good technical skills
The leader discusses the stages of each plan with the whole team
Tasks and authority being delegated by the leader
The whole team communicating well together, with information being
passed both to and from the leader
Conviviality and good social skills
All team members being encouraged to comment assertively if they
think the agreed plan is not working
People around the leader will argue the case, disagree with him and
courteously oppose him. He avoids ‘yes men’ and discourages over
deferential behaviour

Human Performance Handbook 26

Definition of consensus: “When the feasible courses of action have been
debated thoroughly by the group and everyone is prepared to accept that in
the circumstances one particular solution is the best way forward, even
though it might not be every person’s preferred solution”.

Figure 3.5

“Autocratic”

Leader ’s Crew
Authority Assertiveness

Autocratic Management Style (Figure 3.5)

With an autocratic style, the leader is unapproachable and believes that he
always knows the answer to every situation or circumstance. Communication
tends to come from the top and subordinates, in this situation, cannot, or will
not, assert themselves. The team member’s reactions, or non-reactions may
result in the manager failing to achieve the desired outcome and at worst may
compromise safety or efficiency. This style can lead to resentment in the
team.

Human Performance Handbook 27

Figure 3.6

“Laisser-faire"

The leader ’s Crew member ’s

authority assertiveness

Laisser-faire Management Style (Figure 3.6)

This management style, also leads to a failure to achieve the desired
outcome. In this style the leader has a ‘cosy’ relationship with his
subordinates. It may result in the important parts of a job often being left with
no particular direction being given, resulting in a loss of ‘focus’. The authority
gradient is flat, and an observer would not be able to identify the leader. In the
case of a particularly assertive subordinate, the authority gradient can reverse
and the de-facto leader can become the subordinate. This style can be
problematic in dynamic situations where good decision making is required and
is particularly undesirable and can be dangerous in an emergency situation.

Figure 3.7

“Self-Centred”

lack of coordination
The leader ’s Crew member ’s
authority assertiveness

Management style also depends on the

willingness of the crew members to work together

Human Performance Handbook 28

Self Centred Management Style (Figure 3.7)
A ‘Self-Centred’ style is one where the leader detaches himself from the team,
does not communicate and the team members have different perceptions of
the desired outcome. To get good results, a team has to work together; a self-
centred style prevents this, with team members not being involved effectively.
This style is common after any conflict situation and can be dangerous.

Synergistic Management Style

“My team are not interested in sharing decisions. They just want me to
tell them what to do”.

If you recognise that this statement applies to you, you should reflect on your
own behaviour to seek out the reasons for your team’s attitude.

Human Performance Handbook 29

 Team Skills

“We made a good team. I’ve come to realise that there’s no ‘I’ in team.”
Peter Andre in I’m a Celebrity Get Me Out of Here! (1/2/04)

“Above all else, I would like to stress our unity as a party. This was
undoubtedly the biggest single factor in the final result, for the ascent of
Everest, perhaps more than most human ventures, demanded a very
high degree of selfless co-operation; no amount of equipment or food
would have compensated for any weakness in this respect.”
From, ‘The ascent of Everest’ by John Hunt. Mount Everest expedition 1953.

Figure 4.1

Team working is an important part of the working environment for most

people. We need to understand why and how teams are formed and how as
individuals we can have an affect on the efficiency of our team. The attitude
that team members have towards teamwork will affect the team’s
performance.

Team Competencies
In order to be effective, team members need to have knowledge about their
own capabilities, the task, other team members, and the environment. Team

Human Performance Handbook 30

members need competence, an understanding of how to ‘gel’ with other team
members and an understanding of the role of other team members in carrying
out the task. See Figure 4.1.

"There is no limit to what can be accomplished if no one cares who gets

the credit!" John Adair (Author and world authority on leadership)

"Effectiveness results from 'doing the right things' and efficiency is the
result of 'doing things right' Peter Drucker (International business adviser)

Figure 4.2

Team-working contributes to the effective running of ships, control rooms, oil

rigs, gas platforms and other industrial and commercial activities. In
emergency situations it is vital that team members understand their collective
and individual roles, particularly when life is threatened. It is extremely
important that team members use communications and feedback to ensure
that each member develops good situational awareness.

In all other situations, team-working brings together individual skill sets and
knowledge, which when combined can achieve the required goals more
effectively. (See Figure 4.2). This requires tolerance and acceptance of
people’s different attitudes and beliefs and these need to be accommodated
by everyone.

“Coming together is a beginning; keeping together is progress; working

together is success” - Henry Ford
“None of us are as good as all of us” – ‘Seaways’ Nautical Institute
Magazine 2005

Human Performance Handbook 31

Understanding the following aspects of behaviour will help team
members’ performance:
People behave differently.
Behavioural differences can affect team performance.
We can change our behaviour through experience.
Challenges to individual behaviour within the team may arise. Honest
critiques and discussions are needed to identify any required changes
to improve team performance.

Understanding team dynamics:

Analyse the roles that people play in teams.
Look for experience when looking for problem solvers.
Issues causing negative behaviour should be dealt with at the earliest
opportunity.
The team needs clear aims.
The team must know and understand each team member’s strengths
and weaknesses and needs to make the best use of the strengths.
The team needs to justify its existence - primarily through results.
The team needs a common language.

Figure 4.3

Individual contribution-
The six deadly killers
• I don ’t know what ’s • I want to help but I ’m not
wanted sure how I can
• I don ’t know what others • I think the boss knows
know and might let me in on it
• I don ’t know my soon …maybe!!!
contribution but I know • Sometimes I find out at
my strengths and I can the canteen or at the
beat those others office party when the
boss has had a few
drinks

Human Performance Handbook 32

Figure 4.4

Stages of a Team’s
Orientation Renewal
Why? Development Why?

High
Trust Building
Performance
Who?
Wow!
Cr

Goal Implementation

g
e

Who does What,

Clarification

in
at

When &

in
in

What? Where?

a
g

st
Su
Commitment
How?

"If it weren't for the last minute, nothing would get done" An anonymous
procrastinator

"Organising is what you do before you do something, so that when you

do it, it's not all mixed up" Christopher Robin from Winnie the Pooh

Requirements for effective teamwork include:

Communication

o Clarity is absolutely vital.

o Encourage the free flow of information between individuals.
o Ideally, team members should have access to each other at all
times.
o Identify any barriers to communication.
o Determine the importance of non-verbal messages.
o Use feedback to reinforce teamwork.
o Consider any personal traits exhibited by other team members.

Leadership

o The leader recognises the need for required action or

information and takes the initiative to obtain the proper results.

Human Performance Handbook 33

 Conflict Management

o Identify when conflict exists.

o Conflict can be productive when it stimulates debate, but it
MUST be resolved.
o Use assertiveness and advocacy relevant to the situation.

Team and Individual performance critique

o Identification of conditions that adversely affect team

performance.
o Identification of behaviours that reinforce or degrade team
performance.
o Determining the strengths and weaknesses of the team.

Assertiveness

o This is the ability to express our feelings, opinions, beliefs and

needs.
o Expressing ourselves in a positive, productive manner. This
involves asking for what we need and saying ‘no’ when
necessary.

Synergistic work

o This means working in a ‘synchronized’ manner and supporting

each other, which will lead to enhanced team efficiency: 1+1>2.
o There will be a shared understanding of the roles and
responsibilities of each team member while people can
understand the situation from the perspective of other team
members.

Watch out for these quotes that DO NOT apply to good teamwork:
"You don't have to agree with me, but it's quicker".
“We are too busy mopping the floor to turn off the tap".
“Anything is possible for the man who doesn't have to do it himself”.
“If you want an easy job to seem difficult, keep putting it off".
“If you have to swallow a frog, don't look at it too long!”

“People acting together as a group can accomplish things which no

individual acting alone could ever hope to bring about”.
Franklin D. Roosevelt, US President 1933 – 1945

Human Performance Handbook 34

This must be our aim:

“Synergy”
Working together as a team

If we do not achieve it then this is what could await us!

Catastrophe

Human Performance Handbook 35

 Management Systems

“All of us who try to change our organisations know that the starting
point is to change oneself” The UK business trouble-shooter, Sir John
Harvey-Jones

‘If you don’t know where you’re going you will end up somewhere else’
Yogi Berra

Successful creation and implementation of the Integrated Management

System (ISM) at a glance (Figure 5.1):

Figure 5.1

Ownership of IMS by ALL employees

Company Create Integrated

Climate Management
Survey System

Leadership & Create a

Management ‘One Team’ Implement Motivation
Skills culture Customer
Development
IMS
satisfaction
Human Factors,
& financial
Teamwork & performance
Communication

Enthusiastic support from Board of Directors

The purpose of an effective Integrated Management System (IMS) is to help

improve business performance by releasing the organisation’s potential for
continuous improvement. To benefit from the full potential of ‘Human
Performance’, as set out in the other sections of this handbook, a business
should aim to have its employees function within the framework of an efficient
and effective IMS. To build this IMS, the following steps should be considered:

Human Performance Handbook 36

 Review the existing management systems and then either revise or
if there is none in place, implement an integrated safety, health,
quality, environmental and service excellence management system.
In carrying out this review and revision, place the focus on
ownership of the IMS by the end users.
Ensure your IMS has all the essential elements, with each
interrelating as shown.

Figure 5.2

Leadership,
Roles
Audit & & Assessment
Review Responsibilities &
Continuous Management
Improvement of Risk
Incident People,
Investigation & Recruitment,
Analysis Training &
Behaviour

Selection &
Emergency Control of
Response Contractors

Interaction Design
with & Construction
Stakeholders of Plant
Procurement

Customer & Operations

Client &
Relationships Maintenance
Documentation Management
& Management of
of Change
Information

The IMS should be based on flow text process maps/flow diagrams and
“hyperlinks” between relevant parts of the system.
The “hyperlinks” should link one part of the system with another to ensure the
system is user-friendly. They should also link the management system to the
specific requirements of the ISM Code – 2002 edition, SOLAS & MARPOL
and as appropriate to OCIMF, ISO 9001:2000, ISO 14001, OHSAS 18001,
and all other relevant marine regulations, Codes and guidelines. The revised
system will therefore, transparently show how a ship owner or manager meets
all regulatory requirements, Codes and guidance.

Human Performance Handbook 37

IMS revisions should be carried out following the principles set out in the UK
Health & Safety Executive’s publication ‘Successful Health & Safety
Management’ (HSG 65). This will ensure the system is at the leading edge of
IMS Management systems thinking.

Implement an electronic audit database that will record all audit findings,
produce audit deficiency reports and produce trend analyses in the form of pie
charts, etc.

“Participative decision making, democratic leadership style and

individual job satisfaction are all positively correlated with low accident
rates” British Health & Safety Executive

Essential elements of a typical IMS:

1. Leadership and Organisation.
2. Performance Standards.
3. Recruitment and Training.
4. Communications.
5. Management of Change.
6. Loss Event Investigation and Analysis.
7. Selection and Control of Contractors.
8. Purchasing Controls.
9. Monitoring, Inspection and Auditing.

1. Leadership & organisation requires:

Policies.
Commitment.
Responsibility.
Accountability.
Authority.
Motivation.
Loss Management Organisation.
Planned Programmes.
Goals & Objectives.

2. The required elements for Performance Standards:

Who does what, when, how and to what effect.
Identification and assessment of all potential hazards and risks.
Procedures for systems of work to control risks associated with normal
and abnormal operating conditions, plant and equipment.
Emergency procedures.

3. Recruitment & training for:

Managers.
Employees.
Contractors’ employees.
Identification and provision of relevant skills and competencies.

Human Performance Handbook 38

4. Communication is required to take place:
Downwards.
Upwards.
Laterally between individuals, workgroups and teams.

5. Management of Change is needed in relation to:

Plant and Equipment.
Processes.
Personnel/Contractors.
Procedures.

6. The required elements for Loss Event Investigation and Analysis:

Investigation of ‘minor’ loss events and ‘learning opportunities’ as well
as serious ones.
Identification of underlying causes as well as immediate ones.
Procedures to act upon findings and prevent recurrences.

7. The required elements for Selection and Control of Contractors:

Pre-contract assessment.
Monitoring during contract.
Post-contract assessment.

8. The required elements for Purchasing Controls

Equipment.
Materials.
Services.

9. Monitoring, Inspection and Auditing:

Closing the loops in all areas. The IMS should be structured, monitored
and audited as set out in Figure 5.3.

Human Performance Handbook 39

Figure 5.3

Integrated Management Systems

Policy
Policy development

Organisational
Organising development

Planning &
Auditing Developing
Implementation
techniques of
planning, measuring
& reviewing
Measuring
Performance
Feedback loop to
improve performance
Reviewing
Performance

From: British Health & Safety Executive Publication HSG 65

(Successful Health & Safety Management)

“While the promotion of job satisfaction is likely to strengthen safety

culture, the reverse is also true”. British Health & Safety Executive

Attempting to achieve world-class safety and business performance presents

a significant challenge to any business. This normally requires a change in an
organisation’s culture and thus the values, beliefs, attitudes and behaviours of
individuals and teams. This is no easy task. People’s diverse perceptions,
misconceptions, backgrounds and previous experiences of organisational
change complicate the task.

However, it can be achieved providing that:

There is strong management commitment at all levels.

The entire revised IMS is ‘owned’ by all members of the company
team.
Appropriate business processes are adopted.
The necessary resources are made available.

Integrated Management System Review and Audit:

Each organisation should develop its review and audit techniques and they
should be tailored for the shipping industry in general and the individual
company in particular, such that the system remains viable in all areas. It
must include methods that allow measurement of the system to take place
and for ongoing and continual review to become a natural occurrence.

Human Performance Handbook 40

To maintain the IMS, a regular audit of what is actually taking place must be
conducted. This operation ties up all of the other stages in a single course of
action.

Audits should never be feared but be used as a means of ensuring all aspects
of the IMS are functioning as intended.

“You are what you spend your time on. You’re as committed – or as
uncommitted – as your diary says you are” Tom Peters (International
business adviser)

A modern integrated management system brings the following benefits:

Improved quality and productivity through more effective management.
Protection of the company’s reputation.
Financial savings from the reduction of loss events.
Safer ships and cleaner seas.
Avoidance of pain and suffering.
Significant cost benefits.
In 1997 the UK Health and Safety Executive (HSE) published a study
entitled “The Costs of Accidents at Work”. The study concluded that
the ratio of uninsured costs to insured costs of accidents was between
8 and 33 to 1. It further concluded that the cost of each one-day lost
time accident and the associated minor accidents and property damage
incidents is a minimum of GBP22,424. One company calculated the
cost of each reportable over three-day accident at GBP61,000.

“Organisations that place a high value on people will seek ways to

involve people in decisions” John Adair

Barriers found when revising the IMS

One of the biggest barriers is the general resistance to change that has to be
managed both by individual companies and by industry. This was summarised
nearly 500 years ago:

“It should be borne in mind that there is nothing more difficult to handle, more
doubtful of success, and more dangerous to carry through than initiating
change. The innovator makes enemies of all those who prosper under the old
order and only lukewarm support is forthcoming from those who would
prosper under the new. Their support is lukewarm partly from fear of their
adversaries, who have the existing laws on their side, and partly because men
are generally incredulous, never really trusting new things unless they have
tested them by experience. In consequence, whenever those who oppose the
changes can do so, they attack vigorously, and the defence made by the
others is only lukewarm. So both the innovator and his friends come to grief.”

Machiavelli ‘The Prince’ 1514

Human Performance Handbook 41

 Professional Conduct

It is becoming accepted that behaviour is the final common factor in nearly all
loss events and injuries. Individual and collective behaviours are driven by
attitudes, beliefs and values, which as well as stemming from individual
upbringing and background, are the ingredients of company and industry
culture. We therefore need to focus on the drivers in the hidden part of the
iceberg in Figure 6.1 and, if we are to change our actions and behaviour to
achieve business and safety excellence, everybody from the boardroom to the
deck boy needs to challenge their attitudes, beliefs and values. (See also
Section 12).

Figure 6.1

Visible Actions
Behaviour

Attitudes
Hidden Values
Beliefs

So, wherever we are working, we should work with a safe, cautious and
professional approach in order to achieve high quality, safe and error free
tasks.

What do we mean by professional? When we think of professionals we might

think of doctors, solicitors, airline pilots, etc.

Human Performance Handbook 42

Professionals are:
Qualified in what they do.
Respected.
Experienced.
Proud of their work.
Willing and keen to work.
Orderly in their approach to work.
Good communicators.
Able to work within Codes of practice.
Able and willing to follow Standard
Operating Procedures (SOP’s).
People with high standards and expectations.

However, some professionals may also exhibit some negative behaviours.

These might include arrogance, aloofness, authoritarianism and non-
approachability, which can impact both safety and efficiency.

Many industries work with rules, standards and good practices but following
these alone does not make a professional. To be a true professional we need
to adopt the good practices (set out above) and avoid the negative ones.

Professional conduct in the workplace

To continuously improve effectiveness, safety and reliability we need to adopt
an attitude that includes:

An intolerance of working around problems. If a procedure (SOP) is

incorrect or missing it must be reported and a suggestion made as to
how it needs to be amended.
Taking a cautious approach to all work, especially if it is the first time
the task has been attempted.
Communicating effectively with others.
Identifying any risks that might affect how we or the team carry out the
work.
Putting into practice the ‘Human Performance’ lessons learnt on the
course and which can be found in this handbook.

Human Performance Handbook 43

 Appraisals

A good leader should be talking to, coaching and guiding his subordinates on
a continuous basis. This appraisal process is ongoing and should be
conducted in a friendly, non threatening style. When the formal appraisal
interview is conducted it should be a friendly affirmation of what is already
known.

To benefit fully from ‘Human Performance’ it is necessary for everyone to

subscribe to the view that they will never be perfect but are willing to aim for
improvement in their performances on a continuous basis. This must of
course include on board managers, as well as office managers and company
directors.

Implementing a 360 degree appraisal system, whereby leaders are appraised

by their subordinates, will help to achieve this. In mature business cultures
and in companies who aspire to excellence, this process is often found and
accepted as normal, and is welcomed by leaders and managers, since it
provides opportunities for them to improve their performance.

It is outside the scope of this handbook to fully describe an effective and

efficient appraisal system in detail but some key points are as follows.

What does an appraisal aim to achieve?

Monitor/Improve performance.
Provide feedback on performance.
Identify training and development needs.
Assess suitability for promotion.
Increase motivation.
Aid career development and organisation
planning.

A good interviewer is:

Able to use all of the non technical skills described Appraisal: Achieving a
on your course and in this handbook. In particular shared commitment to
they are: continuous improvement
Someone who seeks and values other’s
ideas.
A good motivator and leader.
Trusted.
Able to empower others.
A role model.
Someone who invites feedback.

Human Performance Handbook 44

Figure 7.1

Key stages of an ‘adult to adult ’ appraisal interview in

pursuit of continuous personal improvement

! Put him at ease (introduction/greetings)

! Explain the purpose is to continue the discussion on areas of
performance that are serving him and the ship well
! Ask him to explain how he sees his job and the challenges
he faces
! Praise specific aspects of his performance sincerely
! Ask which areas of his performance he thinks could be
improved
! In response, ask why does he think this problem exists
! Ask what are his ideas to correct the situation
! Offer your commitment and ask for his commitment for action
! Put in place agreed actions

The ingredients of a successful appraisal interview:

Use the communication skills described in Section 2, follow the key stages in
Figure 7.1 and in addition:

Use an ‘adult to adult’ transaction style and avoid being patronising,

condescending, rude or antagonistic.

‘Pull’ information from individuals by using an open questioning style.

Actively listen a lot and do not ‘push’ your views by ‘telling’ and using
closed questions. Even criticisms you may have can be drawn out
through discussion.

Why? Think how you felt the last time you were criticised? Did you
think in a logical and supportive way?

When ‘pulling’, ensure the interviewee is learning by ‘discovery’. People

learn by grafting new knowledge onto existing knowledge, once they
decide upon the correctness. To do this they must be in ‘adult’
unthreatened mode and have made up their own mind on something.

Use non threatening body language, namely:

o Smile, get up, shake hands and use the person’s first name.
o Do not put an obstruction, like a desk, between yourself and the
interviewee.
o Sit at 45 degrees to one another at a comfortable distance.

Human Performance Handbook 45

 o Show you are listening with attentiveness and make frequent,
but not continuous, eye contact.
o Relax and do not sit with your arms folded; open your arms and
use palm up gestures.

Watch for their body language. Is it open and friendly or closed and
threatened? If they are threatened and you have hooked their ‘child’
they may:
o Have their arms folded as if they are cold.
o Avoid eye contact, often looking down and to the right.
o Touch their throat to reveal they are feeling vulnerable.
o Look uneasy and threatened.
o Use confrontational language.
o Deny the undeniable.

These actions occur because if people feel threatened they react rather
than reflect and they tend to defend their actions to maintain their self
esteem – which for you as the interviewer is an area that can lead to
conflict.

Use sincere praise as and where deserved. 70% of all human

motivation is driven by positive reinforcement and praise. It is a very
critical ‘weapon’ in the armoury of a good leader. There is always
something worthy of praise.

Show empathy and be understanding.

Demonstrate tact, diplomacy, objectivity, and fairness.

Guidelines for successful interviews include:

Being properly prepared, whether one is the interviewer or the
interviewee.
Not allowing interruptions during the interview.
Communicating appropriately.
Summarising for mutual understanding.
Parting courteously.

Human Performance Handbook 46

 Situational Awareness (SA)

Definition
“Situational awareness is the perception of the elements in the
environment within a volume of time and space, the comprehension of
their meaning, and the projection of their status into the near future”
(Endsley. M)

The concept of Situational Awareness has its origins during World War One
when it was noticed that a relatively small number of pilots were responsible
for a high number of ‘hits’. It was considered to be a ‘sixth sense’ that some
pilots developed through flying experience (Patrick, J. 1998). A study by Kelly
et al. (1979) noted that the decisive tactical advantage achieved by superior
fighter pilots during over four hundred air to air engagements in simulators
was attributable to their heightened situational awareness. If enhanced,
situational awareness contributes positively to superior performance, and
conversely, a lack of situational awareness may be responsible for poor
performance (Patrick. J.1998).

Situational Awareness is made up of three parts:

Perception
This is how we perceive the current situation that surrounds us. For example,
the state of the plant, ship, the indications / messages we are receiving, etc. It
is our general spatial awareness.

Comprehension
What we understand to be the meaning of the situation. This is the picture in
our mind that is our mental model or mental ‘DVD’.

Projection
Projecting into the future and ‘getting ahead of the ship’. Asking ourselves
‘What if’ and ‘Where are we going’ types of questions.

We build a mental picture or model of how we think the state of things are
around us; this is the perception and the comprehension stage. In order to
achieve complete situational awareness we need to think about the immediate
future, ‘projecting’ what will happen and the situation that will exist then if
events continue the way they are. We need to:

Steam ahead of the ship.

Stay ahead of the plant.
Fly ahead of the plane, etc.

Human Performance Handbook 47

Projecting the situation into the future is important because it is only if we
know and understand what is really happening and what the projected
possible occurrences are, that we can ‘control’ the process. This is particularly
important if a serious incident is beginning to unfold.

Mental models are improved by:

The use of good, meaningful briefings.
The collective experience and knowledge of the team members.
The application of a synergistic management style.
The use of Standard Operating Procedures (SOPs).
The use of well prepared check lists.
Individual expectations of what may happen in the future.

Whilst working within a team it is essential to share the understanding of

situations and mental models by effective communication. This will ensure the
whole team has similar levels of situational awareness.

It is situational awareness that drives our decision making processes, which

leads to the achievement of good quality decisions and improved
performance. If not………

Herald of Free Enterprise 1987

Achieving good SA is not always easy. As an example of how difficult it is to

achieve, we should consider the Officer of the Watch on a ship’s bridge at
night. Navigating the vessel, mainly on instrumentation (radar, GPS, ECDIS)
while at the same time using bearings from charted lights, buoys, etc. is a
complex task. Further difficulties will be created by such navigational factors
as bad weather, fog, restricted waters and heavy traffic.

There can be many barriers preventing us from correctly interpreting the ‘real
world’, such as automatic systems, differing interfaces, human and machine
capabilities, etc. How we interpret this information depends to a large degree

Human Performance Handbook 48

on our own and other’s knowledge, training and experience and our mental
and physical state at the time. We may end up with good or bad SA, a lack of
understanding or an incorrect interpretation.

Some of the factors that can influence us achieving Situational Awareness

include:

Representation Error
Representation error occurs when there is a discrepancy between reality and
our own mental model of a situation. Sometimes this discrepancy will remain
right to the ’point of impact’ because our mental model or ‘DVD’ is highly
resistant to contradiction. This resistance to reasoning out a fresh solution to a
problem is particularly dangerous because it occurs subconsciously and is
due to the fact our mind requires mental resources to carry out this task. Also
it takes an unknown length of time to complete. There is therefore a tendency
to ‘stick with it’. When these resources are in short supply, due to excess
stress and/or fatigue, it is even more likely that a person will maintain the
original mental model rather than reason out a fresh solution.

Defences against representation error are:

Synergistic leadership.
Assertive teamwork and communication.
Consciously standing back and reviewing the mental model.
Following Standard Operating Procedures.

Confirmation Bias (Mind set)

Confirmation bias is the human tendency to look for information that tells us a
decision is correct and to reject information that would lead us to conclude the
decision is wrong. Confirmation bias adversely affects our ability to look at
information objectively and to review whether any decisions taken are correct.

This bias is related to representation error and is the most important of the
decision making biases. It is very powerful and people can become defensive
of the decisions they have made.

We are all affected by confirmation bias through the decisions we make and
the views and the beliefs that we hold. When we evaluate and formulate
information to make decisions, our views and deeply held beliefs, together
with any other information that becomes available, serve to confirm these
views. We may decide that the information (good or bad) is erroneous. Once
we have made a decision it is difficult to change, just as it is to change our
views and beliefs. We need to maintain an open mind and sometimes
question our views.

As with representation error, the only defences against this are:

Synergistic leadership.

Human Performance Handbook 49

 Assertive teamwork, when each member of the team reviews the
decision to ensure it is having the desired outcome.
Consciously standing back and reviewing the decision.
Following Standard Operating Procedures.

Long Term Memory (LTM) and Experience

Long term memory is where all of our lifetime experiences and knowledge are
stored; it is of endless capacity. Both LTM and experience can affect our
ability to maintain good SA, due to memories of past events influencing our
perception of present events. For example, a person might say to himself,
“The last time I faced this situation, I found that doing nothing served me well:
there was no problem”. This stored memory and experience may now affect
how the person interprets the present situation and this may prove to be a
serious mistake. We must always have the discipline to question ourselves
(and others) as to how we (or they) interpret the situation in order to have a
chance of the best outcome.

Another problem with LTM is speed of access to information. Recovering

information can take a long time and this might not be compatible with the
time available especially in a moving dynamic situation. The use of standard
operating procedures, emergency procedures and checklists are designed to
overcome the problem of recovery. Most, if not all activities, are covered by
procedures and or checklists and must be referred to, especially in emergency
situations.

Short Term Memory (STM)

Short term memory, or working memory, is the store where essential
information relevant to the current situation is retained for a short period of
time. However, STM has major drawbacks in that its storage capacity is
limited and information held is sensitive to interruptions and distractions and
therefore is easily lost. To overcome these you should ensure that you:

Eliminate unnecessary interruptions on the bridge or in the control

room when the vessel is in ‘red’ waters (i.e. during periods of increased
workload activities). For example, when in close quarters situations,
while berthing or un-berthing, when under pilotage, while experiencing
problems with the plant, etc.
Write information down that may need to be referred to later.
Hold regular team briefings, for example, pre-arrival, pre-departure,
before carrying out major engine maintenance, etc. Keep briefings
clear, relevant, to the point and include only a few (around seven) very
salient points.

Communication
This subject is covered fully in Section 2 but it is vital to understand that
without good effective communication then it is impossible for members of a
team to share the same situational awareness or mental model. Inadequate
information exchange can often occur during a period of transition, watch or

Human Performance Handbook 50

duty shift handover for example, or when plant or other priorities change.
Achieving and maintaining SA depends on the quality of information passed
within the team, as well as information between different departments and
disciplines. Too little information leads to a loss of SA amongst team
members, while too much leads to overload and thus loss of SA. Quality
communication is essential to maintain situational awareness.

Other threats to Situational Awareness include:

Finding that confusion, questions or statements of concern are not
being resolved. Comments like, ‘Isn’t it?’ ‘Can’t we?’ ‘Won’t it?’
Different sources of information not agreeing.
The attention of the whole team being focused on one aspect of the
task to the detriment of the “big picture”.
Subconsciously thinking we are right even when incoming information
differs with our view - confirmation bias. Do not ‘bend’ facts to fit your
mental model of the world.

Figure 8.1

Situational Awareness
Factors affecting situational awareness
Real World

Interface
Radar / Bridge & Engine Equipment / Documentation

Abilities, Knowledge, Training

Skills, Experience (of crew / pilot)

Interruption Concentration
Workload Stress
Fatigue Mind set

Attention Management
Attention Management is paying attention to the right thing at the right time.

It is important that we do this by:

Being in skill based behaviour whenever possible. This is a function of
acquired skill and expertise. See Section 12 – ‘Risk Management for a
full explanation.

Human Performance Handbook 51

 Keeping ahead of the situation (keeping ahead of the ship).
Stick to facts that are relevant to the current situation.

Several things can affect our ability to pay attention and these are particularly
important if there are changing circumstances.

They include:
Small talk – chit chat.
Interruptions caused by mobile phones, VHF & UHF radios,
unanswered alarms, etc.
Attempting to carry out simultaneous tasks unless they are skill based
routines.
Routines causing hypo vigilance (day dreaming) and/or boredom.
Fatigue and/or excess stress.

Enhancing performance and improving situational awareness can be

helped by:
Knowing your own limitations and those of your team.
Increasing your knowledge and training.
Using Standard Operating Procedures as a ‘safety rail’.
Encouraging the use of ‘briefings’.
Working as a team.
Gathering as much data and information as possible prior to making
decisions.
Taking a ‘time out’ occasionally to take stock of the situation even once
we have made up our mind.
Questioning whether the plan still fits the situation, even as events
progress.
Ensuring that we do not interpret a situation in terms of how we would
like it to be, but in terms of how it is.
Regulating our own and the team’s workload.

Human Performance Handbook 52

 Decision Making

“Your people are always better than you think they are. Train equip and
encourage them to share decision making” John Adair

Good decision making is the key to a safe situation and to avoiding accidents
and loss events. Decisions are required whenever there are various options
open to us, but decision making is not an automatic process and should be
supported by data collection and through reasoning and the evaluation of any
associated risks. See Figure 9.1.

Figure 9.1

Making a Decision

What options?
Consider Time factors
Consult procedures We need to diagnose the situation and
use our knowledge and procedures to
Deadline
team and specialists identify all possible options
TAKE DECISION
We must realise that in all dynamic
Diagnose Review
Take Action time situations most options will have a time
limit for implementation
EVENT
Depending on the dynamics, any action
Judgement - when a decision is taken which
taken may or may not be irreversible
is based on all relevant available information
and is:
We may have to ‘stick with it’
 Consistent with team knowledge
and experience
 Risk assessed
 Able to be implemented in a timely
manner

Good SA is essential if high quality decision making, yielding safe and

efficient outcomes, is to become normal. There are various types of decision
making strategies and which one is adopted will depend on criteria such as
the structure of the problem, whether there are ill-defined or competing goals
and how dynamic the environment is.

A systematic approach is often the best policy, as this will have the added
effect of reducing stress levels and will usually result in a quality decision.
There are several decision making models. One recommended example is
outlined below.

53
DODAR - A systematic decision making process
1. DIAGNOSIS

2. OPTIONS and CONSEQUENCES

3. DECISION – SAFETY FIRST

4. ACTIONS

5. REVIEW

Diagnosis
Time spent on diagnosis is rarely wasted.

Ask: (Using all resources including all five senses):

What is the problem NOT what is the solution?

What are the symptoms?
How do we diagnose?
What? Who? When? Where? Why? How?
Each other, team members, specialists, experts, etc.

Options and Consequences

Consultation is NOT a sign of weakness.
Is there more than one option?
Doing nothing may be an option in the first instance.
Has anyone else thought of an option?
Consult colleagues.
Is there a Standard Operating Procedure that should be applied?
Are any options applicable and viable?
Always consider the consequences of any option prior to applying it.

Decision – Safety First (Very often decision making is inseparable from

risk)
Safety comes first – before commercial considerations.
Question: Is there a ‘perfect decision’? Answer: Not always.
However, if we have done a thorough diagnosis, considered the
options available, together with the consequences, then we have the
best chance of making the most appropriate decision at the time.

Actions
We may need to take action and assign tasks, so:

Consider workload and experience when assigning tasks.

Ensure that everyone understands that it is OK to say 'I’m overloaded'.
Check by questioning that all involved understand their role.

54
Review (Time-Out)
Always find time for a review. Changing a decision is NOT indecision.

Question: What is the value of a review? Answer: To ask ourselves:

Is the decision still valid?

Has everything been done?
Are the outcomes as expected?
Does everyone know the current situation?

Figure 9.2

In Figure 9.2 consider the ‘Incident’ to be a fire. The fire will have started and
not been noticed until some time later (speed of response of fire detection
system) by which time the event is proceeding. It will take time to accept and
analyse the alarm and more time to understand and then decide the correct
course of action before acting. In this situation the fire will be proceeding
unchecked for some time. A standard alarm response, using a Standard
Emergency Procedure that has been planned and thoroughly rehearsed using
drills would be preferable, because this is invaluable in making correct and
timely decisions with regard to the unfolding incident. If a fixed extinguishing
system is available, the effects of the incident will be mitigated sooner than if
deployment of a fire team is required.

“Some leaders assume being decisive means making quick decisions

by themselves – actually they should be made at the right time and in
the right way” John Adair

55
Decision Making Traps
Depending on the incident, it is easy to fall into ‘traps’ when trying to decide
the most appropriate course of action for any given scenario. For example,
we can be called upon to make decisions in emergency situations when high
workload and high stress levels adversely affects our reasoning processes.
To combat this we need to:

Remain in control of ourselves.

Become a synergistic leader.
Follow Standard Emergency Procedures.
Conduct meaningful drills of all reasonably foreseeable incidents.
Engage competent and well trained people.

The traps that we need to avoid are:

Jumping to solutions
As we get older, our store of experience increases. When faced with a set of
circumstances we may be tempted to recall a similar situation that we have
met before or heard or read about. In this case there could be a tendency to
‘bend the facts’ of the current situation to fit with our past knowledge or
experience. We may then try to find evidence to support our own ideas, rather
than look at things as they really are. This Confirmation Bias (described
earlier) with its associated dangers can be countered by self-control and
teamwork assessing each situation objectively.

Failing to communicate
Some of the reasons for this may be:

Not wanting to appear to not have the answer.

Not wanting to appear unable to make a decision.
Some people find it difficult to share their thought processes.
Some people (often newly promoted) feel they should know, and may
try to hide a lack of knowledge and experience.
Needing to adopt a questioning attitude and maybe needing to
challenge other’s views or advice.

Groupthink
‘Groupthink’ is the term that was coined by psychologist Irving Janis in 1972,
and refers to faulty decision-making in a group. In a ‘groupthink’ situation,
each member of the group attempts to make his or her opinions conform to
what they believe to be the consensus of the group. This results in the group
ultimately agreeing on an action, which each member individually might
consider being unwise. When groups experience this phenomenon they do
not usually consider all the alternatives, often to the detriment of good
decision making.

‘Groupthink’ happens frequently when a group / team is under pressure to

make a decision. It can lead to bad judgements and poor decisions being

56
made. This can also lead, after the fact, to decision makers rationalising their
poor decisions.

Avoiding ‘groupthink’ is possible by implementing a number of actions which

include:

Appointing a ‘devil’s advocate’ whose role is to challenge the group

and look for flaws in logic and information that is being presented.
Ensure the leader encourages dissent from the team and the team
present alternative strategies for discussion.
Ensure the leader remains impartial. The leader should remind the
group that open and frank discussion is essential to good decision
making and promotes a healthy culture.
Bringing a fresh mind to the problem.
Giving everyone a ‘second chance’ to express doubts.

Examples where ‘groupthink’ was instrumental in poor decisions were the

Space Shuttle Columbia and Challenger disasters in February 2003 and
January 1986 respectively, and the Bay of Pigs invasion Cuba in April 1961.

57
 Nationality, Language & Culture

Multicultural Crews

Over recent decades, maritime operations have become a global business,

with all types of merchant ships being manned by multinational as well as
multilingual and multicultural crews. This has the potential to pose risks, in
particular with respect to communication.

Areas for consideration when working with a multi cultural team:

Capabilities in the English language of the team members.
Differing work role expectations.
Differing leadership expectations.
Attitudes to safety.
Mutual understanding.

According to G. Hofstede’s research for the Boeing Corporation, there is a

strong correlation between high accident rates, and cultures that are
hierarchical with people who are reluctant to assert themselves as individuals.

Cultural differences can be overcome by the leader and the team members
practicing mutual respect, taking the trouble to understand different cultures,
and by everyone getting to know other team members as individuals.

58
The ship’s team must be able to converse in a common language. The
‘Human Performance’ lessons on the WWTL courses and in this handbook
are difficult to conduct without this prerequisite requirement.

The following is included to maximize your ‘Human Performance’

understanding in respect of culture and language and the lessons here fit with
the lessons set out in the rest of this handbook.

Distillation of the learning points from the 2005 BIMCO study conducted
by Jan Horck from the World Maritime University in Malmö Sweden,
entitled “Getting the best from multi-cultural manning”:

The main points are:

About two thirds of the world’s merchant marine sails with a crew
composed of several nationalities. At times, the crew mixture may
experience behavioural problems both at work and off duty that can
affect ship safety, pollution prevention and security. Crews need to
learn to work together. With less prejudice and stereotyping in this
multicultural-setting this might be feasible. A true global shipping
community requires cooperation over both cultural and language
boundaries.

A well-trained safety-communicating crew has become a prerequisite

and a mandatory requirement in today’s global shipping fleet. Skills and
motivation do not have anything to do with nationality.

One benefit of working with people from other cultures is the

opportunity to learn about their cultures and languages. People from
other cultures have goals, customs, thought-patterns and values that
may be different from your own.

Gonzales (2000) found that the factor most important to improve

relations onboard the Spanish merchant marine, is the officers’
command abilities, including management & communication skills.

A study conducted by the Filipino National Maritime Polytechnic

(Espiritu, 2003) found that 66% of the respondents (1140 persons) did
not encounter any problem working with other nationalities. However
31% (a high figure) said otherwise and they mainly referred to
problems with superiors. Communication and languages were the most
commonly encountered problem and poor command of English.
Problems related to attitude were: arrogance, superiority complex,
racial prejudice and ethnocentricity. In summary, the report states that
problems are mostly culture related.

Prior to deployment, crew should be given a course on familiarisation

of cultures they are assigned to work with. This will help to avoid
stereotypical behaviour that can often create racial bias and

59
misunderstanding. The study recommends a Code of Conduct for
Mixed Nationality Crew.

The Oil Companies International Maritime Forum’s (OCIMF) (2004)

Tanker management and self-assessment, a best-practice guide for
ship operators (TMSA) is strictly used by most oil-majors. TMSA has
twelve elements for the owners to follow: Two of them are directed to
the issue of language and culture. These elements are not only a guide
for tanker operators but could well be used for any ship operation.

Possible advantages of a multicultural crew:

1) People from different cultures often have a different way of
thinking and analysing and this aids teamwork and decision
making.
2) When selecting crew members from a global pool, there are
better opportunities to find the most competent.
3) Each culture brings transferable knowledge that can be
effectively used in the global market in which shipping operates.
4) Hiring seamen from developing countries supports the
development of those developing countries.

To be successful it is vital to educate ourselves in the behaviour of

other cultures. This must be achieved by adopting stronger leadership,
effective teamwork and by making the effort to talk to each other.

Introduce a multi-cultural curriculum in each nation’s maritime

education. Maritime education and training institutions should take a
hard look at the communication competence required to be an effective
officer at sea and at the skills required to adapt to social situations.
People solve problems more in teams today and that is why it is of high
interest to employ staff with good social competence; more important
than employing people with high intelligence (IQ).

Culture and Language

Alarm calls
and messages
were not given
in languages
spoken by the
majority of the
passengers

199 people died in the the fire on board Scandinavian Star, 1990

60
 Health Issues – Stress and fatigue

Many aspects of our health can affect performance and it is important to

recognise these in ourselves and others. Some, such as excess stress and
fatigue, may adversely affect our performance, while others, such as poor
vision or hearing may affect our physical state. Good general fitness can help
mitigate stress, fatigue and some injuries and maintaining a level of regular
exercise is recommended to maintain general health. Figure 11.1 shows how
excess stress and fatigue can drain our mental resources. Without that ‘fuel’
the processor (brain) cannot effectively drive our cognitive system.

Figure 11.1

The Mental Effect of Stress and Fatigue

Mental
Resources

Processor

Excess Fatigue
Attention Stress
Communicate
Management

Memory
Reasoning
Data Retrieval

Stress
Stress is positively linked to human performance, in that individuals need
some stress in order to be able to perform effectively. However, excess stress
will reduce our performance, affect our wellbeing, can cause serious illness,
and can endanger lives. Excess stress has been referred to by the medical
profession as 'the modern day plague'.

61
Figure 11.2

Human Performance Curve

Good
Optimum Performance

Effective Reduced Efficiency

Performance
Creative Difficulty Concentrating
Decisive
Indecisive
Alert
Irritable
Stimulated
Anxious
Under involved Confused
Boredom Fatigue
Frustration Exhaustion
Rust Out Burnout
Poor

Low Demands High

Looking at the Human Performance curve in Figure 11.2, it can be seen that
when demands are low our performance is generally poor and as demands
increase our interest is stimulated. We perform better from about halfway way
up the curve to a point near the top. Most individuals find that they are able to
cope and operate to their maximum potential and are at their happiest when in
this region. We will usually contribute positively to the task and we can sustain
this performance for long periods. However, as demands increase further,
performance will reduce. Many things can cause this including:

Excessive workload.
Inadequate resources, both physical and material.
Excess stress and fatigue.
Real or imagined anxiety - caused by job, home, competency, lack of
confidence, etc. (Panic attacks).
Lack of teamwork and synergy.
Lack of recuperation.

These are just some of the aspects and the greater the continuous level of
demands, the more the possibility of serious health problems arise. Having an
awareness of what is happening will help mitigate the effects.

In the context of Human Performance Figure 11.3 shows the important

connection between good leadership, synergy and team work and low levels
of stress. However, equally true is that poor leadership, synergy and team
work will lead to high levels of stress. It is a straightforward relationship, as
depicted in the Figure.

62
Your leadership, communication and team working skills will directly
affect levels of stress in the members of your team – positively and
negatively.

Figure 11.3

Stress
Managing Stress
Synergy

• Stick to the facts – stressed

people are very touchy

• Always try to be one step

ahead of the game

• Work as a team

• Humour is a good stress

reliever
The effect of stress decreases when synergy increases

Reducing the effects of stress

It is possible to reduce the negative effects of stress (providing they have
been recognised in the first place) by a few simple coping strategies, as
follows:

Goal setting and prioritizing.

Being assertive.
Time management.
Confronting the problem and talking it out.
Sharing problems.
Relaxing.
Taking up a hobby.
Exercising.

Exercise is particularly effective as this helps to reduce the amount of

chemicals in the body caused by stress.

63
Symptoms of stress:

Behavioural symptoms Physical symptoms

Constantly irritable Headaches

Loss of sense of humour Lack of appetite

Suppressed anger Frequent indigestion or

heartburn
Difficulty in making decisions Craving for food when under
pressure

Feeling unable to cope Insomnia

Constant tiredness Tendency to sweat

Unable to finish a task before rushing to Constipation or diarrhea

start another
Feeling of animosity from others Cramps and muscle spasms

Lack of interest in doing things at home Nervous twitches, nail-biting etc.

Wanting to cry at the smallest problem Nausea

Feeling tired in the mornings after an early Breathlessness without exertion

night
Impotency or frigidity

Skin complaints

What we eat and drink can also have an effect on our mood and alertness.
This is especially relevant to people who carry out watch keeping duties or
shift work.

Recognising stress in self and in others

It is important for us to realise that stress cannot only affect our health but
also our ability to make decisions. We need to be able to recognise symptoms
of stress in ourselves and in others.

Symptoms to watch out for include those concerned with the following
aspects of ourselves:

64
 Emotional This may be general, such as depression,
or specific such as panic in certain
situations.

Behavioural Irritability, abrupt speech, hostility, poor

motor co-ordination.

Mental Confused thinking, procrastination, and

difficulty in prioritising.

Physiological Headaches, muscular tension, impaired

digestion, skin rashes.

Altered appearance Lack of interest in appearance, looks

and habits miserable, tired or nervous and agitated

To help in identifying stress we need to ask ourselves some questions:

Do I feel guilty when relaxing – uneasy if ‘not on the go’?
Do I lie awake worrying about tomorrow?
Do I feel that I have a lot on my mind – do I have difficulty
concentrating?
Am I tense? Does my neck feel ‘knotted up’?
Am I smoking or drinking more or do I eat in a hurry?
Am I irritable or impatient with others – do I interrupt when others are
talking?
Does life seem to be full of crises – am I always having rows?
Do I find it difficult to make decisions?
Do I feel frustrated when people don’t do what I want?

Sleep and Fatigue

Sleep is vital for our wellbeing. Lack of sleep can cause fatigue and health
problems and is detrimental to good performance. However, it is important to
note that individuals cope with lack of sleep very differently.

Long hours of work, disrupted sleep, poor quality sleep and periods of sleep
that are too short, can cause both mental and physical fatigue. All this can
give rise to reduced alertness, chronic sleep deprivation, automatic behaviour
syndrome and hypovigilance. This might lead to falling asleep while working.

The effect of fatigue is to reduce performance. This may sometimes be

expressed by low morale, a decrease in motivation and the possibility of
increased errors. Our health can suffer with existing conditions being made
worse, while cardiovascular disease, circulatory disorders and gastro-
intestinal problems are areas for particular concern.

65
Biological Clocks and Circadian Rhythms
Our bodies are designed to be awake during the day and asleep during the
night. Our biology is governed by the twenty four hour rotation of the earth
and our circadian rhythms have evolved to mirror this. Thus our normal
functions and energy levels are enhanced after sunrise and gradually decline
as the day progresses. Our biological processes such as body temperature,
digestion, sleep and hormone release, follow a rhythmic pattern, as do
psychological states such as alertness and behaviour. This is important when
we consider people who work unsocial hours and those who regularly work
extended or irregular hours.

In these cases our body clock is trying to run normal body cycles in normal
daytime and night time rhythms. However this will now be out of
synchronisation with the pattern of activity that our work requires.

Figure 11.4

Day Working Night Working

Sleep No Sleep
37

Body
Core Max Sleepiness
Temp
Deg C
Post Lunch
Dip
36

11pm 7am 11pm 7am

Figure 11.4 shows our body temperature over a twenty four hour period, with
the cycle continuing, even if working a nightshift or irregular hours. This can
give rise to problems in our performance, since maximum sleepiness occurs
when the body temperature falls. At the same time we are generally less alert,
more prone to making mistakes and our decision making ability is affected.

During the ‘post lunch dip’ period between around 1300 and 1500 we often
experience a feeling of tiredness. This is also because our natural rhythms
reduce our body temperature during this period.

66
Sleep
In order to function correctly and to maintain our general health, it is important
that we have good quality sleep. This can be a problem to those who work
unsocial hours, but the situation can be improved by adopting coping
strategies.

There are two commonly used classifications of sleep, REM (Rapid Eye
Movement) and NREM (Non Rapid Eye Movement). NREM is normally sub-
divided into four stages, or depths, of sleep.

REM sleep is essentially the dreaming form of sleep and accounts for about
15% to 20% of a nights sleep. It occurs regularly during the night, typically at
90 minute intervals, and its duration gradually lengthens through the sleep
period. (See Figure 11.5). If people wake up naturally it will be from a period
of REM sleep, unless they are disturbed earlier during one of the other stages
of sleep.

The other four stages of sleep are important because of their restorative
effects on our body and mind. They are:

Stage 1 – Our muscles relax and our pulse and breathing slow, as do
our electrical brain waves. It is the transition stage between waking and
sleeping.

Stage 2 – In this stage blood pressure drops, heart rate decreases and
our brain waves follow an irregular pattern.

Stages 3 and 4 – Both of these are known as ‘slow wave’ sleep‘.

During these two stages, brain waves follow a slow cycle and we sleep
deeply, with the depth of sleep and duration of the stage being greatest
in the early cycles. These stages are particularly important, as it is
during this time that our body recovers from the physical activity of the
day. It is also known as ‘restorative sleep’ and plays an important role
in maintaining our general health. It is particularly crucial for young
children as it is during this phase of sleep that the growth inducing
properties occur.

Additionally, REM sleep is a period of time that completes each cycle and
becomes progressively longer during sleep. Dreaming and cognitive
restoration (similar to defrag of a computer) takes place during this period.

67
Figure 11.5

Histogram of Normal Sleep

Wake

REM

Stage 1

Stage 2

Stage 3

Stage 4 Deep Sleep

2400 0100 0200 0300 0400 0500 0600 0700

Time

We can adopt several strategies in order to achieve good sleep patterns.

What we eat and drink can affect the way we feel; our body clock controls our
digestive system by regulating the excretion of the enzymes and digestive
juices to the stomach. This happens at generally the same time every day, so
if eating a heavy meal in the very late evening or early hours, the food will
remain in the stomach until the body clock releases the digestive juices in the
morning, typically around 0600 to 0700. This can give rise to feeling sluggish
and bloated during the night. The same occurs for other meal times during the
day, around 1200 to 1300 and 1800 to 1900, so we are naturally programmed
to eat at those times.

Caffeine, found in coffee, tea, cola, stimulant drinks, etc. can interfere with
sleep and may contribute to restlessness, irritability, tension and insomnia and
can also cause high blood pressure.

Figure 11.6

Sleeping Environment
• Make your cabin as dark as possible
• A comfortable temperature
• No caffeine for 4-6 hours before sleep
• Do not drink too much alcohol
• Take exercise, but not just before you go
to bed
• Do not eat just before you go to bed
• Introduce a noise generator

68
Take care of your sleep needs, or if not maybe!.....

69
 Risk Management

Risk Assessment and Loss Avoidance

Human factors knowledge should be addressed as part of a company’s risk
assessment programme.

It should be noted that risk assessment tools can be used for assessing all
risks that could lead to business loss. This includes, but is not limited by,
safety related risk assessment.

Figure 12.1 shows one proven method that can be used to brainstorm the
hazards associated with a particular task. It is called a cause and effect
analysis, or fishbone diagram.

To use this tool effectively, you should assemble a risk assessment team who
are closely involved with the task in question and develop the diagram on a
whiteboard. This method works well because it uses the right brain, or
picturing brain, to build up the picture of the hazards involved.

Figure 12.1

Risk Assessment for Ro-Ro Ferry Operations

(Cause and Effect Analysis)
Location: Vessel ‘Seaway Carrier’ Department: Deck Activity: Vehicle Deck Loading

Planning Procedures Access/Egress Communications

Ship to/from Shore to/from
Loading/unloading ship (ports)
Securing Stowage Crew briefing On Quay office
Ramps
Interdepartmental
Loading methods Approved sea Tool box
fastenings Passenger routes
From vehicle deck talks
Safety meetings

Effect
Accident/Incident, Damage,
Operations delay
Loading speed Vehicle deck Manning
with safety Non-slip surfaces levels Crew/officer
Ease of hardware W/T doors appraisal
Bow door design
cleaning
Cleaning Hydraulics Qualifications /
schedules Cleaning systems experience Crew on board training
Vehicle deck Fire doors
design equipment

Design & Hardware Housekeeping Maintenance Competence

Causes (Hazards)

70
Once all the hazards have been uncovered, together with the risks associated
with those hazards, the risks can now be assessed. The following risk
assessment matrix (Figure 12.2) will assist in this task:

For each risk the likelihood of occurrence and severity is assessed using a
simple 1 to 5 scale for each. The risk factor is the likelihood multiplied by the
severity.

Risk Assessment Matrix (Figure 12.2)

Severity
1 2 3 4 5
Negligible Minor injury Injury Involving a Multiple
injury, no requiring leading to a single
deaths
absence first aid lost time death or
from work treatment accident serious
injury
1
A freak
combination of
1 2 3 4 5
factors would be
required for an
incident to result
2
A rare
Likelihood of Occurrence

combination of
2 4 6 8 10
factors would be
required for an
incident to result
3
Could happen
when additional
3 6 9 12 15
factors are
present, otherwise
unlikely to occur
4
Not certain to
happen but an
4 8 12 16 20
additional factor
may result in an
accident
5
Almost inevitable 5 10 15 20 25
that an incident
would result

May be acceptable, however, review task to

1-6
see if risk can be reduced further.

Task should only proceed with appropriate

7 - 14 management authorisation after
consultation with specialist personnel and
assessment team. Where possible, the task

71
 should be redefined to take account of the
hazards involved or the risk should be
reduced further prior to task
commencement.

Task must not proceed. It should be

15 - 25 redefined or further control measures put in
place to reduce risk. The controls should
be re-assessed for adequacy prior to task
commencement.

Please Note: By redefining the hazard severity, risk evaluation matrices

can be used to assess health, production/service and environmental risk
as well as the risk of accident and injury: In other words, all loss events
can be assessed in this way. (See also Figures 12.3 and 12.4).

Example definitions of the hazard severities:

1. Negligible injury or health implications, no absence from work.

Negligible loss of function/production/service, with no damage to
equipment or the environment.

2 Minor injury requiring first-aid treatment or headache, nausea,

dizziness, mild rashes.
Damage to equipment requiring minor remedial repair, loss of
production/service or impact to the environment.

3 Event leading to a lost time incident or persistent dermatitis, acne or

asthma.
Localised damage to equipment requiring extensive repair, significant
loss of function/production/service or moderate pollution incurring some
restitution costs.

4 Involving a single death or severe injury, poisoning, sensitisation or

dangerous infection.
Damage to equipment resulting in production shutdown or service loss
and significant production/service loss.
Severe pollution with short term localised implications incurring
significant restitution costs.

5 Multiple deaths, lung diseases, permanent debility or fatality.

Business fatally damaged or bankrupt.
Major pollution with long term implication and very high restitution
costs.

72
Figure 12.3

All business risk can be

managed with... Company
Policy

Necessary
Organisation
improvements
and Personnel

Management Identification Identification

reviews of impacts and of hazards and
evaluation of assessment of
significance risks

Monitoring
and auditing
Setting
company
objectives
Performance Internal
Measurement control
measures

Figure 12.4

Operational risk
• Key ship machinery faults
• Critical defects
• Catastrophic accident Input risk
Product market risk • ‘Bugs’ crash company IT systems
• Labour strikes
• Customer loss • Key employees leave
• Competition increases • Key supplier fails
• Product demand decreases
• Brand becomes a turn-off

Tax risk
TOTAL • Shipping related tax
COMPANY increases
Financial risk RISK • Taxation on bunkers
• Uninsured costs
• Capital costs change
Exchange rate changes drastically
• Inflation
• Lack of due diligence Regulatory risk
• Default on debt • Shipping Laws change
Legal risk • Price supports end
• Product liability • Competition opens up
• Employee claims
• Major health and safety claims

73
Another tool that might assist in analysing areas of concern is the Pareto
Analysis or 80/20 Rule (See Figure 12.5). This states that for any particular
area of interest, including risk assessment, 80% of the issues can be found
within 20% of the subject areas.

In Figure 12.5, if 20% of the areas containing hazards are addressed (in this
case in the areas of communication and maintenance) you will have reduced
80% of the risks to ALARP (As Low As Reasonably Practicable).

Figure 12.5

Pareto Analysis
80 / 20 Rule
80%
83

77

17

12 5
Risks 2 1 1 1 1
(associated) Comms Procedures Competence Access
Maintenance Planning Housekeeping Design

20% Category

74
Figure 12.6

The Steps Leading to an

Accident, Incident or Loss Event
Organisational
Causes Contributory
Company Policies: Causes Immediate
Translated into action? Causes Defences
Measured? Software:
Latent Failures
Reviewed?
(Pathogens) Human Errors
Audited?
Risk Assessed? (Lapses, Slips,
Examples: Trips, Mistakes)
Tools: Poor Inspection Human Violations
Supervision failure
Communication? Mismatch Job / Hardware:
Procedures (SOP’s)? Individual Engineering
Training/Competence? Equipment Design Technical Failures
‘One Team’ approach? Accident /
Workplace Design
Involvement? Incident /
Commitment? Loss Event

When investigating an accident, incident or loss event (see Figure 12.6) it is

tempting to focus only on the immediate causes, the human errors and
hardware failures, and then apportion blame. An incident is usually a result of
an error chain, which is a number of errors combining in an unbroken
sequence. This chain regularly, but not always, commences from
organisational causes within the management system. It is essential that
these causes are examined and the resultant latent defects or ‘pathogens’
uncovered, in order to arrive at the root causes of the loss event.

Focusing only on the human errors is like swatting individual mosquitoes,

whereas uncovering the organisational latent pathogens is like draining the
swamp (where the mosquitoes breed). The latter is of course much more
productive.

75
Figure 12.7

Loss Causation Sequence

Top level
decision makers

Human Involvement Line management

Designers, planners etc.
Fallible decisions
Line management

Latent failures Operators, maintenance etc.

Preconditions
Unsafe Acts

System Defences

Causal sequence
Loss
Local triggers Event
Technical faults
Atypical conditions Limited windows of
Environmental conditions etc. Accident opportunity

The ‘Swiss cheese’ model. Figure 12.7 (developed from Professor James
Reason’s work - Professor of Psychology Manchester University, England)
shows the incident causal sequence in more detail. Decisions taken by the
Board of Directors can have far reaching consequences for the organisation.
These decisions are made by fallible humans, which means the decisions can
be wrong, or when correct are taken in a different time and place from the
eventual incident, so still they can set up undesirable latent pathogens. In the
‘Swiss cheese’ the holes in each stage of the causal sequence demonstrate
that anything man made is imperfect, and can be breached.

Line managers, like ship’s masters and chief engineers, sometimes have an
opportunity to break this error chain by altering the preconditions for the loss
event by decisions they take on board as shipboard managers. How much
they are willing to make these interventions is a function of their own
management and leadership capabilities, and of the company culture that
empowers them to act in favour of proactive loss avoidance behaviour and the
encouragement of such behaviour in their subordinates.

The number of ‘arrows’ leaving the company head office directly relates to the
strength of the loss avoidance culture of the organisation. The stronger the
culture the less arrows are released and the less chance of a breach all the
way through to a loss event.

Each individual is capable of thinking, and in this regard can alter his own
behaviour to avert the incident. This free will has brought about the popularity
of behavioural based safety programmes to influence individual behaviour and
there is no doubt that, for the companies with very robust management
systems, this type of intervention has improved loss avoidance performance.

76
However, it must never be forgotten that the biggest single influence upon an
individual’s behaviour is the company culture created in the corporate
boardroom and in this respect this model holds good.

Figure 12.8

Underlying Causes of Loss Events (The ‘Onion ’ )

Organisational Culture
Hardware Training

Co Error Enforcing
mm le
un
Conditions
a tib
ic p
ati c om als
on In Go

Procedures
Design

Defences

Maintenance
Housekeeping
Management

Underlying Causes of Loss Events

Figure 12.8 is a model of root causes for loss events (taken from Professor
James Reason’s research, professor of psychology at Manchester University
in England. See also Appendix B). They are known as latent pathogens
because the factors that cause the losses to occur remain within the system,
sometimes for years, until a triggering mechanism completes the chain of
events that will lead to a loss event.

Correction of identified latent pathogens lies within the management system.

One of the major keys to a successful business is management accepting that
meaningful root cause analysis of loss can deliver significant benefits.

The main aim of loss investigation is to prevent the recurrence of similar

incidents and, therefore, the actual cause of any incident is a matter of prime
importance. The aim of accident investigation is NOT to lay blame.

Why Investigate?
To establish all the facts relating to the loss event.
To draw conclusions from the facts.
To identify the immediate and underlying causes.
To identify weaknesses in management control.
To calculate the financial costs to the organisation.

77
 To ensure that a repetition of the chain of events is not possible.
To make recommendations to prevent a recurrence of the loss event.
To improve/develop an open culture.
To share lessons learnt with others.

Accident Investigation and Follow-up

Systems should be in place to:

Determine the root cause of each loss event.

Identify specific follow-up action and systems to be corrected.
Analyse all loss events to identify common root causes and to
determine changes necessary to prevent future incidents by elimination
of those causes.
Ensure close out of follow-up items and assess or measure the
success or failure of actions taken to reduce loss events.
Encourage open and frank loss event reporting by all employees
through reducing emphasis on apportioning blame and emphasising
the benefits of lessons learned.

Immediate Causes relating to a Loss Event (Figure

12.9)
Figure 12.9

Immediate Causes of Loss Events

Immediate Cause
(Unsafe Act)

Intended Action
*Unintended Action

Violation Mistake Lapse Slip

Rule mode Memory Attention

Routine, Situational mistake Failure Failure
and Exceptional Violations &
Act of Sabotage Knowledge mode * Skill mode routine errors
(Deliberate and malevolent) mistake

78
Skill, Rule and Knowledge Based Behaviour
Figure 12.9 shows how our actions break into two, intended or unintended.

Unintended actions break into two types of skill based routine errors which
are:
Lapses of memory.
Lapses of attention.

Intended actions also break into two:

Rule based mistakes - caused by following the wrong rule, or following
the right rule but wrongly executing it.
Knowledge based mistake – caused by a lack of knowledge or
experience to undertake a task, or being unable to recover information
from long term memory.
Violation – caused by breaching a safety rule or procedure.

Our familiarity with a particular task will influence the number of errors that we
may commit. While carrying out a task, the amount of thought we give to
completing it will vary. Some tasks become so familiar that we do not have to
concentrate too much and this means that we may have the mental resources
available to simultaneously think about something else.

For example, when making a cup of tea, we might be so familiar with the
procedure that we could also think of other things like our next holiday. When
we have learned a procedure, such as making tea or driving a car (when
experienced) and it has become embedded in our subconscious mind, we use
that to complete the task automatically. This we call, ‘skill based behaviour’.
This is the behaviour mode that we all use for about 80% of the time and it
occurs when the skills required are mastered and when most of our actions
are reflex. This means the allocation of mental resources to that particular
task is minimal, and active allocation of resources (attention) to other activities
becomes possible. This is the desirable behaviour mode but it is very
sensitive to routine error.

Although we make infrequent errors in this behaviour mode, it is not error free.
Our defence against errors comes most often from other members of the
team spotting our errors and the synergistic management style of the team
leader, which promotes assertive error spotting amongst team members.

When we are not so familiar with the task, but have possibly seen it before, or
seen someone else perform it, we will often use a procedure, instructions or
work manual. This is called ‘rule based behaviour’ and it occurs when a
greater level of concentration is necessary to undertake a given task or when
following a set of rules and procedures. This also occurs when we are still
acquiring our skill and expertise and is normal in training situations. This
mode consumes a lot of mental resources leaving little room to pay attention
to anything other than the task we are focused upon.

When in rule based behaviour mode, work overload and making rule-based
mistakes are possible. In this mode we need to apply concentration to what

79
 we are doing. More mental resources are used in this behaviour mode than in
skill based behaviour.

When things become harder and we find ourselves facing a particular task or
situation that is outside our experience, or one we have not done for many
years, we find ourselves in what is known as ‘knowledge based behaviour’.
This is the behaviour mode where we either do not have the required
knowledge, or we have the knowledge but cannot easily recover it from our
long term memory, perhaps because it is many years since we were last
called upon to do this particular task.

Finding ourselves in this mode is rare but we are sometimes forced into it
when faced with a situation of which we have no experience, such as
research based work or when at the cutting edge of technology and design.
Tools such as peer checking and independent verification of results will help
reduce the higher likelihood of errors.

When in knowledge based behaviour it is necessary to fully focus, reason and

concentrate on seeking a fresh solution to what may be a unique task or
situation. An enormous amount of mental resources are used and it is
extremely difficult to use this behavioural mode when fatigued and/or suffering
with excess stress.

We need to avoid working in rule based and, especially, knowledge based

behaviour as much as possible, as these modes increase the likelihood of
errors being made. This is a function of our skill, expertise and experience.
Research shows that whilst in ‘skill based behaviour’ the likelihood of
mistakes being made is 1:10,000, in ‘rule based behaviour’ it is 1:1000 and
when in ‘knowledge based behaviour’ it is an alarming 1:2 (see Figure 12.10).

Figure 12.10
High

Inaccurate Mental Model

Knowledge
Based
Attention (to task)

Misinterpretation
1:2 or misapplication
Rule
Based
Inattention
1:1K
Skill
Based

1:10K
Low

Low Familiarity (with task) High

80
Violations
Violations are deliberate, but normally non malevolent, breaches of rules.
Seeking out the root causes of these breaches is usually very productive,
since people do not usually plan, nor intend to be malevolent. There are four
types of violation as follows:

Routine: This occurs when breaking the rule or procedure has become an
accepted way of working. There may be many reasons for this, including an
individual desire to cut corners or even a belief that the rules are too
restrictive or don’t apply.

Situational: These occur when the rules are broken due to pressures of the
job. Corner cutting violations are an example.

Exceptional: These occur when something has gone wrong and the decision
is made to deliberately break a rule in order to solve a new problem. It will be
assessed in this case that the benefits of breaking the rule outweigh the risks.

Malevolent: Malicious and / or criminal act.

Figure 12.11

The Practical Effects of Errors

The effects of an error depend entirely
on the structure of the system in which
it occurs
error
The two main characteristics of the
system are that it must be:
Protected system

Error tolerant – designed to ensure that

no single error can trigger a loss event

error Highly visible and/or audible –

systems are in place to monitor, detect
Vulnerable System and warn of errors

Since no behaviour mode is error free, it is important to construct business

and safety systems to be error tolerant and for errors made to be highly visible
or audible. Therefore, our systems should be protected and not vulnerable, as
illustrated in Figure 12.11.

81
Figure 12.12

Loss Triangle
1
Fatality
Bankruptcy

400 Reportable Injuries

Serious business loss

20,000 Minor injuries / financial loss

240,000 Near misses (Business & Safety)

2,000,000 Unsafe acts / Incorrect actions

Figure 12.12 shows the relationship between unsafe acts / incorrect actions
and learning opportunities at one end of the scale and serious accidents /
bankruptcy at the other.

We need to identify where we should focus our attention: It is of course at the

bottom of the triangle. To identify the thousands of near misses, or ‘learning
opportunities’, we need to create the correct company and industry culture
and steer away from the tendency to say, “give me a name” after a loss event
has been suffered.

Having gathered the ‘learning opportunities’, it is important to classify each by

potential to cause harm. Figure 12.13 (an incident potential matrix) shows
how this can be done. Remember that the outcome of any loss event is a
function of luck and it is important to investigate it on the basis of the
potential outcome.

Understanding the potential for causing harm of each ‘learning opportunity’

will allow you to determine the amount of time, effort and money it is
reasonable to spend on ensuring the risk of repetition has been reduced so
far as reasonably practicable. A future similar incident may have a far more
serious outcome.

For example, the X in box A1 represents a near miss involving a main engine
crank case incident in the engine room of a vessel where luckily no damage
was caused or injury sustained, but the potential loss could have been, but
for luck, a fatality with costs exceeding $1,000,000 (box D4).

82
Figure 12.13: Incident Potential Matrix

Number of Persons Affected/At Risk

Loss/Potential Loss

A B C D E
Injuries/Damage 0 1 2 – 10 11 – 100 >100
$0 <$10000 $<100000 <$1000000 >$1000000
Minor injuries,
miscellaneous
damage, no
business impact 1 X

Moderate injuries,
damage with
some business
impact 2

Severe injuries,
damage,
business impact 3

Fatality,
explosion with
moderate
damage, 4 O
significant
adverse business
impact

Multiple fatalities,
explosion with
major loss, 5
catastrophic
business and/or
environmental
impact

Please note: The above incident potential matrix may be used to assess the
potential severity of a financial loss event just as readily as for an HSE
incident. Imagine, for example, using this for the Enron or Barings Bank cases
before each incident realised its full potential.

Remember:
Good safety is good business.
Peter Drucker (international business adviser) said: “The first law of
business is not to make a profit; it is to avoid making a loss.”

83
 Summary

Many companies have identified the need for change, to improve business
and loss management performance. A fundamental part of this change is the
development of people’s non technical skills and improving communication in
all areas of the business. Developing ‘Human Performance’ to full potential is
no longer ‘nice to have’ but is now a ‘must have’ for business survival in the
single global economy of the 21st Century. You can play an active part in this
by the way you run your ship(s) and support your crew(s).

This can be achieved by:

Developing leadership and management skills.
Developing communication and team working skills.
Systematically seeking out obstacles to job satisfaction.
Empowering people.
Allowing the workforce to invent and own the business processes.
Introduce self imposed accountabilities and measures for workforce to
monitor their own performance. These measures should form an
integral part of the company appraisal system and should affect career
development.
Developing business risk management and loss tracking tools.
Providing relevant technical and non technical skills training.

The philosophy is simple: optimising ‘Human Performance’ delivers a

workforce that performs at or near its capable limits. Most people naturally
come to work to do their best but are regularly prevented from so.

Achieving all of this in an organisation normally requires culture change.

However, the benefits to the industry, ship owners, ship managers, masters,
chief engineers and individuals, from understanding ‘Human Performance’
and its application, are listed below.

Common characteristics that are in evidence include:

Very strong management leadership and example setting throughout
the organisation.
Responsibility and authority are inseparable, leading to accountability
being readily accepted.
Extensive and meaningful employee involvement in continuous
improvement.
Improved performance, quality and productivity through effective
engagement and communication. People routinely ‘get it right’ first
time.
All staff with complementary aims and expectations.

84
 Better employee relationships as employees recognise that the
company and its management care for their well being and that of the
environment.
Staff setting standards and expectations for themselves in a whole
range of features including attitudes and behaviours.
Management requiring and measuring conformance from both
themselves and their people.
Clearly defined procedures and systems that are adhered to and
comprehensively audited.
An effective communications system.
An honest loss event and ‘learning opportunity’ reporting scheme.
A real commitment to training and development.
Protection of the company’s reputation by avoiding adverse publicity
and creating a positive image with employees, contractors, and
customers.
Kudos for the company, from the achievement of an improved safety
and business performance.

Being a manager and an effective leader involves many skills and attributes.
As a manager or leader you have enormous responsibility, not only to your
employer, but also to your team. The needs of your team members must be
met if both you and your company are to be successful.

If you apply the Human Performance tools you were given on the course(s)
and in this handbook, you can hone your leadership skills and help people to
understand themselves, their natural human weaknesses and how to
effectively guard against them.

Above all, you can be instrumental in avoiding pain and suffering

caused by accidents, and bring about safer ship operations and cleaner
seas.

To be effective it must form part of a commitment to an overall management

culture within each company that has, at its core, a commitment to and a trust
of its people. The industry will always need trained inspirational leaders who
will head the drive to industry culture change. There is no reason why one of
those leaders could not be you.

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 Acknowledgements

WrightWay wish to acknowledge various authors and their publications in the

compiling of this Human Performance Handbook. Specifically they are, in
order of appearance in the Handbook:

Author Publication

Steve Hein (The EQ Institute) Developing Emotional Intelligence

Steve Hein (The EQ Institute) Emotional Honesty, Emotional Safety in
Organisations
John Adair ‘Not Bosses But Leaders’
Jonathan Coates & Claire Breeze ‘Delegating with Confidence’
Terry Gillen ‘Assertiveness’
British Health & Safety Executive ‘Successful Health & Safety
Management’ (HSG65)
Jan Horck (World Maritime The 2005 BIMCO study ‘Getting the
University, Malmö Sweden Best from Multi-Cultural Manning’
Professor James Reason Various publications on accidents and
their causation

Other useful Titles

Dr. Philip Anderson (with others) ‘Cracking the Code’

Dennis W Bakke ‘Joy at Work’
Daniel Goleman ‘The New Leaders’
David R Caruso ‘The Emotionally Intelligent Manager
Daniel Goleman ‘Emotional Intelligence’
Steven R Covey ‘The Seven Habits of Highly Effective
People’
William C Byham ‘Zapp! – The lightning of Empowerment’
Rob Parsons ‘The Heart of Success’
Cynthia D Scott ‘Managing Organisational Change’
British Health & Safety Executive ‘Reducing Error and Influencing
Behaviour’ (HSG48)
Dan Petersen ‘Techniques of Safety Management’
Allan & Barbara Pease ‘The Definitive Book of Body Language’
Thomas A Harris ‘I’m OK – You’re OK’
Michael Hammer ‘Beyond Reengineering’
Charles Perrow ‘Normal Accidents’

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Appendices

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Appendix A
Incident Analysis Checklist

When carrying out a Loss Event Investigation you should ask the
following general questions:

Loss Event Causation

1. What were the immediate human causes (unsafe acts, omissions,
incorrect actions) - lapses, slips, or violations?
2. What were the immediate hardware causes (failures, breakages,
malfunctions etc.)?
3. Have there been any similar or related incidents on board or
elsewhere in the fleet?
4. Is there a discernible pattern to these incidents?
5. What were the underlying causes? It is important that you address
the causes, as they will focus your attention on any latent
pathogens present in the management system, rather than limiting
your investigation to a thorough analysis of the symptoms.

The underlying causes can be categorised into one or more of the

following eleven areas of concern:

Failures in the organisation; communication; training; procedures;

housekeeping; maintenance management; hardware; design;
defences; the presence of incompatible goals or error enforcing
conditions.

(See Appendix B)

When carrying out a Loss Event Investigation you should ask the
following specific questions:
What was communication like within the team?
Were briefings held?
What was the management style set by the leader - Autocratic, Self
centred, Laisser Faire or Synergistic?
Was there synergy within the team?
Was the workload shared equally amongst the team?
Who had situational awareness?
Were any of the team being distracted?
Were checklists and / or standard operating procedures being used?
Was the system error tolerant and error visible?
What was the behavioural mode of each participant? Skill, Rule or
Knowledge?
What was the error type involved in the immediate cause, unsafe act or
incorrect action? Skill = Attention or memory failure (Routine error);
Rule or Knowledge = Mistake; OR was a violation committed?
(Deliberate, non malevolent, breach of safety rules).

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 Was Representation Error present?
Were any of the 11 underlying causes (latent pathogens – root causes)
present and if so, which?
Was there evidence that DODAR was used to assist in good decision
making?
Was any bias present that influenced the decisions - i.e. group
pressure or confirmation?
Was stress or fatigue present in any member of the team?

Note: Not all of the questions above will apply in your investigation.

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Appendix B
Incident Investigation Prompt List for Underlying
Causes (Latent Failures or Pathogens)
Remember to track any errors back to the organisation to get to the root
cause. If this is done thoroughly it will lead you to question things such as the
understanding of the board of directors, the middle managers and the on
board managers of:

The crucial effect of the company culture.

Loss event causation and root cause analysis.
The costs of loss events and ‘learning opportunities’ and the
importance of measuring each by potential rather than outcome.

Remember it is common for more than one underlying cause to be identified.

All underlying causes generate an error enforcing condition. In other words
every accident will have one or more traceable error enforcing conditions. For
example, a common error enforcing condition is lack of familiarity with
equipment or insufficient experience to carry out the job in hand. This would
clearly implicate training as a further underlying cause.

FAILURE TYPES
Organisation
Definition:
Organisational deficiencies in either the structure of the company or the way it
conducts its business, which allows responsibilities to become blurred and
warning signs to be overlooked. Certain aspects of loss avoidance can get
lost in the organisational cracks. This happens even when a company has a
long-standing loss management culture.

Main Features
There are clear definitions of roles, responsibilities, authorities and
accountabilities, which must be known by all. Loss avoidance is a line
management responsibility.

There are no ‘quick fix’ loss avoidance solutions. You should resist the
natural preference to implement a local repair rather than introduce a
company wide reform.

Remedial Actions
‘Healthy’ organisations are characterised by their commitment to constant
self-appraisal and reform. Two things are necessary. A willingness to take
the long view on loss avoidance and tackle the underlying loss management
‘health’ problems rather than their short-term symptoms, and a willingness to

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endure a state of chronic unease whenever loss avoidance matters are
considered. There are no clear victories in the loss prevention war.

Questions to ask of the organisation

Organisational Structure
Is the organisational structure appropriate to the declared mission?
Is there any failure in developing loss management policies?
Are safety responsibilities ill defined?
Are loss avoidance aspects clouded by rationalisation and
reorganisation?

Organisation Responsibilities
Is there any lack of commitment to loss avoidance goals?
Are individuals all aware of their responsibilities and accountabilities?
Is there any lack of competence?
Is there any lack of cognisance of the real problems?
Do other pressures underplay safety?
Were organisational warning signs disregarded?

Communication
Definition
Communication can be implicated as an underlying cause when the
information necessary for the safe and effective functioning of the
organisation as a whole, or for some part of it, does not reach the appropriate
people in a clear, unambiguous or intelligible form. The intended receiver is
known but the message fails to be received, understood or is late.

Main Features
Organisational communication failures fall into three categories:

System failures, in which the necessary channels of communication do

not exist, are not functioning, or are not regularly used.
Message failures, in which channels exist, but the necessary
information is not transmitted.
Reception failures, in which the channels exist and the right message
is sent but is misinterpreted or arrives too late.

Remedial Actions
Invest in good communication equipment.
Ensure communication is standard, unambiguous, and uses
professional language.
Make sure that critical messages are checked for accurate
understanding.
Ensure that the sense of the message is clear and simply stated.

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Incompatible Goals
Definition
This underlying failure recognises that organisations and people are usually
pursuing a number of goals at the same time, and that some of them are likely
to be in conflict. Although such conflicts cannot always be avoided, they
should be recognised and their possible safety consequences appreciated.
Goal conflicts can generate latent failures, which may interact with local
triggers at some later time to cause an accident. Incompatible goals become
a problem when top management give no guidelines on priorities.

Main Features
Goal conflicts can occur at any of three levels:

Individual goal conflicts: preoccupation with domestic or other concerns

cause slips and lapses.
Group goal conflicts: work groups operate with two sets of guidelines.
One imposed by the company, the other generated informally by the
group. Dangerous conflicts can exist between formal and informal
practices.
Organisational goal conflicts: although in the long term, loss
prevention and productivity are compatible, there can be conflicts in the
short and medium term. Goal conflicts in the higher reaches of the
organisation are the principal source of latent failures. Other
organisational goal conflicts can also have knock-on loss management
consequences, even when loss avoidance is given a top priority.

Remedial Actions
At the individual level: bridging the separation gap between a worker and their
families is a good investment, particularly with regard to communications.

At the group level: understanding informal work group norms can greatly
improve the targeting of motivators and information. The message should be
that safe work practices are not something to be imposed from outside. They
should develop as part of the group norms.

At the organisational level: it is important to distinguish between those

conflicts you have to live with (managed around) and those that can be
resolved (managed away). In both cases, however, it is necessary to
examine the operation as a whole and identify exactly which goals are
causing the problems.

Training
Definition
Formal training is a management responsibility. Those at the shop floor can
request more training or even possibly refuse to work if they have not had

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proper training. However, workers who lack adequate training will also tend to
lack an appreciation of its necessity.

Training comes in many forms and ranges from that carried out at school, to
on the job training, and local experience. This implicates recruitment and
selection, as well as job-related training, when investigating training as a loss
event root cause.

Main Features
Training problems may arise for one or more of the following reasons:

Training requirements are not understood.

Training requirements are understood, but compromised for other
reasons.
Training requirements are not imposed.
Training is obstructed, for example by:
o Highly qualified people being employed in the wrong job.
o An entire shift being replaced resulting in the new shift having no
experienced members.
o Staff numbers being reduced, so that under-qualified people
take on jobs beyond their competence.
o Changes being made without making corresponding changes in
staff training.

Remedial Actions
If training requirements are not understood then a detailed task analysis is
necessary. If proper training requirements are overruled, then the decision
makers themselves should receive further training so that they can better
understand these requirements. Where the wrong training is being provided,
there is more feedback should be given to the training department. If training
is not conducted, there could be a major organisational problem that needs to
be addressed at high level. Where training is obstructed through conflicting
priorities, it is important to reappraise these priorities before (rather than after)
a serious training related loss event has occurred.

Housekeeping
Definition
Housekeeping is an underlying failure when it has been neglected for a long
time and when various levels of the company have been aware of it, but done
nothing. It refers to the tidiness and cleanliness of vessels, together with the
provision of adequate resources for cleaning and waste removal.

Main Features
Poor housekeeping cannot go unchecked for long periods unless there are
management failures. These failures are of three kinds:

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 Management makes vessel visits, is aware of the problem, but does
nothing about it.
Management makes vessel visits, but is unaware of the problem.
Management does not make vessel visits.

Remedial Actions
The trick with housekeeping is to find a way that, on the one hand, avoids the
extremes of an over meticulous concern with cleanliness, tidiness and
outward appearance and, on the other hand, avoids dangerous slovenliness.
Either extreme carries penalties. We need to find a standard of housekeeping
that matches the needs of safe and effective operation, but does not go too
far beyond these objectives.

Error Enforcing Conditions

Definition
These are conditions relating to either the individual or the workplace that can
lead to the performance of unsafe acts (errors and violations). This failure
category refers to a chronic situation in which errors and violations are made
more probable.

Main Features
Factors known to increase error rates - listed in table 1

Factors likely to promote violations - listed in table 2

Table 1
Category Context Error Type

Unfamiliarity Potentially dangerous or important Knowledge based

situation which is novel or occurs mistakes
infrequently.
Condition in which a person has to think
and make critical decisions on his feet
with little or no prior experience.
Time shortage Limited time available for error detection All types are possible
or correction. Time pressure is an
extremely potent error producer and will
impair quality of decisions.
Communication Poor communications between groups Misunderstandings.
marred by background working separately from each other. Groups are not in the
"noise" same context
Poor system/human Equipment fails to convey vital Slips
interface information, or has controls which
conflict with the user's expectation.
Designer/user The user's and the designer's ideas on Slips and mistakes
mismatch how the equipment should be used are
different. The user's ideas are frequently
ignored because these conflict with the
designer's.
Lack of error tolerance Unforgiving system or item, for which an Slips and mistakes
error cannot be reversed.

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Information overload Situation in which the user receives Perceptual slips
excessive important information possibly
from more than one source.
Technique unlearning Need to unlearn a technique and apply a Strong habit intrusions;
new one requiring different philosophy or worse under stress
an opposite action.
Knowledge transfer Need to transfer knowledge/training from Strong habit intrusions
task to task without loss.
Misperception of risk Mismatch between real and perceived Mistakes
risk.
Poor feedback System, situation, or equipment item Slips and mistakes
giving incomplete, ambiguous or
delayed feedback to the user regarding
the effects of previous action.
Time of day Shift work, '3 a.m. effect', jet lag. Slips lapses and
mistakes
Inexperience Training or experience insufficient for the Mistakes, clumsiness
demands of the job. and misperceptions
Poor instructions or Insufficient task information supplied by Mistakes
procedures supervisor or the written procedures.
Inadequate checking Little or no independent checking or Undetected errors
testing of work done.
Substance abuse Use of alcohol or drugs, which affect Slips and lapses
work performance.
Educational mismatch Mismatch between educational Mistakes
achievement level of individual and
demands of the job.
Macho Inducements to use other more Slips, mistakes and
culture/dangerous dangerous procedures. violations
incentives
Physical capabilities Certain aspects of task exceed normal Slips, mistakes and
exceeded physical capabilities. violations
Hostile environment A poor or hostile environment which Slips, lapses, mistakes
could have a life threatening aspect
Low morale Working groups in which morale is low Slips, lapses and
and where there is loss of confidence in violations
supervisory and management structure.
Monotony and Prolonged inactivity or highly repetitious Reduced attention and
boredom (low cycle of low workload tasks. vigilance
workload,
hypovigilance)
Disturbed sleep Disruption of normal work / sleep cycles Slips and mistakes.
patterns

Table two

Category Context
Poor safety culture Learned helplessness (‘who gives a damn
anyway?)
Worker/management conflict Perceived licence to bend rules
Poor morale Unclear or apparently meaningless rules
Poor supervision and checking Low self esteem
Inappropriate work group norms Macho culture
Belief that bad outcomes will not happen "Can do" culture
Little élan or pride in work Excessive zeal

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Remedial Actions
Error-producing conditions are dealt with by improving accepted working
situations, reducing time stress, improved training, retraining, redesign of
workplace, improved procedures and memory aids, better information and
heightened awareness of risk.

Violation producing conditions are dealt with by changing attitudes, beliefs

and work group norms, and by improving morale and overall loss prevention
culture.

Note: This is a cultural change, the difficulty of which should not be

underestimated. Telling people not to do something is not an answer. For
example, because engineers are human they think they understand other
people as well as they understand machines. This may not be the case. Many
people have been injured or even killed by this attitude.

Procedures
Definition
Procedures communicate task know-how. They are an underlying cause
when they are unclear or incorrect or otherwise unusable. Many unsafe acts
have their roots in poor procedures.

Procedures are necessary because:

Many tasks are too complicated for the individual steps to be self
evident.
The necessary task information is often too much to be held in short
term memory.
People change jobs frequently.

Main Features
The following checklist will help you identify procedural problems:

Are the procedures physically accessible to those who use them?

Are the procedures intelligible and unambiguous?
Do the procedures promote preventable errors?
Do the procedures contain omissions or factual errors?
Are procedures being followed or capable of being followed?
When did the procedure writers last attempt to execute their own
procedures?
Do the procedures have sufficient contingencies to allow for different to
expected circumstances?
What ‘unwritten’ safety message is being communicated by the
procedure(s)?
Are there too many procedures for a user to know what to do?

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Remedial Action
Make the procedures accessible and user friendly. Make them easy to
understand, portable and well indexed. Ensure that they are intelligible to
people for whom English is not a first language and who are likely to be
working in difficult conditions. Ensure the procedures do not promote
omissions. Build in checks and forcing functions. Be aware of potentially
isolated steps. Break tasks down into readily memorable steps. Ensure that
there are adequate feedback channels from the users to the writers. Monitor
these channels to see that user comments are noted and acted upon. Be
aware of common problems and write in contingencies to deal with them.
Make sure the correct balance is struck between safety and production
messages. Keep procedures up to date by constantly reviewing and updating
them. Make the procedures controlled documents in the quality system.

Maintenance Management
Definition
This underlying cause is concerned with the management of maintenance
rather than the execution of maintenance jobs. Many studies have revealed
that maintenance management failures make a significant contribution to loss
events.

Main Features
Maintenance management may fail due to the lack of a proper programme,
the exclusion of equipment items from the programme or through inadequate
systems, planning and scheduling. A crucial question is whether there is a
philosophy that encourages maintenance, and if so whether this is appropriate
to the object of the maintenance (i.e. preventative, condition based, or
breakdown maintenance, are all possible and justifiable under the right
circumstances - is the right one being applied?)

Many maintenance problems arise out of the conflict between cost and safety.
In an ideal world, maintenance resources will be determined by maintenance
objectives, although in reality they are often limited by cost factors. Other
problems include the failure to co-ordinate activities, particularly with ongoing
operations, to plan safe work, to supervise the work adequately and also to
audit the work and provide the necessary feedback. Additional problems
occur from an inability to keep adequate documentation and records.

Remedial Actions
The basic rules of safe maintenance management can be expressed very
simply:

Ensure the job is planned safely.

Ensure that the hazards caused by executing each maintenance task
are adequately controlled.
Ensure the timely execution of jobs.
Ensure the adequacy of maintenance execution.

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 Ensure the adequacy of feedback.

Other points for consideration include workload strategy, resource adequacy,

administrative structure, work planning and control, plant reliability and
control.

Design
Definition
Design can be an underlying cause of unsafe acts, when it increases the
chance of particular types of errors and violations. Many design failures arise
from the physical and professional separation of the designer and the end-
user, and from the fact that the designer often has a different ‘representation’
(‘mental DVD’ or ‘mental model’) of the designed item, than the person who
will use it. Poor design may also cause something to be misused. Insufficient
attention paid to planning, layout and ergonomics, even when the components
themselves are good, is a common design problem.

Main Features
Design failures break down into three parts:

The knowledge gulf: This is a failure by the designer to understand how

much the user depends on ease of use without having to remember or
read instructions. Designers often place too much reliance upon a
user’s memory of what to do based on detailed instructions.
The execution gulf: The inner workings, or range of possible safe
actions of designed objects or equipment, are often unclear. They also
do not reveal what the user must do to achieve a particular goal. Thus,
they fail to prompt the actions necessary for correct and/or safe
performance.
The evaluation gulf: Designed items do not always make it obvious to
users either what the results of their actions were, or what the current
condition of the item is. Dangerous errors occur because users are
unable to gauge accurately the consequences of their actions.

Remedial Actions
Produce ‘user friendly’ designs as far as possible and reduce reliance on
written procedures. Design equipment so that each user step is, as far as
possible, self-evident. Design items so as to minimise the mental resource
‘load’ placed on the user during each phase of operation. Make both the
execution and the evaluation aspects of an action transparent. This means
ensuring that users know what is possible and how it should be done, and
allowing them to understand directly the consequences of their actions. Make
use of designed-in constraints to guide the user to the next appropriate action
and to block the error pathways. Design for errors. Assume they will occur
and facilitate error detection and recovery. Make operations easily reversible.
Standardise actions, outcomes, layouts and displays.

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Hardware
Definition
This underlying cause implicates the quality, availability and position in the life
cycle of tools, equipment and components. It is concerned with the materials
rather than the design or poor maintenance of equipment.

Main Features
Hardware problems can be categorised under three broad headings:

Position in the life cycle: Is the equipment new or old? The number of
breakdowns and amount of corrective maintenance provides important
clues.
Specification and standards: Discrepancies between the specification
of the equipment and the operational needs of its users can arise
through differences of opinions about the specifications, cheap brand
purchasing and buying of the wrong equipment. Indications of
problems in this area are the reordering of the same equipment,
frequent manufacturer call back, high incidence of breakdowns, more
hours of maintenance than expected, high number of spare parts
ordered, and unused or abandoned equipment.
Availability: Problems to do with availability of equipment items can
often be traced to a poor ordering system, a poor logging system or to
theft. These result in inappropriate use of available tools and spares.

Remedial Actions
Hardware problems are one of the more easily identifiable and easily
remediable underlying causes. Most of the remedial actions follow directly
from an accurate identification of the underlying problem. For example, life-
cycle problems may be overcome by replacement or by repair and
maintenance, construction problems may be addressed by better
specifications or the purchase of high quality items, and availability problems
can be minimised by improving the ordering and logging systems and by
better security.

Defences
Definition
Defences are designed to serve four basic functions. These are
detection/warning, control/recovery, protection/containment and escape and
rescue, and individual awareness and use of protective equipment.
Weaknesses in one or more of these functions implicate defences as an
underlying cause.

Main Features
Problems can be categorised in relation to the functions listed in the definition:

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 Awareness: Failure to fully appreciate the likely hazards associated
with the work site.
Detection and Warning: Common problems are detection failures, false
alarms and informational failures.
Recovery: Control and interim recovery systems may be either human
or mechanical. Human beings are poor at detecting their diagnostic
mistakes (roughly a 40% detection rate), but relatively good at
detecting slips and lapses (roughly a 75% detection rate). Engineered
recovery systems can fail because they are not tested frequently
enough, or because problems, once discovered, are not rectified
quickly enough.
Protection and containment: Violations involving the disablement of
physical barriers, or not using personal protection items, are among the
most common type of defence removal.
Escape and rescue: One of the important lessons of the Piper Alpha
incident is that serious accidents can take unexpected forms. Escape
plans that do not take account of these contingencies can be lethal.

Remedial Actions
Each incident reveals how defences can be breached. One of the
prerequisites of effective loss management is the ability to learn the right
lessons from the past. This does not mean making ‘local repairs’. However it
does mean working back from the immediate causes to the latent failures, and
then intervening at those points that will have the greatest remedial
consequences. The basic rule is reform is better than repair.

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If you would like further information on the contents of this
Human Performance Handbook contact WrightWay Training
Limited at:

WrightWay House
27 The Meadows
Milltimber
ABERDEEN
AB13 0JT
Scotland

Tel: (00) 44 1224 733313

Fax: (00) 44 8707 621606

Email: info@[Link]

Web: [Link]

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