Transcript Ljudske prednosti i ograničenja

Doc. dr. sc. Pero Vidan
Faculty of Maritime Studies Split
E-mail: [email protected]
Gdynia, 13 May 2014
Ecuadoreanregistered ship
Jessica, spilled
175,000 gallons of
diesel and bunker oil
into the sea off the
Galapagos Islands
At 10 a.m., March 17, 1978, the supertanker Amoco Cadiz broke in two,
releasing its entire cargo of 1.6 million
barrels (250,000 m3)
Management errors
Outside control of crew:
Lack of skills:
Crew management errors:
33%, 19%
10%
(Source: NTSB, DNV)
Preoccupation with minor (technical) problems
Failure to delegate tasks and responsibilities
Failure to set priorities
Inadequate monitoring
Failure to utilize available data
Failure to communicate intent and plans
Failure to detect and challenge deviations from
SOP’s, rules and safe actions
57 %, 71%
The balance
Safety is often a trade-off between optimising
Production or Safety
P
Adapted from
Reason
S
An orgnisation must know where it stands in order to make informed
decisions
Reason’s Swiss Cheese Model
Holes caused by actions
Holes caused by ”latent
problems-pathogens”
Human weaknesses
Stress factors:
Consequences:
• Danger
• Decision errors
• Hostile environment (temperature,
• Restricted attention
motions, etc.)
• Distorted time-perception
• Time pressure
• Weakened short-term memory
• Workload
• Frequent change of problem
• Distractions
• Performance pressure
• Social interaction
solving strategies
Human weaknesses
Fatigue:
Consequences:
• Inadequate rest
• Slower reactions
• Disturbance of
• Less capable of creative
biological rhythm
problem solving
• Heavy cognitive work
• Difficulties to remember data
• Physical work
• Denial of negative messages
Human weaknesses
Hazardous attitude:
•”I know best”
• ”I am not good enough”
Consequences:
• Captain failing to listen to First Officer
• Third Eng. failing to provide critical info
Culture
Culture is
…“The way we
do things
around here
and why we do
them.”
Carroll & Quijada (2004).
http://www.safetycenter.navy.mil/photo/archive/
Personality
Behavior
Social environment:
• Family
• Schools
• National culture
• Professional culture
• Organizational culture
• Safety culture
Attitudes
Values
Skills
(SOP’s, etc.)
CRM/MCRM
training
Knowledge,
experiences
NASA - Good Teams
• Good situational awareness - anticipated next condition
• Cognitive resources free - secured time to think
• Relevant information early - during time of low workload
• Built a shared mental model - a common understanding
• Conservative strategies - kept options open
• Decisions were sensitive to constraints. Resources & Environment
• Explicit task allocation - clear action commands and delegation
• Monitored progress. Verbalised stratagies
Dr. Judith Orasano
Some solutions from CRM
Focus on willingness to :
Manage Trade-offs
Follow Rules & procedures
Avoid violations
Inter-personal relations & communication
Team work
Understand human error and manage it !
Can be divided into two groups:
• Physical
• Mental
•
•
•
•
•
•
•
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Physical:
Sleep disorder
Fatigue
Motivation
Seasickness
Speed and walking
Drugs and alcohol
Hunger and thirst
Physical discomfort and pain
Disease and infection
Mental
• Current and situational stress
• Change in time perception
• Perception impossibility
• Concern and anger
• Loss of memory
• Motivation
Seasickness can be dangerous for seamen
because it causes attention deficit.
 Prevention: walking restriction, nicotin, alcohol,
caffeine and salt avoidance. Do not talk to the
person who has seasickness.

“Stress is basically a physical and
psychological mechanism that
starts working when we are
exposed to strain of any kind physical, psychological or social
to make it possible for us to
cope with whatever caused the
strain - it prepares the organism
to cope with the new
situation…..”
Good
Stress
Bad
Stress
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Your own personality
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Your family
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Your working
surroundings
The actual situation
On a ship environmental stress
includes:
• Excessive noise
• Heat
• Vibration
• Low humidity
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Physical
disabilities
Clumsiness
Disorientation
Anxiety
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Cognitive
disability
Poor leadership
High workload
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Tiredness
Time zone change
Time of the day
Temperature
Uncomfortable
environment
Degree of influence depends on:
 Physical
and mental fitness
 Experience
 Training received
 Crew composition
training received
Personality:
Traits
Attitudes
Needs
Experience
Assessment
Amount of stress
Coping?
No
Increased Stress
Yes
Environment:
Situational factors
Workload
Cockpit environment
etc...
Solution
“Panic” amygdala hijack
Increased stress tolerance
Long term effects
How does stress influence human performance?
1. Experienced/skilled
P
e
r
f
o
r
m
a
n
c
e
2. Low experience / skill
high
low
Activation
P
e
r
f
o
r
m
a
n
c
e
low
high
Activation
Brain Activity level
Time
Brain activity level
Time
Stress is the product of a whole lifestyle. It is not
just the product of an occasional crisis!
BUT a crisis can accelerate the effects! Leading to
IQ dump
Consequently each person must learn to monitor
personal internal stress-levels (and symptoms)
and find ways to relieve such conditions!
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Insomnia
Interrupted sleep
Nightmares
Excessive sleeping
Lack of energy
Fatigue
Hyperactivity
Mood changes
Worry
Depression
Stress reduces the effect of work and prevents
judgement
Them affects:
 Physical rhythm
 Human clock allows vigilance through the day and good
sleep or lack of attention at night
 Problems on board
 Adaptation to night work or early morning job
 Day and night changing during shifts
 Biological rhythm of most people is updated 1-2 hours per
day
 The human body is the most sensitive to light around 5:00
a.m
 Shifts in the clockwise direction: Morning ⇒ Afternoon
 It is easier to get used to the night shift than mixed ones
Medical care
 Loss of productivity
 Loss of material
 Administration cost
 Costs of social help and of life quality
improving

Sweden categorized the risk of life on:
 Decks:
1. Embroidery
2. Hatches handling
3. Working at height
 Machine:
1. Tools handling in a limited place
2. Handling with big machines and tools
3. Carrying scales and ladders
 Hotel: bif
1. Slippery floor
2. hot or sharp objects due to the rolling of the
shipOpći problemi:
3. Ladders
4. Slippery or uneven deck floor
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Danish research shows that 50% of injuries are
related to work on the deck
Other critical activities are walking and working in
the engine room
Suggestions for improvements:
Terms of walking on the deck, scales, climbing a
ladder
Gangway and access to the ship-shore
Assessment of safety equipment for embroidery
Lashing
Access Safety
Wheelhouse: enough handles and avoidance of
sharp edges
Fatigue is one of the most dangerous
phenomena on board.
 It is cause of the false judgments,
management and operations.
 Fatigue often occurs due to improper
organization of work on the ship, but ship's
specific environment as well, etc.
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Fatigue is considered undesirable physical
and mental state of crew members. It is a
frequent cause of human errors that results
in distress (Figures 1 and 2) as it reduces the
ability of perception and thinking.
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The most common causes of collisions
COLREG violation
wrong decission
poor looking
poor training
poor familiarisation
fatigue
unexperience
poor communication between crew
failure of communication devices
poor use of radar
0
5
10
15
20
Izvor: http://www.brighthub.com/engineering/marine/articles/106516.aspx?image=151636
25
30
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The most common causes of stranding
broj pojava u vremenskom razdoblju
poor decission
fatigue
unexperiance
poor communication
poor use of radar
igmorance areas
wrong passage plan
wrong percepction of…
tiredness
poor visibility
poor use of ECDIS
failure of devices
0
2
4
6
8
10
12
14
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The growth of technology standards of
construction and equipment of ships and
maritime competitiveness of the market has
led to the emergence of saving the human
workforce and reducing costs at the expense
of the crew. Reducing these costs included
the emergence of hiring cheaper crews from
the east. These crews are often less educated.
Percentege
of crew
40
(%)
20
0
Phillippines Russia
Ukraine
Poland
Crew nationality
China
Greek
Croatia
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Another phenomenon that follows global maritime
industry is to reduce the number of crew to
"minimum safety" given by the legislature of the
state of the vessel (Minimum Manning Document).
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Fatigue is a phenomenon that accompanies
human activity, reduces operating efficiency
and adversely affects the attitude towards
work. If one looks through the production,
fatigue is defined by reducing the
performance over time.
Crews often do more contracts for small
amounts of money. Time longer contracts of
seamen mean increased fatigue arising from
such relationships and lifestyle.
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Studies have shown that the speed of doing
business increases with shorter working day.
During a long day of work worker fights
fatigue actively by frequent and longer breaks
and a slower pace of work. Lengthening of
working time significantly increases the
negative effects of fatigue.
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Figure 4. Average of daily working and overtime hours
according to the workplace
Master
Chief Engineer
Chief mate
engine officers
deck officers
cattering
engine crew
deck crew
0
2
4
6
8
10
12
14
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Figure 5. Dependence on night’s sleep and composure
Full awareness
Level of awareness
Medium awareness
Low awareness
Total sleepiness
Time of sleep previous night
Figure 6. Dependence on night’s sleep and composure
Full awareness
Level of awareness

Medium awareness
Low awareness
Total sleepiness
Consecutive days of reduce sleeping
Izvor:
http://ajitvadakayil.blogspot.com/2010/12/fa
tigue-on-chemical-tankers-capt-ajit.htm
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The ILO and the ITF do not allow exceeding the
scheduled number of hours of overtime because of the
level of safety. Therefore shipper and administration
regulate by the contract of seaman the by collective
agreement for seafarers number of overtime hours. The
overtime hours include hours outside of working hours,
which include:
maneuver of the ship
periodic maintenance and repair of the ship
stay in the port
enhanced marine guard because of the conditions (low
visibility, bad weather, etc.)
unadjusted schedule of stays in port and navigation
time zone changes
other hours outside of working hours.
Research have shown that except insomnia
other factors affect the fatigue;
 light
 noise
 vibrations
 ventilation
 temperature and
 ship movement.
Figure 7. The effect of the employee during the day
Perfomance
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Working hours
Izvor: http://ajitvadakayil.blogspot.com/2010/12/fatigue-on-chemical-tankers-capt-ajit.htm
Fatigue has a negative impact on safe work. It
increases human error. Errors occur as a result
of lack of mental function.
The immediate effects of human fatigue are:
 error in the judge
 loss of productivity
 errors in decisions
 injury at work.
In the ship's organization fatigue effects the
occurrence of human errors, which often
manifests by:
 accident
 collision
 damage to the ship or cargo
by environmental pollution.
Fatigue can be divided into five categories:
 physical discomfort
 loss of energy
 loss of motivation
 sleepiness.
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Fatigue affects the health of the seamen and
causes:
cardiovascular diseases
hypertension
diabetes
stomach problems
insomnia.
In addition, fatigue affects the social aspect of
the seamen and the organizing crew and
causes:
 problems with family
 reduces workperformance
 increases the number of errors
 increases sleepiness
 reduces teamwork
 reduces motivation
 increases physical effort.
The intensity of fatigue is not manifested at all
crew members the same, but it depends on:
 age
 lifestyles
 rhythm of life
 anamnesis
 weight
 previous working experience and habit.
Insomnia causes a decrease in energy,
increase of fatigue and exhaustion. Fatigue
caused in the history some of the greatest
maritime accidents:
 Stranding the Exxon Valdez (1989)
 The fire in the cargo holds Kometik (2006)
 Stranding Algomarine (2008).
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Fatigue can be prevented by proper organization
of activities on board. Assessment of human
capabilities for performing the tasks is of crucial
importance. Therefore, an officer during the
organization of work on board must be familiar
with:
 culture of crew members
 age of crew members
 nationality
 work experience
 physical fitness
 training programmes
Officers are trained for work organization
through special programs: Psychosociology,
human resources management of the bridge
(Bridge Resource Management-BRM) and
engine room (Engine Management teamETM), etc. They are explained individual,
national and cultural differences of
multinational crew, their advantages and
defects. In addition, officers are taught the
proper work organization, avoiding stressful
situations, behavior in crisis situations, etc.
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Facts:
 The relaxation time of the organism
 Reducing of metabolism
 Pressure, pulse and respiration decline
 The muscle tension relief
 Resting in a dream is more intense at the beginning and lower at the end. If we wake up
before time, rest is not complete.
Rest periods for adults are on average 7 hours and 23 minutes on working days and one hour
longer on non-working days (weekend)
Stages of sleep
Phase 1: Transition from vigilance to sleep
Phase 2: Sleeping with relaxing in smaller extent
Phase 3 i 4: Sleeping with bigger relaxing, vigilance is harder
REM phase = we are dreaming, brain is active. REM is not important for short-term but
for longterm memory.
Non-sleeping:
 Overwork
 Long vigilance
 Possible disorders the day earlier
 Nightwork
Morning work
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Sleep interrupts clock in the final stage of sleep
The period of sleep is often 5 hours
Increased sleepiness in the day, especially in the
afternoon.
Increased risk of accidents
Evening work
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No sleepiness and work is safer
Problem can be if you start earlier next week (shift
change)
Other factors
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Long working shift (longer than 10 hours)
Short rest periods (less than 11 hours)
Monotonous, hard, stressful work
Drug use (abuse)
Sleeping problems occur in the 45 year of life
Antimeasures
 Sleep will be compensated by increased sleep.
 Missed night of sleep can be replaced by another
 Break of 30 minutes is required, especially if there are messy shifts
Schedule techniques
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Night shift should not be longer than four repeatedly
Rotation in a clockwise direction
Maximum of 8 hours, 11 hours of rest
If you work the night shift
 Have peace of sleeping
 Plan your sleep
 Slumber before shift
 Avoid heavy meals, especially carbo hydrates and fiber food
 Avoid taking fluids before sleeping
Measures against fatigue
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Change your work
Sit in uncomfortable position
Stand up
Take a walk
Breath fresh air
Expose to noise
Amplify the light
Talk to your colleagues
Coffee
Song
These anti measures give short-term performance, the best anti measure is rest.
Caffeine stimulates alertness (Coca-Cola, tea
contains 1/3 the caffeine of regular coffee).
The normal dose of coffee gives vigilance.
The effect lasts 6 hours, and the maximum
effect gives the first cup.
 Nicotine is a stimulant. Smokers are worse
sleepers than non-smokers.
 Alcohol increases sleepiness.
 Sleeping and anti-seasickness pills increase
sleepiness.
 The suppression of deep sleep has a negative
impact.
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Exon Valdez
 Estonia
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3 truths:
 Sea is dangerous
 You cannot change the rules of nature
 Men can go wrong
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The Master does not use proper human
resources, only one man on the bridge.
It is important to have it, so the following
should be considered:
 Time (past or required)
 Position
 Speed
 Automatism
 Resources
 Personality, health, attitude
Frequent questions
Take information-What is happening?
 Answer- What does it mean for you and the
ship?
 Foresight- What can happen?
 Examples: noone is navigating the ship,
veering of the ship, information quality,
susceptibility
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Thank you!
Questions???