Martin Shaw – what “human element” means

Feb 13 2020

Tanker companies which embrace the “human element” appreciate people’s role as successful goalkeepers (rather than someone to blame), acknowledge the limits of procedures, manage onboard complexity, are careful about how we introduce automation, and reduce major risks like enclosed space deaths, said tanker technical expert Martin Shaw.

There is still too much misuse of the term “human error”. It is used after nearly any incident, and there are many debates about the percentage of incidents that are due to human error, Mr Shaw said.

In fact, virtually all incidents are born of “human error”, but an error made at some point in the regulation, design, build, operate, maintain cycle, he said. But the culture of shipping only considers errors by seafarers.

This focus on the seafarer means the main “tool in the toolbox” to improve safety is changing procedures to prevent the incident from re-occurring, he said.

But it might be better if energies were spent looking at what is behind this seafarer error, and finding better ways to ensure the seafarer feels supported by everyone around, he said.

Martin Shaw’s background is in tanker operations, originally working as an engineer at sea, and then running a ship vetting organization for an oil company, and then managing an oil company fleet. He has been consulting for the past 8-10 years and becoming “more and more interested in the human element”.

Types of human error

One of the world experts on human error, James Reason, has said that human errors can be categorized as “skill-based errors, mistakes and violations.”

A violation is defined as someone deliberately doing something wrong. But seafarers’ mistakes might be viewed too often as “violations”. Normally people don’t deliberately set out to make mistakes, Mr Shaw said. This view links to the increased criminalization of seafarers. Normally someone would need to have deliberately done something wrong for it to be considered a crime. After a major incident, often “the first thing that happens is that seafarers are locked up.”

It would be better if there was more willingness to accept that seafarers might make unintended mistakes – and look at whether the environment they work in can be changed to make them less likely.

In a 1991 book “Human Error”, James Reason differentiated two different drivers for unsafe acts – local workplace factors (including technical factors), and organizational factors.

Mr Shaw presented this quote from the book. “Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects created by poor design, incorrect installation and bad management decisions. Their part is usually that of adding the final garnish to a lethal brew whose ingredients have been long in the cooking.”

But in the shipping industry, the attitude too often is still, “it’s the seafarer’s fault, how did he make that stupid mistake.”

The seafarers should be supported by their shore-based management, regulators, and other recognized organisations. Other relevant parties are the equipment designers, system designers, programmers, port operators, terminal operators, charterers, vetting organisations, industry bodies.

As a seafarer, Mr Shaw recalls making some mistakes at sea which caused shipboard electricity supply to trip. As a fleet manager, “I made some quite huge mistakes”.

“We’re all prone to human error. We get ourselves hung up that the only person who makes errors in the shipping business is the seafarer, because we view the seafarer as a hazard.”

“We make the assumption that all ships are correctly designed, all the procedures around that are fine, the only thing that’s wrong is those damn fool seafarers who keep making mistakes. We make the assumption that if you focus on those mistakes you prevent accidents – monitor them more and pushing them more. That’s what’s called ‘work as imagined,’” Mr Shaw said.

But in the real world, management systems are not perfect, things go wrong all the time.

“The only reason things don’t go wrong is that seafarers make them operate. They are the glue that make things keep running.”

“What would happen if you focus on the other 99 per cent of the operation and the things that went right?”

Seafarers as goalkeepers

Mr Shaw sees seafarers like goalkeepers, the people who prevent problems from becoming big problems.

“If you are manager of a [football] team, the team loses five nil, do you sack the goalkeeper? Maybe you should. But what if he saved 50 goals? That means 55 times the ball is kicked to the net. What about the other 10 people – what were they doing? How do you stop the ball getting close to the net? You need to do a lot more work on that one. At present the seafarer may feel alone on the pitch with an angry opposition bearing down on them.”

In 2008 James Reason wrote ‘the Human Contribution, where instead of focusing on human error, he wanted to focus on the human contribution, the good things people have done.

So if you tell the story of the Titanic, you could focus on the Carpathia, the ship which rescued the survivors, including preparing for them to come onboard, recording their names, and informing their relatives.

The limits of procedures?

Efforts to improve safety have been through a number of waves. The first stage was improving the hardware, the machinery itself. The second stage was to focus heavily on competence.

The third stage, starting about 1990, was to focus on improving procedures and management systems. In the tanker business the owner and flag took responsibility for compliance with these. Vetting organisations provided a further layer which could be described as ‘enforcement’ as well as generating best practice.

Shipowners developed continuous improvement systems, identifying what they thought they could improve, and then doing it. “They improved things dramatically.” They basically removed all the systemic problems from the system.

This focus was successful at improving the safety record. Data of tanker industry casualties shows a steady decline in accidents, measured by casualties and pollution incidents. The introduction of double hull tankers during the same period also helps.

But in the past decade, the accident trend goes up slightly, partly due to the increased number of tankers following the Chinese boom, and partly because of some things going wrong, including more groundings which may have been caused by problems introducing ECDIS, Mr Shaw said.

So it may be fair to argue that a limit was reached of what could be achieved with procedures and what can be achieved with simpler accident investigation models which stop at what happened aboard ship.

Ultimately, if people are given more to do with more complex systems the potential for error rises, he said.

Procedures are an important part of how you run ships – you can’t not have them. But they need to be useful, not a stick to beat people with.

“In many cases the last people who read procedures are the lawyers, to see if there’s any liability in there, not to see how easy they are to follow,” he said.

Complexity onboard

Today’s seafarers have security and environmental requirements in addition to safety requirements. There can be 5 or 6 things they need to assimilate in their heads and connect to make decisions, and sometimes people need to decide what gets priority.

“You reach this horrible phase called complexity,” he said.

To understand where the complexity comes from, we can break down what work is like on a ship.

The core of the work is “relatively straightforward” tasks, like navigating, loading and discharging cargo. You have engineering systems to support you. Behind that, you have a lot of processes to assist, including procedures, checklists and forms.

Then there is a large amount of communications which need to be done during port calls. “Someone comes onboard asking for the captain’s time. They’ve got statutory powers behind them. ‘We are here, and you’ll do what we tell you to do.’”

This is where it starts to get complex. “The captain gets tied up. The terminal is desperate to get you in and out as quickly as possible. You may well have port state inspections, charterers inspections, maintenance.”

There are people who can help you with maintenance, such as “riding squads” (crews which stay on the vessel for a short time for a certain task). But operations generally rely only on those onboard.

Behind that, are a number of maintenance processes and planned maintenance systems, class requirements, and stores and spares to manage.

You have a shipowner making sure everything works correctly, and a regulator making sure the shipowner is making sure.

Regulators ‘not in touch’

The problems arise because these people making regulations are not in touch with how people currently work onboard ships. They believe that ships work the way they did when they were seafarers themselves, 30 years earlier, he said.

The way the industry is meant to work is with a ship interacting with ports, a shipowner interacting with the ship, the shipowner being in charge of how ships are designed, operated and maintained, and national regulatory bodies – and the IMO – making regulations.

But there are now about 170 different flag state regulatory bodies, over 30 classification societies, and thousands of owners and ships, all working in different ways.

In the 1990s, there were a number of tanker incidents leading to oil on people’s shorelines, leading to a call for a new sort of locally controlled regulatory body, known as port state control. “Coastal states wanted to have some sort of leverage on the ships coming in and out of ports.”

The port states influence flag states and class by creating black lists of bad flags, so vessels with these flags were subject to more port state inspection. “Nobody wanted to have a flag that meant they would be targeted by port states, and so the black listed flags had to improve and quickly.

Then you have the vetting organisations, working on behalf of oil companies – the charterers – whose big concern was that they would be the ‘deep pockets’ for a major pollution incident.

So there are multiple organisations with slightly different goals and requirements. “There are all sorts of systems that people have got to understand, all sorts of communications that people are having to deal with. They are all sitting on top of the poor chap in the middle as he tries to make sense of it.”

Increasing automation

We also have increasing use of automation, but no opportunity to practice running without it, he said.

“In my days [at sea] automation was nice to have – but when automation went wrong, you knew roughly what to do.

“If the main interface is the computer systems, then you need to understand the logic of the control system as well as that of the system it is controlling.”

Today, we hear stories about systems affecting each other which should not have any connection, such as an alarm system which would somehow cause the ship to turn to starboard when it was tested, he said.

Enclosed space deaths

Investigation into accidents such as enclosed space deaths, the second largest killer on ships, often ends up saying that the individual did not follow procedures. “It doesn’t look at what is behind that.”

For example, time pressure might be an indirect cause. Time pressure can be explicit – if you are asked to do something quickly. But can also be implicit, when someone does something because they feel under pressure.

If someone senior believes they are under time pressure, that is pushed onto everyone beneath them.

There can be systemic pressures – where a system is designed to function quickly, for example a system designed for fast loading of car carriers.

In the tanker sector, a terminal operator may need to make a choice between building a new jetty, so there is ample space, or just trying to increase the throughput to get more tankers in and out more quickly.

You have charterers who expect “utmost dispatch” and owners who want to maximise their earnings.

Usually, there will be enough people in the management structure who are aware of the dangers of putting crew under time pressure. But there are also situations where commercial management is handled by brokers, manning is handled by manning managers, ship management is handled by technical managers, and the captain sits in the middle.

Time pressure is not something which can be removed completely, the question is making sure people are able to say when it is too much. “That to me is the difficult bit. You’ve got to create armour for the captain. The shipowner has got to make it explicitly clear, If the captain feels under pressure, he has a right to say no.”

Another way to reduce enclosed deaths could be to try to reduce the problem. While we can’t prevent seafarers from having to enter enclosed spaces at all, we can try to reduce the number of times they have to do it. There can be better arrangements for ventilation. A current method is to use a thick pipe to pump air into the space, which also blocks the same hole which is needed for someone to exit.

The industry takes a bias towards trying to solve problems with administrative methods, and “that’s where we get into problems”.

It shouldn’t be necessary for someone to enter a tank with breathing apparatus, except in an extreme emergency to rescue someone else.