A K Tatman, D M Turner and E J Hughes, Maritime and Coastguard Agency, UK SUMMARY
The human element remains not only the most significant risk to shipping safety and marine pollution but also the most challenging issue for the industry to develop effective approaches to minimize the risk. This paper aims to highlight significant work that the Maritime and Coastguard Agency has undertaken in collaboration with leading researchers to further our understanding of the human element so that we may develop and implement effective risk mitigation strategies.
1. INTRODUCTION
Since 2005 the UK government has been following an agenda that places risk at the centre of regulatory decision making, inspection and enforcement1. For many years now the maritime industry has acknowledged that a significant risk to maritime safety and pollution prevention is the human element in shipping. The Maritime and Coastguard Agency, as the UK’s shipping regulator, has since 2003 had in place a Human Element Strategy for addressing this risk. Key to delivering this strategy, and so improving our understanding of the human element risk, is the identification, commissioning and dissemination of human element research. This paper presents some of the outcomes of the research undertaken to date, how that research has been used to inform and support UK policy on the human element and, importantly, its use to input to the human element initiatives at the International Maritime Organization (IMO) and in the wider maritime community.
The MCA views the International Safety Management (ISM) Code [1] as one of the primary instruments for identifying and managing risks to maritime safety and marine pollution. Specifically the ISM Code should be used to facilitate both the pro-active and continuous improvement of safety performance both on board the ship and in the Company. This paper goes on to identify the Designated Person as being the key individual responsible for developing and effectively implementing the ISM Code in the Company’s fleet, and highlights what the UK believes to be a significant omission of DP competency statements from the IMO guidelines on implementation of the ISM Code by Administrations [2].
1.1 AREAS WHERE MCA IS ACTING
Introducing some current work by the MCA risks the misunderstanding that nothing has been done to date, or is being done on a continuing basis. The MCA already acts, inter alia, in the areas of seafarer competence, training, examination and certification, safe manning, seafarer medical standards and health and safety at work, the application of the Maritime Labour Convention,
(with special emphasis on fatigue), company and seafarer personnel performance in the safety management system, design equivalence for example in SOLAS V Regulation 15, and escape and evacuation systems and performance.
This points to the proposition that, contrary to what was said above in the introduction, the MCA has had a human element policy (although it was not called that) since its formation in 1998, and probably before that within the individual constituent organizations and agencies.
Considering how to take this existing work to the next levels of understanding lead the MCA to further examination of the behavioural attributes which contribute to the human element as part of the maritime safety system, and the paper will now briefly look at these areas.
2. STRUCTURES AND EXTERNAL INDUSTRY INFLUENCE ON SAFETY MANAGEMENT PERFORMANCE (RESEARCH PROJECT 547 AND MARINE
INFORMATION NOTE 267(M)) [3]
A previous human element research project identified the leadership qualities which can be conducive to effective safety management (RP521, “Driving Safety Culture:
Identification of leadership qualities for effective safety management”). It also concluded that another substantial constraint to the delivery of a viable safety culture, i.e.
one which effectively balances safety and commercial pressures, is the influence of the internal company organisational structure and indeed the wider industry structure in which it sits. This includes the designation of individual roles and responsibilities.
An additional factor is the structure of the overall maritime industry itself, including how the industry is organised and the influences it creates. Maritime organisations operate under these pressures, and can be controlled by them in the case of regulatory or financial influences etc. For example, the International Maritime Organization’s Model Audit Scheme has been designed
Human Factors in Ship Design, Safety and Operation, London, UK
© 2007: The Royal Institution of Naval Architects disseminate it to other flag states. The results of this
research project have been promulgated by the MCA in Marine Information Note MIN 267(M) and subsequently for the consideration by the IMO’s Joint Maritime Safety Committee (MSC) and Marine Environmental Protection Committee (MEPC) working group on the Human Element (HEWG) during the meeting of the Maritime Safety Committee in December 2006 (MSC 82).
Where Ship operating Companies are concerned, the research understandably concluded that no single organizational structure model was necessarily suited to all enterprises or sectors of the industry; ‘one size fits all’
does not apply. Nevertheless, certain structures actively constrain the ability of the Company to find an effective safety / commercial balance, although the authors believe that SAFETY = PROFIT is a maxim which is gaining currency. Structures which have this self-limiting effect on the degree to which openness, transparency, fostering a safety culture, and continuous improvement in safety performance, should be challenged and modified where possible. Structures which encourage and facilitate these safe operating characteristics should be established (perhaps through benchmarking) and institutionalized through good Board Leadership. One example of an effective organization structure might include robust, systematic and frequent contact with, and access to, the Executive Board by the Designated Person, and the paper will return to this theme later.
One (perhaps disappointing) factor to emerge from the research was the perceived, very limited ability of some key stakeholder groups to exert a positive influence on organizational safety performance. Moreover, dominant safety influences (and the corollary, lack of influence), changed between industry sectors. Common areas of positive safety influence perceived to be limited by structure (not intent) and thereby less robust than others included accident investigation, ship construction, non- governmental organizations, training colleges, and seafarers themselves. Providing strong enough platforms for their good influences to be felt effectively may be a way to release potential safety performance benefit.
To be best able to lead change as required, the MCA needs to determine whether it can make improvements in maritime safety most effectively by working within the current industry structure or by challenging and proposing changes to it. To do this the MCA needs to enhance its understanding of all the influences on safety management performance, including its own as the UK regulator. This will allow the MCA to be able to continue to help the industry drive safety, quality, and continuous improvement at all levels, with confidence that we are all collectively aware of how those changes will influence, and be influenced, by the wider industry.
The findings of this work were considered by the IMO Human Element Working Group (HEWG) at MSC 82 and have been passed to IMO’s Flag State
Implementation sub-committee for consideration at its next meeting in June (FSI 15).
3. DEVELOPMENT OF GUIDANCE FOR THE MITIGATION OF HUMAN ERROR IN AUTOMATED SHIP-BORNE MARITIME SYSTEMS (RESEARCH PROJECT 545 AND MARINE INFORMATION NOTE 261(M)) [4]
Moving from the general organizational structures affecting the industry to more direct human element investigation, this project was designed to investigate the potential effects on safety of the increasing use of automation on board ships (especially on bridges, in engine rooms and for cargo handling).
While automated systems bring benefits to both seafarers and ship owners/operators, they have also been identified as a potentially significant contributory factor in accidents and incidents at sea. Possibly the most famous incident involved the Royal Majesty, when those on the bridge were not aware that, due to a failure of the ship’s global positioning system, her GPS had defaulted to dead-reckoning position fixing for 34 hours. Royal Majesty ended up 17 nautical miles off course and grounded before anyone was aware that there was a problem. The research report also includes three other interesting case studies, MT RANDGRID, HMAS BALLARAT (FFGH 155) and MV BRIGHT FIELD;
each illustrates a different facet of the complexities involved in operating automated systems and of the potential pitfalls associated with closely coupled systems.
The work identified mitigation strategies to reduce human error when using automated ship-borne systems.
It is hoped that all those involved in the design, construction, purchasing, operation and training will be able to feed the findings from this report into their respective areas of the maritime industry. Another paper at this conference will look at this work in more detail.
The findings of this work were considered by the IMO Human Element Working Group (HEWG) at MSC 82 and were passed to IMO’s Standards of Training and Watchkeeping sub-committee in January (STW38) for incorporation into their review work of the STCW code.
4. DEVELOPMENT OF A HUMAN COGNITIVE WORKLOAD ASSESSMENT TOOL (CLIMATE) (RESEARCH PROJECT 546) [5]
Taking our enquiry even further to the individual seafarer level, considerable work has been undertaken into the physiological contributors to fatigue. However the mental or cognitive aspects are less well understood.
The July 2004 MAIB Bridge Watchkeeping Safety Study
Human Factors in Ship Design, Safety and Operation, London, UK
report highlighted the significant risks to the safe operation of ships that result from an inadequate understanding of crew work/rest patterns.
Specifically, little is known about methods of evaluating people’s mental processing abilities and requirements and the development of a tool to assess human cognitive workload will assist companies to address this need. The tool does not only apply to cognitive overload, i.e. when too much is asked of an individual or team for them to cope with safely, but also to cognitive underload. This can arise in particularly passive conditions such as maintaining watch with autopilot on in an open and calm sea at night. Vigilance levels, and the ability to react to a sudden development, can be substantially reduced in such conditions.
Again, the findings of this project will be addressed in detail in a separate paper at this conference. As this article was submitted, the MCA had yet to establish how this tool will be distributed to the industry, but work is proceeding to accomplish this.
5. HUMAN ELEMENT ASSESSMENT TOOLS (HEAT-S (SHIP) AND HEAT-C (COMPANY))
HEAT is a questionnaire-based tool, developed as a proactive method of improving industry consideration of the human element. It is designed to complement the ISM Code, by evaluating the capability of those responsible for safety management to address the human element. HEAT goes further than ISM by encouraging continuous improvement rather than superficial compliance, and is intended to assess where human element risks are not being adequately addressed.
HEAT is designed to help safety managers focus resources on key safety issues for the most efficient method of addressing human element-related risks. It is based on the Capability Maturity Model, which gives organisations a five level process of evaluating their practices in a particular area.
x HEAT-S complements the ISM Safety Management Certificate for the ship and has been released to the marine industry. This is freely available from the MCA at humanelement@mcga.gov.uk.
x HEAT-C complements the ISM Document of Compliance for the operating company and is currently under evaluation by industry.
6. SAFETY MANAGEMENT AND POLLUTION PREVENTION [6]
prevention. The UK considers the instrument as key to improving safety and reducing pollution from vessels registered under our flag. Hence audit of both the Company (Document of Compliance) and ship (Safety Management Certificate) is not delegated. Key to the effective implementation of the ISM Code is the Company’s ability to introduce and manage an effective Safety Management System (SMS) ashore and in its fleet.
Increasing emphasis is therefore on the Company, and specifically the Designated Person, to identify and manage risk effectively.
6.1 DESIGNATED PERSON
A key role in the Company, as identified by the ISM Code, in the development and implementation of the Safety Management System and of a maritime safety culture is that of the Designated Person. This is the individual based ashore whose influence and responsibilities should significantly affect the attitudes and behaviours of those working ashore to support the ship operations, and who supports and influences a positive attitude to safety and environmental protection by those working on ships being managed.
The ISM Code makes it a requirement for compliance with the Code for the Company to have in place a Designated Person (Section 4):
“To ensure the safe operation of each ship and to provide a link between the Company and those on board, every company, as appropriate, should designate a person or persons ashore having direct access to the highest level of management. The responsibility and authority of the Designated Person or persons should include monitoring the safety and pollution prevention aspects of the operation of each ship and ensuring that adequate resources and shore based support are applied, as required”.
Further, Sections 6.4 and 6.5 of the Code require the Company to ensure that all personnel have “an adequate understanding of relevant rules, regulations, codes and guidelines” and under Section 6.5 “establish and maintain procedures for identifying any training which may be required” and ensure such training is provided.
Significantly neither the ISM Code nor the Revised Guidelines on Implementation of the ISM Code (Res.A.913(22)) identify minimum requirements for Designated Person experience, qualifications and training.
Without minimum competency standards for the Designated Person it is difficult to see how Companies are able to assure themselves that the experience, qualifications and training of the Designated Person are adequate and to identify if further training is required. Indeed Section 3.2.
of the Appendix of the Revised Guidelines on
Human Factors in Ship Design, Safety and Operation, London, UK
© 2007: The Royal Institution of Naval Architects ISM audits to comply with to assure they have a basic
competence for performing verification.
At the IMO's Maritime and Safety Committee (MSC) 82nd session in December 2006 the Joint Maritime Safety Committee (MSC)/ Marine Environment Protection Committee (MEPC) Human Element Working Group noted that research by UK into the influence of organizational structures on safety management performance (see above) had identified a need to strengthen the implementation and enforcement of the requirements of the ISM Code. The research confirmed the principal internal enablers of safety management which can be influenced by the Company ashore as being:
x clear safety policy and strategy
x consistent leadership and demonstrable commitment to safety
x reliable systems to measure the effectiveness of the structure in place
x clear and effective communication
x positive safety culture, including “fair blame” only;
x effective accident/incident reporting systems x appreciation of cultural differences onboard ships x building of crew loyalty
x support for structured career progression x appropriate selection for roles
x encouraging ownership of safety x effective management of new ship
x management of owner-operator relationship (ship operating company); and
x building competence of crew.
The UK considers the Designated Person to have a significant role in developing and managing these principal internal enablers, and they may indicate that the provision of minimum competency requirements (experience, qualifications and training) for the Designated Person would strengthen the implementation of the Code in that the Designated Person would be confirmed as having the required competence to carry out the responsibilities of the role effectively.
This view is supported by an increasing number of Port State Control inspections that are recording deficiencies under ISM related codes. Additionally UK accident investigations have identified the following ISM related root causes, which are themselves issues that should be addressed by the Designated Person:
x Lack of management support for ships’ officers and crews
x Time pressures at change of crew x Time pressures at change of owner
x Lack of continuity or records at change of owner x Poor quality of instructions
x Lack of definition of non-conformity.
Further, it is suggested that formal recognition by the maritime community of the experience, qualifications and training needed to undertake the important role of Designated Person, would enhance the role’s status in the maritime industry. There is anecdotal evidence that some candidates do not consider the Designated Person role as having merit due to a lack of formally recognized transferable qualifications and training. Minimum competency requirements would have the benefit of making the Designated Person role more attractive to a wider pool of experienced candidates. The benefit for the Company of defined competency requirements for the Designated Person would be that investment in specific Designated Person training would not place them at a competitive disadvantage as all Companies would be guided in this direction.
A key element of Document of Compliance audits for the Company should be a determination of the extent to which the Designated Person does positively influence attitudes and behaviours, and that the positive influence extends to the fleet. This could be confirmed during Safety Management Certificate audits. Minimum requirements would assist Administrations to audit against an appropriate and reasonable standard which currently is not possible due to a lack of an international guideline.
This is particularly applicable when considering the Designated Person for a multi-flagged shipping fleet and where the operating company owns multiple ship types and areas of operation.
At its 82nd session in December 2006 the IMO’s Maritime and Safety Committee (MSC) invited Member governments to submit proposals to the next session of the Joint MSC/MEPC Human Element Working Group on:
x the revision of guidelines for Administrations to make them more effective and user-friendly; and x the development of guidelines and associated
training to assist companies and seafarers in improving the implementation of the ISM Code.
Currently the Maritime & Coastguard Agency is preparing proposals for submission to the 56th session of the Marine Environment Protection Committee (MEPC) in July 2007.
7. CONCLUSIONS
As a UK regulatory authority the MCA seeks to take a risk-based approach to regulation. This indicates that with a responsibility for shipping safety and pollution prevention our focus on the human element will continue. Failure to do so would reduce our effectiveness as a regulator and so reduce the likelihood that we attain our goals of safer lives, safer ships, cleaner seas. In maintaining its focus on the human element in the period ahead the MCA recognizes that the shipping industry
Human Factors in Ship Design, Safety and Operation, London, UK
itself has to increasingly place human element issues at the centre of its thinking if the industry is to make greater gains in efficiency and safety performance.
The MCA is encouraged by the response to its human element activities by many in industry; however, it will seek to encourage greater involvement and input from the wider maritime community.
8. REFERENCES
1. International Maritime Organization. ISM Code:
International Safety Management Code and revised guidelines on implementation of the ISM Code. 2002.
2. International Maritime Organization. Revised guidelines on the implementation of the International Safety Management (ISM) Code by Administrations: Resolution A.913(22). 2002.
3. Great Britain. Maritime and Coastguard Agency.
(2006). MCA RP547: Organisational Structures:
The Influence of Internal and External Structures on Safety Management Performance.
Southampton: MCA and GreenStreet Berman.
4. Great Britain. Maritime and Coastguard Agency.
(2006). MCA RP545: Development of guidance for the mitigation of human error in automated shipborne maritime systems. Southampton: MCA and Qinetiq.
5. Great Britain. Maritime and Coastguard Agency.
(2006). MCA RP546: Development of a Human Cognition Workload Assessment Tool.
Southampton: MCA and Human Reliability Associates.
6. ICS and ISF. (1996). Guidelines on the application of the IMO International Safety Management (ISM) Code (3rd Ed.). London: ICS and ISF.
9. AUTHORS’ BIOGRAPHIES
Keith Tatman joined the MCA's Formal Safety Assessment Branch in 2002. Now as a Branch Head (of Risk, Analysis and Prevention Branch), his responsibilities include maritime safety risk policy, knowledge management, human element, and ISM policy. Prior to the MCA he was a ship, helicopter and fast jet navigator and operations specialist in the Royal Navy for 35 years. On leaving he worked in industry for a safety risk management company for 2 years.
Captain David Turner is the Human Element Policy Manager for the Maritime & Coastguard Agency and moved to the MCA in 2003. Within the MCA he has worked in both the directorate of operations and standards and his present priorities are in the development, delivery and embedment of human element tools. Prior to joining the MCA he was a senior consultant in the cargo risk management industry. He has an operational background from 25 years at sea, having been Master in the passenger, high speed and ferry sectors.
Dr Edmund Hughes holds the position of Policy Manager for the International Safety Management (ISM) Code at the Maritime and Coastguard Agency. He is responsible for ensuring that good practice in safety risk management is transferred to the commercial shipping industry. His previous experience includes Lead Policy Adviser on Risk Management for HM Treasury and Human Element. Development Manager for the Maritime
& Coastguard Agency.