1. by: G Sachdeva 1 16 th July 2015 HUMAN ELEMENT WHY DO THINGS GO WRONG?

2. by: G Sachdeva 2 30th April 2014 SOME NUMBERS TO THINK ABOUT……. 4 – Major Incidents occurred EVERY TWO DAYS due to Human Errors during 2008. 40 - Ships collided, grounded or suffered explosions EVERY 3 DAYS from 2000 to 2005. $ 4,000,000 - WAS THE VALUE OF CLAIM EVERY DAY from 2000 to 2010 $ 400,000,000 – THE VALUE OF CLAIMS PAID OUT BY underwriters in 2008. $ 4,000,000,000 – was the cost of claim for Exxon Valdez. $ 40,000,000,000 – EXPECTED LOSS FOR BP FROM SPILL IN THE US GULF. $ 400,000,000,000,000 – Estimated Market Value of ExxonMobil in 2012. HUMAN ELEMENT WHY DO THINGS GO WRONG?

3. by: G Sachdeva 3 16 th July 2015 HUMAN ELEMENT

4. 30th April 2015by: G Sachdeva4

5. 16 th July 2015by: G Sachdeva5

6. 30th April 2015by: G Sachdeva6 The EIGHT traits of human element? 1. Make sense of things 2. Take risks 3. Make decisions 4. Get tired and stressed 5. Learn and develop 6. Work with others 7. Make mistakes 8. Communicate with others HUMANS

7. 16 th July 2015by: G Sachdeva7 Human Traits What is obvious to you, might not be same to the others. What you see and understand, is what you expect to see. Situations are constantly unfolding, you must share with colleagues. Making mistakes and recovering from them is a fundamental human strength Without error there is no learning. Potentially harmful mistakes must be prevented or minimised. Both individual competence and organisational culture are important for this. 1. Make sense of things 4. Make mistakes 3. Make decisions People make decisions differently to how they think they make decisions. Decision making is different when you are learning as compared to when you are an expert. Experience does not make you an expert, but to be an expert you must be experienced. 2. Take Risks Everybody takes risk at some time or the other and this is inescapable. Human perception of risk is quite different from the probability with which events occur. We have to ensure that our perception of risk maps well into the world with which we interact..

8. 16 th July 2015by: G Sachdeva8 Human Traits People learn all the time.. It is important to learn the right thing at the right time. People aspire to learn and the organisation should manage this to enhance safety and profitability. In the absence of good management, these aspirations may dominate or be ignored – bad outcome. Fatigue and Stress have their causes and consequences. We must always know how to avoid fatigue and stress Workload can be managed with experience even when the job demands are high 6. Learn and develop 5. Get tired & stressed 7. Work with others Sometimes we work alone, at other times we work as a team member Key problem is to have people skills as well as technical task skills Things go wrong when these two skills are absent.. 8. Communic ate with others Successful communication involves clear transmission, is only part of the story Even with clear transmission, both parties were interpreting different meanings Responsibility of the listener as well as the person sending the message should be understood..

9. 16 th July 2015by: G Sachdeva9 Human Traits What is obvious to you, might not be same to the others. What you see and understand, is what you expect to see. Situations are constantly unfolding, you must share with colleagues. 1. Make sense of things

10. 30th April 2014by: G Sachdeva10 Human Traits We make sense of things which support our goals, plans and activities. We see what we expect to see. Each person’s sense making is unique based on their physiology, self culture, experience, social and intellectual needs. Each person interprets the same situation differently. We make sense of things based on – 1.Our personal needs 2.Our self concept 3.Our past experience 4.The goals we share with others 5.Our current practicalities. 1. Make sense of things

11. 30th April 2014by: G Sachdeva11 Human Traits 1 - Our personal needs We have huge amounts of information. Our mind filters these based on the needs The most basic filter concerns our survival. We get hungry, thirsty and tired. These demand attention. When ignored these needs dominate our behaviour. A more advanced filter deals with the need to find acceptance by social groups we value, such as family, friends and colleagues. Yet another advanced filter is concerned with recognition by our peers for our personal achievements. The most advanced filter looks at how the world can contribute to our own growth and development – for personal fulfillment. 1. Make sense of things

12. 30th April 2014by: G Sachdeva12 Human Traits 2 - Our self-concept Each of us know who we are and what we are like. Our sense of personal identity is developed through contact with friends, family, workmates, managers and our cross cultural colleagues. How we make sense of the same situation depends on our sense of self – whether we want to listen what we are told to, or, to follow instructions, or to negotiate with authority etc. and this influences our approach to team working. Sometimes we may overload ourselves, in order to comply with what we believe is expected of us, due to our own self-esteem. This could cause to making incorrect sense of things by ignoring the big picture and concentrating on a narrow focus to our self esteem. 1. Make sense of things

13. 30th April 2014by: G Sachdeva13 Human Traits 3 - Our past experience The conclusions and reflections from past Experience shape how we make sense of present situation. The past experience may consists of beliefs, mental models, rules, procedures and stories which we apply to the present environment to make it meaningful. The more experience we have, the more we apply the past to the present, even this it is only a projection and may not be the best in the present situation. Failure to appreciate this sometimes results in serious incidents such as grounding, collisions etc. We also confuse experience with expertise. Experience may result in wrong conclusions, over confidence, complacency and risk taking. 1. Make sense of things

14. 30th April 2014by: G Sachdeva14 Human Traits 4 – Our shared goals If we share a common goal, agree on a joint goal and refine our understanding, We can make better sense of things. Goal sharing can be helped by training in teamwork and understanding of each others roles, capabilities and limitations. Where goals are different, problems occur. For eg: when Safety considerations are given a lower priority over Commercial matters and is seen to conflict with profit making. When one perspective is allowed to dominate the other – common goals cease to exist. If situation is allowed to continue – failure occurs. For eg: if Regulators dominate Ship owners, there is room for failure due conflict of interests. 1. Make sense of things

15. 30th April 2014by: G Sachdeva15 Human Traits 5 – Our need to be practical As we have limited time always, we process tasks based on incomplete Information. We go for a working level of understanding rather than dig deep to get all the facts. An example of this is the modern Bridge technology and computers. ECDIS, ARPA, RADAR, UMS, Computers, OWS, ODME, PMS etc are all examples of technology advances which are complex and we settle for the bare working knowledge. In times of Crisis, we need simplicity of equipment to get the job done practically and as best possible. 1. Make sense of things

16. 30th April 2014by: G Sachdeva16 Human Traits How big is SENSE MAKING problem? Inappropriate sense making is a costly problem in terms of lost profits, fines, injuries, investigations, legal costs, insurance costs, environment damages or sheer human misery. As per Lloyds Register, an average of 182 ships were lost EVERY YEAR between 1995 and 2007. This amounts to 160 Mill GRT lost. When does SENSE MAKING get out of control? 1.Too many procedures, rules, regulations and technologies. These are well intended, but land up doing the opposite. 2.Every incident leads to investigations & new recommendations to plug the loop holes – these are over-prescriptive & complicated. 3.Bigger rule books and more gadgets increase uncertainty, ambiguity and complexity. 4.Automation leads to over-reliance on machines and lack of inter-personal relations. Confusion reigns, when this fails 5.Insufficient attention to Team Work and Training, communication skills and cross culture tolerances. 1. Make sense of things

17. 30th April 2014by: G Sachdeva17 Human Traits 1. Make sense of things SOME DO’s Ask your people – perhaps they know or observe something you missed. If you observe an unsafe behaviour – go for the root cause and ask the 5 WHY’s, which is turn will help you understand more. Get the team work training, to understand what motivates your team and how they interpret your messages. SOME DON’T’S Don’t assume other people think and understand like you do. They have different backgrounds and pressures and see differently. Don’t ignore the hierarchy of others needs – physiological, safety, social, self respect and self development. Don’t under-estimate the power of your feelings, personal circumstances, current pressures and past experiences. They decide how you react next.

18. 30th April 2015by: G Sachdeva18 Human Traits No matter how good is our sense making, we can never match the complexity of the world. The assumptions we make and the things we do attract an element of RISK. RISK refers to the chance that our sense-making will be inadequate to deal safely and effectively. OUR PERCEPTION OF RISK HAS LITTLE TO DO WITH ACTUAL PROBABILITY The THREE main factors that influence our sense of risk are – 1.The amount of control we think we have – PERCEIVED CONTROL 2.The amount of value something has for us – PERCEIVED VALUE 3.The extent to which things are familiar to us – PERCEIVED FAMILIARITY 2. Take Risks

19. 30th April 5014by: G Sachdeva19 Human Traits 1.PERCEIVED CONTROL The more control WE BELIEVE we have, the less risk WE BELIEVE we are taking. Shore staff believe the risk of ship incidents is TWICE of that believed by Crew. Overconfidence, skills or knowledge missing, Stress or fatigue lead to wrong beliefs. People with well developed skills and highly pertinent assessment have a better control over any situation. Example of flipping a coin 8 times – What is the probability of the following sequence? 1 – HHTHTTHT 2 – HHHHTTTT 3 - TTTTTTTT What is the probability of the 9 th flip coming out TAIL? 2. Take Risks

20. 30th April 2015by: G Sachdeva20 Human Traits 2 – PERCEIVED VALUE The more an action appears to support a goal that WE BELIEVE is important or highly desirable, the LESS RISKY it will appear to be. e:g:1) Entering into a port beyond the point of no return to pick up pilot. 2) Leaving berth hastily in foggy condition to arrive at the next port earlier. An action can also appear to be high value if it is the easiest way to achieve the goal. e:g: We routinely take short cuts in flogging reports / checklists to satisfy the company requirements for Hot-work, tank entry or Bunkering etc. 2. Take Risks

21. 30th April 2015by: G Sachdeva21 Human Traits 3 – PERCEIVED FAMILIARITY THE MORE FAMILIAR AN ACTION IS, THE LESS RISKY IT WILL APPEAR TO BE This is also known as COMPLACENCY which is known to be a major contributor to most accidents. Like HUMAN ERROR, complacency is an effect rather than a cause. If our surroundings are familiar, we feel safer and more comfortable and less prone to examine the risks on the job. E:g: Pilotage in Singapore traits – done it a 100 times What can go wrong now? ZOEY 2. Take Risks

22. 30th April 2014by: G Sachdeva22 Human Traits HOW TO GET BETTER AWARE OF RISKS? Understand that RISK CANNOT BE TOTALLY ELIMINATED. People NEED RISKS to provide excitement and avoid boredom. It is not the Risk elimination that we seek, it is the AWARENESS of Risk in their OWN BEHAVIOUR and the BEHAVIOUR OF THEIR COLLEAGUES. This awareness can be raised by training in human perception of Risk and the factors that influence it. 2. Take Risks

23. 30th April 2015by: G Sachdeva23 Human Traits SOME DO’S Do be suspicious if things seem under control and on track, familiar, comfortable, quiet and safe. You might be missing something. Do try to train yourself and your team for HUMAN PERCEPTION OF RISK. It will avert the development of Complacency. Do try to maintain your fall back measures when faced with new and sophisticated equipment. Going back to basic seamanship might get you out of trouble should these complex instruments fail. SOME DON’T’S Do Not confuse qualification with experience. People cannot become aware of equipment risks by just studying the books. They need to experience these first hand, and mentored, monitored by other colleagues. If people are promoted without enough experience, they will under-estimate the risks they take and expose all toe great dangers and costs. DO NOT confuse a person’s rank with his status of information. The higher the rank, the greater the responsibility but they have to ensure that those with relevant knowledge are heard. 2. Take Risks

24. 30th April 2014by: G Sachdeva24 Human Traits HOW DO PEOPLE MAKE DECISIONS? To make a rational decision, you must – Have complete information about alternatives Be able to distinguish between alternatives Use comprehensive criteria Have the time to do all this. In practical situation, this does not happen as TIME IS ALWAYS LIMITED and INFORMATION IS NEVER COMPLETE. People’s decisions are a trade-off between available information (thoroughness) and the time available (efficiency) 3. Make decisions

25. 30th April 2014by: G Sachdeva25 Human Traits EFFICIENCY vs THOROUGHNESS Efficiency increases when people spend less time and effort in thinking and more time in action. When this is reversed, thoroughness increases at the cost of efficiency. For an organisation – If Safety and Quality are very important then thoroughness is favoured. If production targets and outputs are emphasised, then efficiency if favoured at the cost of safety. Every decision made is a compromise between Efficiency and Thoroughness. Thoroughness is produced by training, mentoring, on-the-job briefing and experience over time. If organisational expectations are too demanding and the staff are not thoroughly trained, this will lead to unnecessary risk taking with drastic consequences. 3. Make decisions

26. 30th April 2014by: G Sachdeva26 Human Traits 10 RULES WHICH GOVERN OUR WORKPLACE BEHAVIOUR 1.It looks fine or it is not really important. (If it ain’t broke, don’t fix it) 2.It’s normally OK or much quicker this way (done it million times) 3.It is good enough for now (it is better than average expectations) 4.It was checked earlier and we will recheck it later (dangerous) 5.There is no time or no one to do it now so do not worry (false hope) 6.I do not remember how to do it and do not have the time (see manual) 7.We must get this done in time – no time for procedures (dangerous) 8.It looks like something we know. (assumption convenient for next step) 9.If you do not tell anyone, I won’t either (lets ssshhh, we took shortcuts) 10.I am not an expert so will let you handle it (don’t want responsibility) 3. Make decisions

27. 30th April 2014by: G Sachdeva27 Human Traits Why do people break rules? At work, people are immersed in organisational culture which favours efficiency. When rules are knowingly broken, it is to improve the teams efficiency. Rule breaking is a major cause of accidents. The violations arise due to following – 1.Trying to solve a pressing problem with limited knowledge instead of stopping and seeking advice. 2.Trying to take a short-cut or work-around. Soon these become the norm as these are seen as efficient measures. When things go wrong, the short-cut taker gets disciplined rather than the Policy maker whose policy might not be practical in the first place. 3.When a supervision is lacking – this allows unchecked broken rules, sets in complacency and allows rule breaking to get worse and frequent due to no accountability. 3. Make decisions

28. 30th April 2014by: G Sachdeva28 Human Traits HOW DOES ORGANISATIONAL CULTURE INFLUENCE DECISIONS? 1.Incident reporting policy – Most companies have it, but reporting should not conflict with reputation, bonus etc. Absence of report does not mean everything is OK. Incident reporting may not increase safety. 2.Management Policy – Managers usually favour efficiency to thoroughness. Non efficiency is noticed fast. If things go well, its all praise. If they do not then the blame is for lack of thoroughness. 3.Subcontracting Policy – Subcontractors are under pressure to perform but if they report too much they may lose contract as they feel efficiency is favoured over thoroughness. 4.Cost Policy – Most Organisations like to reduce cost by cutting down unnecessary, but the interpretation may be different. It is often used to favour efficiency over thoroughness. 5.Policy Integrity – Organisations say they want Safety (thoroughness) but their Policies and performance measures target efficiency. 3. Make decisions

29. 30th April 2014by: G Sachdeva29 Human Traits Expert decision making Decision makers are dependent on their training and experience. Expert decision makers – 1.Have an accurate mental picture of what is going on and what can happen next. – Situational Awareness. Perception, Comprehension and Projection. 2.Are able to arrive at good decisions directly – often under time pressure. – Situational Familiarity. Using past similarity of incident or from stories heard before to compare the present situation and to project it to the end result. Novice decision makers – must rely on the rule book or look for a mentor which takes time and they may take decisions based on what makes most sense in their limited experience background. 3. Make decisions

30. 30th April 2014by: G Sachdeva30 Human Traits SOME DO’S Do recognise that everyone in the organisation balances efficiency with thoroughness. If people are untrained or inexperienced and cross the line, they sacrifice thoroughness and cause unsafe situations, risks. Do support investment in training and competency testing, apprenticeship, mentoring. Do find ways to motivate and retain staff following the 10 years to make them experts in your organisation. 3. Make decisions SOME DON’T’S 1.Don’t send mixed messages to your staff asking for safety and demanding efficiency at the same time to push them to take short cuts. Rule breaking is a major cause of accidents. 2.Don’t assume that you can take shortcuts in getting expertise. It takes about 10 years of structures and guided experience to develop an expert – do not lose him.

31. 30th April 2014by: G Sachdeva31 Human Traits 4. Make mistakes Making mistakes is normal for people including experts, but safety critical mistakes can have serious consequences. The mistakes we make could be – 1.Skill based – well practiced, so tend to lose focus or suffer memory lapse and can lead to mistakes. 2.Rule based – where we focus more on procedures and rules or apply rule incorrectly than use good seamanship and common sense and make mistakes. 3.Knowledge based – where what needs to be done requires knowledge, but, we make incorrect sense of situation on wrong information. This is usually a result of insufficient training or experience or bad communication.

32. 30th April 2014by: G Sachdeva32 Human Traits 4. Make mistakes 2008 – A DISASTEROUS YEAR? US$ 548, 000, 000 PAID IN CLAIMS DURING 2008 135 VESSELS WERE LOST, NEARLY 3 PER WEEK 41 OF THESE WERE DISASTERS (CLAIM $ 18M, IMPACT OVER $85M) 1600 PEOPLE DIED OR WENT MISSING DUE MARITIME DISASTERS 150 PEOPLE DIED ON GEN CARGO SHIPS YEARLY FROM 2002- 2008

33. 30th April 2014by: G Sachdeva33 Human Traits 4. Make mistakes Factors which mostly lead to mistakes Inadequate rest or high stress level – reduces attention, concentration and slow reaction. Insufficient training and experience – trying to do a job with little knowledge or failure to understand and prevent a dangerous situation. Inadequate Communications – It involves clear messaging, empathy, active listening and understanding cultural norms. Inadequate time – Time pressure where thoroughness is sacrificed for efficiency Inadequate design – Poor design or over complicated design increases stress and encourages use of short cuts and mistakes. Inadequate staffing – Less people or people with extended contracts tend to cause stress, de-motivation, low morale and overload others. Inadequate Safety culture – MOST IMPORTANT – Commitment from Senior management ashore, investment in training, making the right policies and procedures and overseeing implementation onboard.

34. 30th April 2014by: G Sachdeva34 Human Traits 4. Make mistakes Mistakes are PREDICTABLE and could be traced down to CAUSE & EFFECT Here the primary cause, secondary cause and root cause is identified and fixed. Safety specialists perform risk assessment and rectify flaws in work procedures. Efficiency usually wins (economic considerations) Behaviour drifts towards danger (also known as Complacency) Mistakes are invisible till a disaster strikes (just a decision before) Accidents keep happening anyway (Organisational culture). The Cause & Effect analysis is mostly historical based on what happened. In live situation as every incident can be traced down to differing circumstances, this usually becomes additional bureaucracy.

35. 30th April 2014by: G Sachdeva35 Human Traits 4. Make mistakes These could happen UNPREDICTABLY from behavior of complex systems This is a new view how mistakes are made. The world today is a complex system of interacting, circular relationships. 1.Humans Create Safety – Humans do not cause errors, but the gaps in any system are corrected by humans if they are given freedom to cope with unexpected, as no system can be made fully tight. 2.Organisations are actually organic – Safety emerges continuously from overall behaviour of an organisation’s components, including its people. A good safety record promotes Complacency and allows risks to grow unseen. Political or economical forces can shift organisations shift away from safety. 3.Organisations create the bahaviour they get – Operating within commercial, political, regulatory framework, they tend to drift away from what is actually beneficial for the organisation. 4.Protecting organisations from things that happen – Rules and procedures design to limit system variability may avert accidents to a point but they also prevent beneficial novel behaviour.

36. 30th April 2014by: G Sachdeva36 Human Traits 4. Make mistakes SUCCESSFUL ORGANISATIONS HAVE FEWER ACCIDENTS BECAUSE Expertise is developed, retained and exploited. to achieve greater efficiency, people in organisation identify failure and develop alternate strategies creating minimal safety margins. Expertise and ability to read complex situations and project into future plays a crucial role in their assessment. Organisation pay attention to their fault lines The real risk to safety is often in interfaces between different parts of organisation such as charterers, builders, crew, managers etc. Good organisations analyse near misses and accidents for interface faults. Decision making is based on system thinking Look for faults in the systems which include PSC, Flag, regulators, Designers, Charterers, managers and the crew. Not just rules.

37. 30th April 2014by: G Sachdeva37 Human Traits 4. Make mistakes WHO IS ACCOUNTABLE – AND WHAT CAN BE DONE? It is normal to make mistakes. Wider organisation factors are critical in shaping our behaviour. The industry has now shifted from Blame Culture to Just Culture. Principles of Just Culture apply to EVERYONE (even staff ashore). Human error is inevitable and organisation’s policies, processes and interfaces must be continually monitored and improved to accommodate these errors. Individuals should be accountable for their actions if they knowingly violate safety procedures and policies.

38. 30th April 2014by: G Sachdeva38 Human Traits 4. Make mistakes SOME DO’S Do recognise that mistake making is part of normal human behaviour and is generated in part by organisational systems. Do look for any downside of cost-oriented changes in your organisation. These will sacrifice thoroughness for efficiency, which leads to more mistakes and less inclination to catch them. Adopt and implement a JUST culture. It needs transparency at ALL levels and open and honest incident reporting. It will improve safety which transforms in profit taking. SOME DON’T’S Don’t be misled by the power of hindsight. It is useful to investigators but not as much when actions unfold. Don’t imagine that there will ever be a rule for every eventuality. Behaviour emerges from complex interactions between people and systems. It is not completely predictable.

39. 30th April 2014by: G Sachdeva39 Human Traits People learn all the time.. It is important to learn the right thing at the right time. People aspire to learn and the organisation should manage this to enhance safety and profitability. In the absence of good management, these aspirations may dominate or be ignored – bad outcome. Fatigue and Stress have their causes and consequences. We must always know how to avoid fatigue and stress Workload can be managed with experience even when the job demands are high 6. Learn and develop 5. Get tired & stressed 7. Work with others Sometimes we work alone, at other times we work as a team member Key problem is to have people skills as well as technical task skills Things go wrong when these two skills are absent.. 8. Communic ate with others Successful communication involves clear transmission, is only part of the story Even with clear transmission, both parties were interpreting different meanings Responsibility of the listener as well as the person sending the message should be understood..

40. 30th April 2014by: G Sachdeva40 Human Traits 5. Get tired & stressed REMEMBERING THE EXXON VALDEZ DISASTER In March 1989, Exxon Valdez struck Bligh Reef off Alaska and spilt 11 Million US Gallons of Crude oil into the sea. The slick covered almost 11 thousand square miles of ocean and killed thousand of sea creatures. The local fishing collapsed and many residents committed suicide. Billions of Dollars were spent on cleanup and compensation. At the time of accident, the 25 year old 3 rd mate and an able seaman were on bridge. Both had not been given the mandatory 6 hours rest before their 12 hour duty. The Company’s manning policy did not consider the increase in workload caused by reduced manning.

41. 30th April 2014by: G Sachdeva41 Human Traits WHAT CAUSES FATIGUE? Workload – The harder people work, the sooner they need time to recover. Workload is influenced by design of tools, equipment, procedures, and expertise gained through training and experience. Sleep debt – This builds up if people do not get enough sleep of the right sort and causes people to misread situations, overlook key information and fall asleep even when this would put them and others to extreme risk. Perceived risk – If people are stimulated by their sense of risk, they can stay awake and alert longer. If doing tedious or boring jobs then they feel tired sooner. People increase their exposure to risk to stimulate themselves. Diet – heavier means with carbohydrates encourage drowsiness whereas lighter protein meals induce wake-fullness. Fitness & Movement – Overweight and non- exercising people feel fatigued earlier. Time of day – People live by natural daily rhythms. They are least alert during early hours of the morning and most alert before mid-day. Environment - Environment with poor lights, noise, vibration, temperature and motion cause fatigue. Some aromas such as lemon encourage alertness. 5. Get tired & stressed

42. 30th April 2014by: G Sachdeva42 Human Traits 5. Get tired & stressed CASE STUDY – GENERAL CARGO VESSEL ANTARI In June 2008, Ch Officer began his 6 hour watch on Bridge on passage from Corpach to Ghent. As vessel headed south at 11 knots with the west coast of Kintyre peninsula on the port side, the next course change off Mull of Kintyre would be 11 miles away. The Ch Off excused the AB who had done the cargo watch earlier and was needed for deck maintenance as was now alone on the Bridge after taking over from the Master who had done the earlier 6 hour shift. With both wheelhouse doors closed, clear, moonless night. Calm sea and slight westerly winds, the Ch Officer settled in the Pilot Chair next to the ECDIS on the Stbd side, to rest a bit. The watch keeping alarm had been switched off earlier, not to disturb the others. He was soon asleep and woke up after the ship had run aground three hours later. The Ch Officer had not shown any outward signs of fatigue even though he was involved with cargo watch the previous night. The Master know that he had slept between 0230 to 0600 hrs the previous night. Antari had made 21 port calls within last 2 months and every port call required both Master and Ch Officer to be involved. Audits and Statutory Inspections had also taken place along with other Port visitors. Both Master and Ch Officer had been doing 6 on 6 off for some time and a TIME BOMB was ticking in terms of SLEEP DEBT. Not having a second person on bridge made matters worse. AS PER MAIB, 82% GROUNDINGS THAT TAKE PLACE BETWEEN 0000 TO 0600 HRS ARE DUE TO FATUGUE.

43. 30th April 2014by: G Sachdeva43 Human Traits 5. Get tired & stressed SIGNS OF FATIGUE External Signs: Vacant stare with sunken, bloodshot eyes, Eye strain, sore or heavy eyes, dim or blurred vision, Droning or humming in the ears, Paleness of Skin, Slurred speech, Headaches, Feeling colder than others in the room, Faintness or dizziness, lack of Energy, drowsiness, Unstable posture / swaying, dropping chin, nodding head, loss of muscular strength, stiffness, cramps, loss of manual dexterity, difficulty in making fine movements. Operational Signs : Degraded mental performance – confusion, poor concentration, narrowed perception, forgetfulness. Leads to poor response to changing situations. Diminished personal Safety – Reduced self and situation awareness, leading to apathy, less attention to personal hygiene, neglect of normal safety precautions and more risk taking. Impaired leadership – Take longer or make poorer decisions. Fatigue makes people accept irrational, erroneous or illegal orders or ignore good ones. Worsening Team Performance – decreased interaction with crew and degraded communication due to lower sensitivity to other people’s needs and aims. Moody, loss of humour, irritable, argumentative, socially withdrawn – all which affects crew relationship. Decreased Morale – Fatigue decreases satisfaction, motivation and interest in team efforts. Pessimism increases, people thing of the worst scenario, reject group and take offence easily. Odd Behaviour – People may talk gibberish, neglect routine tasks, have stupid accidents and suffer hallucinations. 24 hours without sleep is same as 25% over the UK drink-drive limit

44. 30th April 2014by: G Sachdeva44 Human Traits 5. Get tired & stressed THE 5 STAGES OF SLEEP 1.Dropping off: Transition stage between wakefulness and light sleep. This stage which is short lived and 5% of your sleep feels like falling off a cliff as muscles suddenly relax. 2.Light sleep: Accounts for about 50% of the sleep. 3.Deep Sleep: Progressively deeper sleep where physical and mental recovery takes place. The amount of deep sleep depends on the fatigue experienced before sleep and harder to get up, longer to be fully alert. Disturbance such as loud noise, takes you back to light sleep. 4.Deep Sleep: Same as above. 5.REM Sleep: This is the dream stage when muscle and spinal reflexes are maximally suppressed. This stage is critical for mental stability. Lack of REM sleep results in irritability, poor judgment and hallucinations. If sleep deprived then REM sleep occurs on the second night after first night of deep sleep.

45. 30th April 2014by: G Sachdeva45 Human Traits 5. Get tired & stressed HOW TO AVOID FATIGUE STICK TO THE RULES: Everyone needs to stick to the work / rest hour regime without fudging records (this offers false security and is often discovered after an incident with disastrous consequences). After Antari grounding investigation, it was found that shipstaff had pre-recorded their work / rest hours irrespective of whether they were working or asleep. STICK TO THE SPIRIT OF THE RULES: People at all levels of the company and ship must facilitate, support and implement existing work / rest hour regimes. Lip Service does not improve safety. The Organisation culture is important here. FOLLOW A FATIGUE MANAGEMENT PLAN: THE SHIPOWNER / MANAGER ENSURES: that the ISM Code is clearly communicated, joining crews are adequately rested, proper hand-over is done on crew change, voyage lengths and leave periods are OK, god use of time in port is given for administrative functions and Language barriers, social, cultural and religious isolation is overcome. THE MASTER ENSURES: Owners policies are implemented, Crew loneliness, boredom, higher workload is met, adequate shore leave, onboard recreation and family contact is maintained, effective work/rest arrangements and napping opportunities are provided.

46. 30th April 2014by: G Sachdeva46 Human Traits WORK REST HOURS RULES Mandated by Article 5 of ILO 180: Maxm hours of work shall not exceed – 14 hours in any 24 hr period 72 hours in any seven day period. Minimum hours of rest shall not be less than – 10 hours in any 24 hour period 77 hours in any seven day period. Hours of rest may be divided into no more than 2 periods of which one shall be at least 6 hours. Interval between two consecutive rest period should not be more than 14 hours. Little more flexibility exists in STCW 1978 Section VIII/I Other facts: 66% seafarers work 4 weeks off / 4 weeks on. 50% seafarers work 12 hours on 12 hours off 25% seafarers work 6 hours on / 6 hours off. Causes most accidents. 200% percent is the probability of an incident in 12 hour shift as compares to 8 hour shift. 40% seafarers think they are in danger to themselves and colleagues due to their working hours 50% reduction in incidents can be achieved by small naps. Most seafarers think that fatigue can be reduced by lesser paperwork and more staff. Get tired & stressed

47. 30th April 2014by: G Sachdeva47 Human Traits 6. Learn and develop People are always learning. We are doing it right now. We learn by aspiring, copying, comparing, interpreting and practicing. As we learn, we change into different people with newer capabilities. The Organisations have to make sure that with the right guidance, they learn the right things. When organisations invest in training, they take control of their own future. Learning depends on the learner and should be within grasp, interesting, rewarding and direct the learner to new levels of performance and achievement.

48. 30th April 2014by: G Sachdeva48 Human Traits 6. Learn and develop What is the difference between EDUCATION and TRAINING The aims of both are different. Education widens and extends people’s horizons. It brings a universe of opportunities. Training focuses on response and behaviour to achieve performance standard. It concentrates on a narrow band of a constrained section. Both demand a large increase in a persons mental and behavioral repertoires.

49. 30th April 2014by: G Sachdeva49 Human Traits FORMAL vs INFORMAL learning Formal learning comes with effective principles. In the absence, most learners learn from colleagues, take shortcuts and learn informally which can lead to unsafe behaviours which may manifest only after an injury or an incident has taken place. People form attitudes about their organisations and the industry. Whatever they learn, they transmit to others, which maintains an overall culture of the organisation. PEOPLE ARE OUR GREATEST ASSET, is true where organisations share their best practices in knowledge, skills and in attitudes focuses on organisations goals. Learning involves deliberate and significant investment of time, money and effort by individuals and organisations. 6. Learn and develop

50. 30th April 2015by: G Sachdeva50 Human Traits LEARNING and SENSE MAKING Whether learning is formal and deliberate or Informal and automatic, people need to create meaningful mental connection between what they understand and what they are trying to understand. The key difference is in emphasis. In Sense making, the focus is on applying knowledge, skills and attitudes from previous learning to current operations. By doing so, new learning results. In learning, the focus is in using sense making to acquire new knowledge, skill and attitude. By doing so, better sense-making and learning capability results. 6. Learn and develop

51. 16 th July 2015by: G Sachdeva51 Human Traits 6. Learn and develop BENEFITS OF TRAINING TO ORGANISATIONS 1.Increased organizational performance 2.Better organizational culture 3.Reduced staffing problems and operational costs. THE FOUR STEPS FOR EFFECTIVE TRAINING 1.Analyse needs – Task identification – Gap identification and solution identification. 2.Design content – Learner engagement – Knowledge training – Skills training – Trainee feedback. Modes used are Hi Fidelity simulation, CBT, Embedded training, Chalk and Talk etc. 3.Evaluate results – Trainee satisfaction – Course objectives – Job performance – Organisational performance. 4.Go to step 1.

52. 30th April 2014by: G Sachdeva52 Human Traits TEN POINT CHECKLIST FOR ORGANISATIONS 1.We know what each of our employee needs to be able to do what is expected in a safe and effective manner – because we have a comprehensive competency network. 2.We know what our employees know because we carry out competency tests in realistic setting within proven framework. 3.The competency framework we use recognizes that many competencies are interdependent and have to be considered together e:g: ships and shore operations. 4.The competency framework is connected to our training needs analysis methods and training courses. 5.The training programs we deliver are based on trainees actual needs by reference to their job they need to do and takes into account their learning styles. 6.Our training is effective because we assess responses to it immediately after each course, again in a few weeks for retention tests and on the job as part of our regular competency assessments. 7.We collect data on job performance, productivity, turnover, incident rates and bahaviour, which is then used to evaluate our training programs and strategy. 8.We understand the training power of communicating by story telling and experience sharing, and, we have created opportunities for doing so in Office and onboard. 9.We understand that good trainers require subject matter expertise and teaching skills, in terms of structuring, pacing, feedback methods, trainee engagement that accounts for age and skills. 10.Our trainers have access to a full range of training aids and know how to use hi fi simulation, CBT, part- task training, classroom training, one to one training and refresher training. 6. Learn and develop

53. 30th April 2014by: G Sachdeva53 Human Traits SOME DO’S DO be aware that people learn all the time and mostly from colleagues. Organisations have to ensure they learn the right stuff by training everybody. Do consider SCOPE or TOTS or SIGGTO for your organisation. Experience is essential but it is equally important to learn to do the right thing in the first place. Do understand that good trainers understand how students view the training and use the material. Having the best material is not enough. Do carry out training needs analysis, training design and outcome evaluation for all staff as continuous improvement in organisation. This leads to better performance, safety culture and lesser problems. SOME DON’TS DON’T assume that one training fits all. Different people need different levels of support depending on their level of expertise. DON’T be satisfied with training evaluation which stops at training satisfaction. Dig deeper and check the course objectives, job execution and organizational performance. This also reassures the organisation that the expertise needed is available to the organisation. 6. Learn and develop

54. 30th April 2014by: G Sachdeva54 Human Traits 7. Work with others Working with individuals requires different sets of skills than when working in teams. Working with Individuals with their own individual goals requires inter personal skills. Working in teams requires people working to support each other to achieve a common goal. Here effective interaction and teamwork is needed. To get the best out of each other, there is a need to assess people, to confront a difficult and complex issue and to negotiate a disagreement and difference of opinion.

55. 30th April 2014by: G Sachdeva55 Human Traits TEAM SKILLS Team Leadership (motivating, directing, coordinating team activities, developing team members knowledge and skills) Mutual mentoring (ability of team members to monitor and guide their colleagues within a common understanding of goal) Back-up behaviour (team members understand each others tasks and work together to lighten or spread the load) Adaptability (Ability of team members to respond to changes in environment and create better ways to improve performance)(Ability of team members to respond to changes in environment and create better ways to improve performance) Team Orientation (This is the ability of the team members to see themselves as team members with a common goal and are highly receptive to each other)(This is the ability of the team members to see themselves as team members with a common goal and are highly receptive to each other) 7. Work with others TEAM GLUE Similar mental models (The mindset should be similar for a common understanding and how each contributes to the joint output and performance) Mutual Trust (this is needed so that each team member feels that their actions, mistakes and misgivings will be supported and dealt efficiently and constructively with regard to common overall goal) Effective communication (this is to ensure that messages between team members are delivered and understood completely and not misinterpreted)

56. 30th April 2014by: G Sachdeva56 Human Traits CASE STUDY – COSCO BUSAN On 7 th Nov 2007 at 0800 hrs. Vessel fully loaded with 900 containers left San Francisco for South Korea in dense fog. The bow was sometimes not visible due to fog swirls. The Pilot was 26 years experienced in the Bay. The vessel has an escort tug aft. The Master, 3 rd Off and helmsman were on Bridge. All crew were Chinese having joined two weeks earlier. They had been supervised by the old Ch. Eng., Suptd and Port Captain during the passage. At 0830 the vessel struck Delta Tower of Bay Bridge. The impact caused hull breach and spill of 53,000 gallons of fuel oil which damaged 26 miles of shoreline, closed 27 public beaches, no fishing for over 3 weeks and death to 3000 birds apart from other marine life. The Direct cost of repair was USD 2,100,000. The cost of repair to the Bridge was USD 1,500,000. The vessel owners paid a fine of USD 10,000,000 to US DOJ. The legal costs are unknown. Findings – The Pilot was on medication and a cocktail of 10 different drugs had clouded his mental ability. There was ineffective communication between Master and Pilot prior departure and during the accident The Master’s monitoring of Pilot’s capability was ineffective. The ship manager failed to adequately train crew. The USCG failed to adequately respond to the Pilot’s medical circumstances. The Far Eastern Crew were submissive and did not challenge the US Pilots expertise, authority and physical condition. The Crew did not speak English well. The Ships SMS was in English and not enough time to read and understand. The Crew did not each other well and being new to the Owner did not know Owners expectations well. No one had received any formal training in Bridge Team Management. The company overlooked Crews need to deal with Foreign port authorities and pilots and had no plans for training. THE PILOT, CREW AND THE MANAGEMENT ASHORE FELL SHORT OF EVERY ASPECT OF EFFECTIVE TEAMWORK. 7. Work with others

57. 30th April 2014by: G Sachdeva57 Human Traits 7. Work with others SOME DO’s DO consider how you can assess the level of teamworking in your organisation. DO insist on training in teamworking. It is different from Technical Skills and Knowledge. DO insist on Cultural difference training. SOME DON’Ts DON’T avoid difficult conversations. These are necessary and avoiding these or not facing these when onboard could lead to greater misunderstanding later. DON’T be afraid to stand up and point out when anything seems to be incorrect or going wrong, even if it means standing up to an expert, Senior or Authority.

58. 30th April 2014by: G Sachdeva58 Human Traits 8. Communicate with others Human communication is the process of influencing a human receiver to create thought and action that is consistent with, and responsive to, the sender’s purpose. Case Study – Pride of Provence Even when the communication is ample, failure can still result because Different perspectives of listeners are ignored There is no common goal and people interpret for the moment without anticipation or the big picture. Even with a common knowledge, culture, country – effective communication can fail because each one of us interprets the situation based on our own ambitions, needs and experiences. To effectively communicate, we must empathise with the other as much as the message we want to convey.

59. 30th April 2014by: G Sachdeva59 Human Traits 8. Communicate with others HOW DO YOU DO? National Cultures affect Communication Power distance – A Measure of where the Power is - In LOW power countries like Denmark, Sweden, US and Germany – the subordinates readily approach and contradict their bosses. The consult with one another often. In HIGH power countries like Panama, India, Philippines and France – The people are more dependent on their bosses and spend less time consulting with one another. Individualism – A Measure of Independence from one another - Individual nationals of USA, UK, Australia, France, Sweden and Denmark value self-respect and speaking one’s mind. Information is explicit and in the message. Collective nationals of Panama, Pakistan, Philippines and Greece value harmony and like to protect the groups goals therefore do not put explicit messages. Masculinity – A measure of assertiveness and materiality - Highly Masculine nations like Japan, Italy, UK and Philippines value material success, progress and competition and see the gulf between facts and feelings. In contrast the Scandinavian nations and Netherlands value modesty, tenderness, consensus and caring relationships. Uncertainty avoidance - A measure of ambiguity tolerance – High tolerance nations like Denmark, Sweden, UK, India, Philippines and the USA are comfortable with unfamiliar risks, innovation and living by the day. They are less comfortable with excessive rules, displays of emotions and have to learn precision and punctuality. Low tolerance nations like Greece, Portugal, Japan, France, Spain and Panama like rules and precision. They are sensitive to anxiety, they need to feel busy and for them time is money.

60. 30th April 2014by: G Sachdeva60 8. Communicate with others HOW BIG IS THE COMMUNICATION FAILURE PROBLEM It is the main feature for 25% of all accidents in UK rail Industry. It is responsible for over 50% of all accidents with track workers in UK rail It is responsible for 25% of all accidents in Australian Aviation Industry. It is responsible for 30% of all accidents in US general Aviation. It contributed to the shooting down of Libyan Airliner by Israel in 1973. It led to shooting down of Iranian Airbus in 1988 by USS Vincennes. It led to the shooting of two Black Hawk helicopters by UN in 1994 It is often the cause of most friendly shootings in defense establishments It is the cause of twice as many deaths in US Health sector as skill lack. It accounts for over 60% of all errors in Operating rooms and ICU in USA. It accounted for the torpedoing of my ships chartered to Red Crescent. AT LEAST 25% OF ALL ACCIDENTS INVOLVE COMMUNICATION FAILURE. PREVENTING COMMUNICATION FAILURES REQUIRES ACTION AT ALL ORGANISATIONAL LEVELS. Human Traits

61. 30th April 2014by: G Sachdeva61 8. Communicate with others PREVENTING COMMUNICATION FAILURE Lack of Media Skills and Knowledge – People may know what, where and how to communicate but may be physically unable to do due to noisy environment, lack of training or lack of common language fluency. Address these by proper recruitment and selection policies, procedural training courses, procedure based manuals and training in Standard Marine Communication phrases (SMCP). Lack of Task Skills and Knowledge – People may not have enough training or skills on the job assigned to know what to communicate and to whom. Address these by task training to performance standards and refresher training to prevent skill fade. Procedure based manuals should be onboard and well understood by all. Lack of team task skills and knowledge – People may not understand the team goals or requirements and to understand what to anticipate and what is critical. Best addressed by training such as BRM, tabletop exercises, team building and Seminars. Lack of social skills and cultural knowledge – People may not appreciate how cultural and demographic differences affect communication understanding or how to overcome personal differences or incompatibilities. Address these by personal skills, leadership, cultural awareness, diversity and equality training programs. Lack of Communication process skills – People may not understand their and others 'mental processes involved in successful communication. This is best addressed by Critical Thinking and leadership training. Lack of time – Fast moving, fast developing, sudden, change conditions or heavy workload distracts people in sensible and effective communication. Best addressed by good job design, mentoring, task / team training programs and regular emergency drills. Human Traits

62. 30th April 2014by: G Sachdeva62 Human Traits 8. Communicate with others SOME DO’S DO ensure that your organisation pays full attention to skills and knowledge which are the basis of effective communication. DO encourage staff to ask and answer clarifying queries. People often assume their situation to be different form the actual. DO understand the risk of communication failure under heavy workload. DO understand the enhanced risk of communication failure with people who lack the knowledge. They may miss vital signs. SOME DON’T’S DON’T assume that the message sent has been received. The importance is not just the receipt but the understanding and implementation. The sender has as much responsibility as the receiver in ensuring effective communication. DON’T underestimate the power of communication failure to wreck your business operations. These account for at least 25% OF ALL ACCIDENTS. DON’T confuse language with communication. Communication only takes place when the receiver makes a decision or chooses an action to the senders response. DON’T assume that NO NEWS IS GOOD NEWS as the sender may be having difficulty in sending his communication due to environment, workload, equipment incorrect assumption, etc.

63. 30th April 2014by: G Sachdeva63 people 1. Make sense 6. Learn & develop 2. Take risks 3. Make decisio ns 7. Work with others 8. Comm unica te 3. Make decisions 5. Get tired and stressed 4. Make mistakes 2. Take risks 5. Get tired and stressed 1. Make sense 8. Comm unicate 7. Work with others 6. Learn & develop 4. Make mistakes SUMMARY SHEET

64. 30th April 2014by: G Sachdeva64 Human Traits Case Study – Collision between Chemical Tanker and Container vessel in Singapore Chemical Tanker “ABC” is in the TSS Singapore Straits heading for Pilot boarding grounds. She is steaming at 9.0 Kts on a steady course. Weather and visibility are good and 2 nd Officer is on watch along with an AB and Senior Cadet. The Master who was on the Bridge earlier has just retired to his room to check emails. Container Vessel “XYZ” is departing Singapore, destined for Hongkong and has slowed to about 6.0 Kts. outside of TSS to drop Pilot. She intends to cross the TSS after dropping Pilot and steam full speed to Hongkong. Master, Ch Off and AB are on the Bridge. 8 minutes before the collision took place, the container vessel was spotted. The Second Officer checked the speed, which was 6 Kts and was confident that the vessel would cross about 2 cables astern of “ABC”. 2 minutes before the collision, VTIS Singapore calls “ABC” advising her of a container ship crossing the TSS. The 2 nd Officer responds that he is aware and takes no further action. The two vessels collide causing hull damages and Pollution from the vessel “XYZ”

65. 30th April 2014by: G Sachdeva65 Human Traits Case Study – Collision between Chemical Tanker and Container vessel in Spore What went wrong? 1.The “ABC” 2 nd Officer believed he was in control of the situation and was confident that the container vessel, then doing 6 kts would cross TSS clear astern. 2.The “ABC” 2 nd Officer having crossed this channel almost every other week, believed he was well familiar with the route and another container vessel crossing her was one of those things you do not worry about. 3.The “ABC” 2 nd Officer did not bother to track the other vessel nor requested the Cadet to assist him or call Master because in his perception there was no Risk. 4.The Master of “ABC” was very experienced and has been trading in this area for years, and confident that nothing would go wrong retired to his room. 5.His perception of Risk of leaving the 2nfd Officer in charge was incorrect due to over-reliance placed on his subordinates. 6.When the collision became imminent, the 2 nd Officer was confused. This situation was out of the ordinary and he was not prepared for it. Had he done nothing, there is a possibility that the ships would have missed each other.

66. 30th April 2014by: G Sachdeva66 ANY QUESTIONS …….. ANY QUESTIONS …….. PLEASE FEEL FREE TO ASK ANY QUESTIONS.

67. by: G Sachdeva 67 16 th July 2015 HUMAN ELEMENT WITH PROPER UNDERSTANDING THINGS WILL NOT GO WRONG THANK YOU PLEASE SEND YOUR FEEDBACK TO sachdeva@targetships.com Ph +65 9182 6775