17 ERM Student Manual REv 3 (1)

S012 Engineroom Resource Management

STUDENT MA

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{This document contains proprietary and confidential business information and is not to be copied or distributed for any purpose outside of Resolve Maritime Academy}


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5 Day Schedule

Time Day 1 Day 2 Day 3 Day 4 Day 5 Time 8:00 AM

Module 1 Course Introduction

Module 5 Situation Awareness Module 9

Communications Module 13

Leadership & Management Skills

Week Review & Prep for Mock Trial

8:00 AM 9:00 AM

Module 2 Human Factors

Module 6 Engineroom

Organization & Company Policy

Module 16 Crisis Management &

ERM

9:00 AM

Module 10 Stress & Distractions

Module 13.1

Decision Making

10:00 AM BREAK BREAK BREAK BREAK BREAK 10:00 AM

Module 3 Marine Casualties

Module 7 Team Building

Stress & Distractions (cont) Module 13.2

Risk Assessment ER Simulator

Ex 6 Catastrophe

Module 11 Fatigue & Crew

Endurance

11:00 AM Module 13.3 Short &

Long term Strategy 11:00 AM

Module 8 Planning Maintenance &

Prioritization

Module 3.1 Case Study Module 13.4 Monitoring

12:00 PM

LUNCH LUNCH LUNCH LUNCH LUNCH 12:00 PM

1:00 PM

Module 4 Threat and Error Management

ER Simulator Ex. 2 Cold ship

Case Study, Video & Class Discussion

Module 14 Cultural Relations

Mock Trial Case Study

1:00 PM 2:00 PM

Module 4.1 Error Chains and Recovery

Module 15 External Team

Members

2:00 PM Module 12

STCW, International Conventions and ERM

3:00 PM BREAK BREAK BREAK BREAK BREAK 3:00 PM

Engineroom Simulator

Familiarization Exercise 1

ER Simulator Ex 3 Departure

ER Simulator Ex 4 Maneuvering

ER Simulator Ex 5

At Sea Watchstanding &

Emergency

Written Assessment & Course Critiques

4:00 PM 4:00 PM 5:00 PM 5:00 PM


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TABLE OF CONTENTS

Description Page Schedules ..............................................................................................................iii Table of Contents ..................................................................................................vii Module 01 Introduction to ERM ...........................................................................1 Module 02 Human Factors and ERM .................................................................7 Module 03 The Causes of Marine Casualties .......................................................13 Module 04 Threat and Error .................................................................................29 Module 05 Situation Awareness ..........................................................................39 Module 06 Engineroom Organization & Co. Policy ..............................................53 Module 07 Team Building ...................................................................................63 Module 08 Planning, Maintenance & Prioritization ..............................................79 Module 09 Communication ..................................................................................89 Module 10 Stress & Distractions..........................................................................107 Module 11 Fatigue &Crew Endurance .................................................................125 Module 12 STCW, International Convention & ERM ...........................................147 Module 13 Leadership & Management Skills .....................................................157 Module 14 Cultural Relations ..............................................................................195 Module 15 External Team Members ....................................................................211 Module 16 Crisis Management ...........................................................................225

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Module 1 Introduction to ERM


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Course Introduction

The Power points and Manual You are responsible to understand the information contained in the student manual modules including the information found in the Appendixes. In order to keep the length of this course to the minimum that NMC would allow, there is more information in the student manual modules than appears in the power point presentations. You should read the student manual each night and if you have any questions please bring them to the instructors attention in the morning. Some of this information will be found in the written assessment. Lectures and Simulation Exercises Through a series of lectures and Full mission simulation exercises, officers will be drilled in standard procedures and methodologies for handling a wide variety of challenges to the engine room team. Every responsible mariner wants to approach his job in a safe, efficient, and professional manner and this course is intended to provide the tools to that end. Customer Satisfaction Survey At the end of the week each student will be given the opportunity to fill out a written customer satisfaction survey. We welcome your input in this manner with to continuous improvement of this course.

Assessments are as follows: The Student will perform all simulations which will satisfy the STCW Code Section A-VIII/1&2 Part 3 Para 8 and 46 CFR part 11. A written test at the end of the week consisting of 25 questions and passing grade is 70% or over.

Retake Policy Opportunity is given to retake the written examination within 2 hours of taking the first exam. Students are given ample opportunity to retake practical assessment during the simulator exercises


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Course Introduction Purpose Human factors account for approximately 80% of accidents. This course's principal aim is to reduce the risk of accidents at sea with a focus on casualty prevention and human error. Definition of ERM The Definition of ERM is the use and co-ordination of all the skills, knowledge, experience and resources available to the team to achieve the established goals of safety and efficiency of a voyage or any other safety critical task. (MRM Wikipedia,

Course Content Overview

accessed 05/2013). It is a technique which uses all available means for the safe operation of a vessel

Theory of human factors Causes of Marine Casualties Error chains Threat and Error management Situational Awareness Engineroom Organization and Company Policy Teamwork Planning Maintenance and prioritization Communication Stress, coping and distractions Fatigue and crew endurance STCW and ERM Leadership and management methods Decision Making Risk assessment Short and long term strategy Cultural differences External Team Members Crisis management Case studies and simulator exercises as a learning tool to backup/illustrate

the theory Engine Room team management, as recommended in STCW 2010, Section B-VIII/2 This course has been designed to meet the requirements of STCW Regulation I/12, Sections A-III/1&2 and A&B-VIII/2. (NMC task Numbers14.1A, 1.4A & 16.1A through 16.4A). This course is intended for engineering officers at both the management and operational level. Program can be tailored to specific shipping company operations.


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Course Introduction Course Objective The Objective of ERM is to motivate the team, as needed, to change its behavior to good resource management practices during everyday operations. This includes understanding the importance of good management and teamwork and the willingness to change behavior. An overall objective is to increase safety, efficiency and job satisfaction in shipping companies and, eventually, in the maritime industry as a whole. (MRM) This is done in the hopes of the following:

To reduce risk and accidents in the fleet by focusing on casualty prevention Through case studies and theory, make the officers aware of human factors To train the officers in cooperation and the coordination of tasks and in the

deployment of resources in crisis and busy situations To create awareness about the different areas of responsibility and working

situations with regard to Engineroom watch keeping and leadership To use the simulators to train and observe and ensure that the officers keep a

high standard of competence within the ERM and leadership principles

Effective ERM Principles Resources are allocated and prioritized correctly and are in accordance with the

rules Communications are clearly and unambiguously given and received Questionable decisions/actions are challenged appropriately Effective leadership behaviors are employed Decisions are effective for each situation Team members share an accurate current and predicted understanding of the

ship status Information flow is in all directions, not just from the top down

Citations 1. Maritime Resource Management (MRM) - Wikipedia, the free ... (n.d.). Retrieved

from http://en.wikipedia.org/wiki/Maritime_Resource_Management_(MRM)


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Module 2

Human Factors and ERM


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Human Factors and ERM Purpose The safety and security of life at sea, protection of the marine environment and over 90% of the world's trade depends on the professionalism and competence of seafarers. Studies of past casualties vary from 60 to 80% human error as the cause. This section is intended to make the officer aware of human factors and the importance of ERM in addressing them. Background of ERM Crew Resource Management (CRM) emerged from the Human Factors Research that was being done in the late 1970s and early 80s. Studies of the accidents revealed that air crews exhibited problems in the area of crew resource management. Failures involving:

Inadequate leadership Failure to communicate intentions and Plans Failure to set priorities

These findings provided the impetus for the FAA to require a program to deal with the Human Factors issues in the cockpit. From there, the Maritime industry adopted Resource Management training form of BRM in the 90s and as of 2010 we have Engineroom Resource Management (AVOPS).

The Human Element The shipping industry is run by people, for people. People design ships, build them, own them, crew them, maintain them, repair them and salvage them. People regulate them, survey them, underwrite them and investigate them when things go wrong. While these people vary in all sorts of ways, they are all, nevertheless, people with the same basic set of capabilities and vulnerabilities. The human element is misnamed. It implies something that happens at the sidelines a piece of the picture that is hopefully being dealt with by a specialist, or else it implies that it is just one of those things.(MCA) Humans are not simply an element like the weather. They are at the very center of the shipping enterprise. They are the secret of its successes and the victims of its failures. It is human nature that drives what happens every day at work from the routine tasks of a ships rating, right through to the policy decisions of the IMO.


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Human Factors Human factors are all the components that influence personnel at work. Human factors are about people in their working and living environment, and their relationship with equipment, procedures and other crew members. These include:

Situational Awareness Self Awareness Engineroom Organization Company Procedures Leadership and management methods Teamwork Communication Stress, coping and distractions Fatigue and crew endurance Cultural differences Design of the ship ergonomically Human interaction with Technology

Every module presented in this course has been the root cause or was a contributing factor in a Maritime Incident

Resources Resources are what we have available to us aboard ship and in the Engineroom, and they are:

1. Human 2. Information 3. Equipment

These resources are all positively or negatively impacted in response to any of the human factors. Of these resources, the human resource is the most fragile and must be addressed. Using ERM we seek to understand human strengths and weaknesses and the mind/body concept.


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Understanding Human Factors These resources are all positively or negatively impacted in response to any of the human factors. But it is the human resource that is the most fragile and must be addressed. Using ERM we seek to understand human strengths and weaknesses and the mind/body concept. This understanding of Human Factors helps to gain:

A better safety record due to raised situational awareness More effective communication Multicultural awareness Successful team-work Better interaction between ranks Thoughtful and effective Management and leadership on board Better time and workload management An understanding of good judgment and decision-making A knowledge of the states of the mind Good contingency management

Human Factors are not the same as human resource. Human Factors affect the Human Resources. (MCA) ERM and the Regulations Evidence of human error as the leading cause of mishaps caused the international community to come together through the IMO and write requirements. These requirements are now:

The Standards for Training, Certification and Watchkeeping (STCW) The International Safety Management (ISM) Code National Law (i.e. CFRs)

In this course we will use lecture, integrated case-studies and role-play exercises to meet these requirements.


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Citations 1. Aviation Operation Website (AVOPS) Human Factors Crew Resource

Management (CRM) Advanced Crew ... (n.d.). Retrieved from http://www.avops.com/CRMCombined.pdf

2. Maritime Coastguard Agency (MCA); The Human Element, a guide to human behavior in the shipping industry The Stationery Office (TSO) 2010 Electronic PDF


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Module 3

The Causes of Marine Casualties and Accident Investigation



Causes of Marine Casualties

Description The Human Factor in maritime casualties turn up in the majority of cases reviewed. The root cause of an incident is often due to one or more of the following:

Lack of communication Bad or missing maintenance Not applying safety or other crucial procedures Insufficient training Poor crew competence Poor judgment of the situation

This general conclusion also means that many of the serious accidents reviewed might have been averted if some of the above deficiencies did not exist. In fact, the USCG Study by Rothblum (n.d.) found that 75-96% human error played a part in all mishaps depending on the type of service as the following shows:

Type of Accident Percent human Error as cause All Tanker Accidents 84%-88% Towing Vessel grounding 79% Collision 89%-96% Allisions 75% Fire and Explosion 75% Ships are faster and larger, the technology is more complex, we have better automation and the crews are smaller.




Terminal Objectives Given the information in this module, the officer shall be able to reconstruct the root causes of an accident and be able to write an incident report that will satisfy most regulatory bodies

Enabling objectives In order that we comprehend the investigatory and reporting process and enable our learning, the following objectives will be covered; the student will:

Define the causes of Accidents Analyze methods of accident investigation Study Casualties Learn about writing incident Reports Practice data gathering skills for the purpose of writing useful Incidence reports

for analysis. Use accident case studies to better understand the human link to the ships

equipment and the information it provides to help us operate in a safer fashion.

The Purpose The purpose of accident and incident investigations is to prevent future accidents. It is not the purpose of the investigation report to blame or to assign responsibility. The use of the reports for reasons other than improvement of safety should be avoided.

1




Definitions Marine Incident means abnormal events occurring in the course of operation of sea-going ships and likely to cause danger to man, ships, or the environment. An incident can be an accident or a near miss

1

Marine Accident means one or more than one undesired marine incident which results in personal injury, damage or loss. Accidents include loss of life or major injury to any person on board, the loss, abandonment or material damage of a ship. It also means collision, grounding, disablement, and material damage caused by a ship. In other words, damage caused to or because of the ship

1

Near Miss 1. An incident with no consequences, but that could have reasonably resulted in

consequences under different conditions. 2. An incident that had some consequences that could have reasonably resulted in

much more severe consequences under different conditions. Example: Restarting a lube oil system before vital system damage or failure occurs

2

Event An event means a happening that does not seem significant at the time, but if lined up with other events could build up a chain of errors that leads to a much more serious incident.3

Bad habits - like always forgetting to clean the strainer that was just switched over

Examples of these could be:

Miscommunications - that occur again and again



Causes of Marine Casualties Types of maritime accidents: Let us look at the list of Maritime accidents

Grounding Stranding Collision (contact with another ship) Allision (contact with a dock) Foundering Fire Explosion Flooding Pollution Structural failure Heeling

Strandings and Groundings are the most frequent type of total loss maritime casualty Fire (mostly in the engine room) ranks second in this type of loss Together, these two make up more than half of all marine casualties (J. R. Kuehmayer Marine Accident and Casualty Investigation Boards)

Salvage of MV Tricolor car carrier (http://archive.org/web/web.php)



Accident Investigation

Goals There are four good reasons to investigate an incident

1. To find the cause 2. To prevent similar occurrences from happening again 3. Establish damages for legal and contractual reasons 4. To take disciplinary proceedings if there was criminal negligence

The Mariners manning the ship are the first on the scene when the evidence is fresh

Who will have an interest in your report? A list of possible interested parties

Company Insurers Flag and Port State Cargo interests

Be prepared to take part in collecting evidence and study the way evidence is collected and recorded for use in making or defending maritime claims. Your evidence could be used in a court of law and the impact criminal prosecutions

Sample Report

4

It is good to study the reports generated after incidents by the USCG, NTSB and by the shipping companies. When reading them, study the forms of evidence gathered, how the evidence was validated and how the report was written. This practice will help when it is your turn to perform an investigation and write up a report. Selections of good reports are provided on the stick drive issued at the beginning of class.



Studying Casualties

Case Studies In order to gain experience from incidents we must dissect the events that led up to it. We can gather information. Examples of the type of data to scrutinize are (ABS 2005):

Equipment type (system, component, subcomponent) Equipment supplier Types of incident Job position of individuals involved in incidents Written Procedures followed Operating modes of equipment Timing (seasons, days, time of day, etc.) Environmental conditions Contributing events Event sequences Root causes

Importance of Data Gathering Factual data-gathering validates all conclusions and recommendations from an investigation. Without effective data gathering, the incident cannot be truly defined and investigated. Gathering data usually takes more time than other investigation steps.(ABS 2005)



Studying Casualties (cont)

Types of Data According to the ABS guidance notes on accident investigations 3

1. People interviews with or written statements from witnesses, participants, etc.

, there are five basic types of data as shown in Section 4, Figure 2, Overall Types of Data listed below:

2. Physical parts, chemical samples, personal protective equipment (PPE), structures, outfitting items, logs, paper charts, correspondences, etc.

3. Paper hard copies of procedures, policies, administrative controls, drawings, sketches, notes, performance and operational data, analysis results, procurement specifications, navigational charts, loading specifications, etc.

4. Electronic electronic copies of procedures, policies, administrative controls, drawings, performance and operational data, analysis results, procurement specifications, e-mail, navigational charts, loading specifications, etc.

5. Position locations of people and physical data.




Move Quickly Data after an accident is fragile and degrades over time Most Fragile Least Fragile

People Electronic Position Physical Paper

By waiting too long evidence could be lost, distorted or broken.

Try for yourself Incident Description The incident occurred when the operators were sandblasting a portion of the structure in preparation for repainting. Each sandblasting machine was staffed with the normal two-person crew. When the nozzle operator observed that abrasive material was no longer flowing through the nozzle of his machine, he suspected a clog in the blast hose. He responded by releasing (disengaging) the deadmans switch and signaling his co-worker. Assuming that the system was depressurized, the co-worker attempted to disconnect the blast hose from the equipment so that he could clean away the suspected clog. The coworker was unable to rotate the quick-disconnect coupling the one-quarter turn required to remove the blast hose. Assuming the fitting was stuck because of dirt or contamination, he asked the nozzle operator to assist him. The two workers, working together, were able to twist the hose fitting to the point where it could be forcibly disconnected. The system rapidly depressurized, spraying abrasive material through the coupling and onto the hands of the worker nearest the outlet. This worker sustained relatively minor, but painful, skin abrasions to both hands. Both workers were fortunate in that their eyes and faces were not injured, and the injured worker was lucky in that his wounds did not become infected from the embedded sand.




What Next? We shall look at two different ways of analyzing data(ABS3

1. A Logic tree (see picture below) )

2. The 5 Whys Technique




The 5-Whys Technique The 5-Whys technique is a simplified version of the logic tree approach and was taken from the 2005 ABS guidelines. The primary difference between the two methods is that the 5-Whys technique does not use any gates. It is a technique that can get you to the root cause of an incident This is how it is done:

1. Select an event 2. Ask why this event occurred (i.e., the most direct cause of the top event). 3. Find answer(s) to this question. The answer may identify more than one sub-

event the cause. 4. Ask why the Sub-event happened 5. Ask WHY about 5 times to get to the root cause ( see picture below)



Writing Incident Reports

Purpose Learning from mistakes is a key element of any safety culture. The purpose of an incident (accident or near miss) report is to set down an accurate account of the incident in order that lessons can be learned by:

The company The mariners Future mariners

We use these reports to work toward continuous improvement, perhaps preventing similar occurrences elsewhere in the fleet.

Reports Writing reports can be embarrassing, especially if the incident was due to human factors. It is important to keep it simple, straight forward and truthful even though the task feels intimidating. (EHS Safety5

An incident report must include all the most important information about the accident or near-miss.

).

You may use a special incident reporting form, and it might be quite extensive. Writing any incident report involves four basic steps.

1. Find the Facts 2. Determine the Sequence 3. Analyze 4. Recommend



Writing Incident Reports (cont)

Find the Facts According to the P&I Loss Prevention hand book, you have to gather and record all the facts. For example (for an injury):

Date, time, and specific location of incident Names, job titles, and department of employees involved and immediate

supervisor(s) Names and accounts of witnesses Events leading up to incident Exactly what employee(s) were doing at the moment of the accident Environmental conditions (e.g. slippery floor, inadequate lighting, noise, etc.) Circumstances (including tasks, work load, equipment, tools, materials, PPE,

etc.) Specific injuries (including part(s) of body injured and nature and extent of

injuries) Type of treatment for injuries Damage to equipment, materials, etc.

Determine the Sequence Based on the facts, you should be able to determine the sequence of events. In your report, describe this sequence in detail, including (EHS Safety5

Events leading up to the incident. Was the employee walking, running, bending over, squatting, climbing, lifting operating machinery, turning a valve, using a tool, handling hazardous materials, etc.?

):

Events involved in the incident. Was the employee struck by an object or caught in/on/between objects? Did the worker fall on the same level or from a height? Did the employee inhale hazardous vapors or get splashed with a hazardous chemical?

Events immediately following the incident. What did the employee do: Grab a knee? Start limping? Hold his/her arm? Complain about back pain? Put a hand over a bleeding wound? Also describe how other co-workers responded. Did they call for help, administer first aid, shut down equipment, move the victim, etc.?



Writing Incident Reports (cont)

Determine the Sequence (cont) The incident should be described on the report in sufficient detail that any reader can clearly picture what happened. You might consider creating a diagram to show, in a simple and visually effective manner, the sequence of events related to the incident and include this in your incident report. You might also wish to include photos of the accident scene, which may help readers follow the sequence of events.

Analyze Your report should include an in-depth analysis of the causes of the accident. Causes include: Root cause (e.g., a spill on the floor that caused a slip and fall) Contributing Factors causes (e.g., employee not wearing appropriate work shoes or carrying a stack of material that blocked vision) Other contributing factors (e.g., burned out light bulb in the area).

Recommend Recommendations for corrective action might include immediate corrective action as well as long-term corrective actions such as:

Employees take training on safe work practices Preventive maintenance activities that keep equipment in good operating

condition Evaluation of old/new job procedures with a recommendation for changes Evaluate any task for hazards and then train employees on these hazards Engineering changes that make the task safer or Make administrative changes that affect the way the task is performed, making it

safer Change is often confused with improvement and that perhaps the best recommendation is a reinforcement of existing procedures that are still valid.



Reading assignment - Case Studies M/V SSG Edward A Carter Jr. (for group discussion)

Summary In this section we:

Defined the causes of Accidents Analyzed methods of accident investigation Studied Casualties Learned about writing incident Reports Practiced data gathering skills. Used accident case studies to understand the human link between equipment

and the information it provides to help us operate in a safer fashion.

Works Cited and Further Reading 1. Kuehmayer J. R. Marine Accident and Investigation boards. 2008. Retrieved from

http://www.amem.at/pdf/AMEM_Marine_Accidents.pdf 2. Near Miss(safety) Free Encyclopedia retrieved (06/2013 ) from

http://en.wikipedia.org/wiki/Near_miss_(safety) 3. American Bureau of shipping(ABS) Guidance Notes on; The Investigation of Marine Incidence June 2005 4. P&I Loss Prevention hand book: The Mariners Role in Collecting Evidence & Handbook. Retrieved from

http://www.northpublications.com/lp_guides/Mariners_Role_In_Collecting_Evidence/#/1 5. How to Write a Good Accident or Incident Report EHS Safety ... (n.d.). Retrieved from

http://ehssafetynews.wordpress.com/2011/08/24/how-to-write-a-good-accident-or-incident-report/



Module 4 Threat and Error Management

Error Chains and Recovery



Threat and Error Management

Terminal Instructional objectives Given the information in this module, the student will be able to use the TEM Model to gain a better understanding of the processes which lead to the commission of errors, identify contextual aspects in which they occur and to design strategies that manage errors more effectively and leads to better situational awareness.

Enabling Objectives In order to fulfill the objectives the student will:

Define types of Threats Understand the types of Error Outline possible threat Strategies and

countermeasures Solve Error Chains with corrective action Discuss Error management

Description The Threat and Error Management (TEM) model was developed to explain, the interaction between safety and human performance during the operation of a ship. It does this by mapping the inter-relationship between the parts within the safety system. The model captures aspects of these relationships that explain both human and system performance from a safety perspective. This model is used extensively to support safety management systems (SMS) such as Engine Resource Management (ERM) training and as a diagnostic application in Safety Audits.



Threat and Error Management (cont)

Explanation of TEM

TEM Model (Adapted by David Rae from TEM Model used in Helmreich & Musson, (2000[ 5 ]).

The TEM Model proposes an error management process that is influenced by two factors: 1. Threats

- influences that are beyond the direct control of the people performing the work tasks and Threats are events or conditions that exist within the operational environment and attack the safety performance of the crew.

2. Threat Management strategies and countermeasures

- The actions of those performing operational tasks used to manage safety.




Threat Types There are two forms of threat described in the TEM model they are latent and overt threat Latent Threat Threats that are not obvious to the crew and are hidden within the system.

Latent Threat (examples)

Professional Culture - Risk taking culture and macho attitudes i.e. PPEs are for children

Organizational Culture - Safety rules and operating procedures not considered important

National Culture - Do not question the person in authority i.e. the captain/ chief is always right, even when he is wrong

Vague Policies - Do not clearly describe what actions are required and when they are required. i.e. previous accidents caused through unclear policies

Overt Threats Are present on the day and are either anticipated or unexpected by the crew.

Overt Threat (examples)

Environmental - Anticipated threat (Bad weather i.e. the crew can plan how it will be managed)

Environmental - Unanticipated (Mechanical failure i.e. the crew are required to use skill and training to manage the threat)

Team or Crew - Lack of familiarity with SOP's

Organizational - Last minute change to schedule i.e. shortened turn-around time.

(Maurino, 2005[ 1 ]

)




According to Helmreich, et al (6) threat Counter Measures fall into hard and soft categories. Hard Counter measures are things like alarms, automation, ship design etc. The soft countermeasures include SOPs, regulations and checklists. These all rely on the human to adequately put them to use. The last line of defense is, as always, the Human Team.

Threat Management strategies and countermeasures

Strategies and countermeasures intervene between the threats and the work tasks; they are best described as the safety tools that exist within the system. They represent aspects of human behavior (i.e. personal strategies and tactics such as vigilance, anticipation and responses) and those intrinsic to the system (i.e. alarm systems or procedures) that collectively support the management of threats This is done by doing two actions

1. Identify 2. Prepare

Threats must first be identified; this can be done during a pre-brief to any maintenance raising awareness by listing anticipated or known threats. Also list possible unanticipated threats and advice vigilance for unknown threats make contingency plans. Threats are effectively prepared for by:

Adhering to policy, following SOP Communicating plans with the team and appropriate resources/agencies Developing contingency plans Once Identified, brief applicable Threat(s), and in particular, the greatest threat.

About one-half of all observed errors are Procedural errors, one-third are operator errors, and one-sixth are Communication errors.( Helmreich, et al (6))



Error Chains and Error Management

Error Chains It is no surprise that most small incidents are caused by small human errors. You might expect that most very large incidents would result from major human errors. They do not! They are also caused by alot of minor errors. Error chains are small errors that when linked together may end in an accident. In order to break the error chain, we must trap the error. We do this by treating them like threats

1. Identify 2. Break

Human Error The large amount of information processed by teams and the many necessary interactions within and between teams provides the opportunity for human error. Chains of human error are normal and should be expected. There are three levels of human error. (USCG Team Coordination Training Student Guide4

1. Slips. )

2. Mistakes. 3. Errors.

Types of Error can include: 1. Failing to perform or omitting a task 2. Performing the task incorrectly 3. Performing an extra or non-required task 4. Performing tasks out of sequence 5. Failing to perform the task within the time limit associated with it 6. Failing to respond adequately to a contingency




Slips Slips are the incorrect sending of information or miscommunication. Often well-formed habits take over, and we make a slip. Slips often occur in giving rudder or engine commands, or in responding on the radio. These slips may be humorous or seem insignificant, but they are a visual or auditory form of human error. They may indicate that the individual making the slip is under added stress. (USCG 4

Unfortunately, the individual may not recognize the slip. Example: An example is a verbal rudder order for left rudder when the direction of the hand was toward the right.

)

Corrective Action: Inform the individual of the slip, regardless of differences in rank.

Mistakes Mistakes are failures in planning. Mistakes almost always have to do with the selection of objectives and the time required achieving them. Example: In the engine room it may be the timing for engine maintenance that conflicts with a planned, though poorly communicated, restricted maneuvering event. Corrective Action: Questioning the plan during the brief and performing thorough double checks can reduce the probability of these mistakes. (USCG 4

Errors

)

Errors are flawed execution; incorrect actions based on either correct or incorrect information. Errors are defined as actions; therefore they are the most serious form of human error. Example: Performing tasks out of sequence; igniting a boiler without a proper purge (USCG 4

Corrective Action: Effective teams are alert to errors and use assertive communications to alert others to the problem.

).

Error Trapping; When to Do It and Who Should Do It Trapping slips, mistakes, and errors, (or breaking an error chain) are key mechanisms to avoiding mishaps. Human error can occur at anytime. The earlier human error enters the process and/or the longer it goes undetected, the less effective the team will be and the greater the potential for mishaps. Regulations are implemented to control some of the known errors, but regulations and standard operating procedures are not fail-safe mechanisms. Team members must be able to identify all levels of human error and be empowered to take corrective action!




Strategies and Countermeasures for Errors Timely error Identification can be difficult. We do not make mistakes on purpose. Techniques to identify errors are:

Monitor and Cross-check or trust but verify. Adequate monitoring of the vessel situation and other team members is a continuous posture of active mental engagement. Monitoring is a skill and discipline that helps maintain an operational mindset. No one should be along for the ride. There should always be one person assigned the task of monitoring, or verifying correct actions and orders. The rest of the team should also be doing their part to monitor the actions of the team and the vessel situation.

Manage workload. Over worked overly busy people do not notice error chains Manage automation, verify that the automation is correctly monitoring and

measuring engineroom parameters Repair - Once we identify an error we need to verbalize the error, using effective

communication to repair the error. NOTE: Communication is one of our ERM tools. Error must be communicated FIRST, and then we can use ERM skills on repairing the error or coming to safe decisions.

Error ManagementEven during active error management, threats remain capable of attacking the safety of the system.

Results

There are three possible responses to a situation by the crew: 1. Trapping the Error- the error is detected and managed before it becomes

consequential. 2. Exacerbate the error- The error is detected, but the crews action or inaction

leads to a negative outcome. 3. Failing to respond to the error- in this instance the crew fails to react to the error

either because it is undetected or ignored. (Helmreich, Klinect, & Wilhelm, 1999[6]).




Summary In this section the student:

Defined types of Threats Appraised the types of Error Outlined possible threat Strategies and countermeasures Studied Error Chains and discussed corrective action Outlined Error management methods

Citations &Further Reading 1. Maurino, D. (2005). THREAT AND ERROR MANAGEMENT (TEM). Canadian Aviation Safety Seminar

(CASS) Vancouver, BC, 18-20 April 2005. Retrieved 8th April 2013 from http://www.skybrary.aero/bookshelf/books/515.pdf.

2. Helmreich, R.L. (1998). Error management as organizational strategy. In Proceedings of the IATA Human Factors Seminar (pp. 1-7). Bangkok, Thailand, April 20-22, 1998. Retrieved 8th April 2013 from http://homepage.psy.utexas.edu/homepage/group/HelmreichLAB/Publications/pubfiles/Pub225.pdf.

3. ICAO. (2005). Threat and Error Management (TEM) in Air Traffic Control. Retrieved August 17th from http://www.flightsafety.org/pdf/tem/tem_icao_10-05.pdf

4. USCG Team Coordination Training Student Guide (8/98) Module Five Pages 8-9 5. Reason, J. (1997). Managing the Risks of Organizational Accidents6. Helmreich, R.L., & Musson, D.M. (2000). The University of Texas Threat and Error Model.

. Aldershot, UK: Ashgate. Chapter 1 UT Human

Factors research Project Retrieved 12th June 2013 http://homepage.psy.utexas.edu/homepage/group/helmreichlab/Medicine/medicine.html

7. Helmreich, R.L., Klinect, J.R., & Wilhelm, J.A. (1999). The Line Operations Safety Audit (LOSA) Observers Manual, Version 7.0. Austin, TX: University of Texas Aerospace Crew Research Project. (591.doc) Retrieved from http://homepage.psy.utexas.edu/homepage/group/HelmreichLAB/Publications/Technical Report 99-04 October 1, 1999 :12th June

8. CASA Threat & Error Management. Retrieved from YouTube http://www.youtube.com/watch?v=mbhvQHekezY&feature=youtu.be on 12th

9. June 2013.

Threat and Error Management Model Aviation Knowledge. (n.d.). Retrieved from http://aviationknowledge.wikidot.com/aviation:tem-model



Module 5

Situation Awareness



Situation Awareness Description The definition of situational awareness is an accurate perception of:

What is going on? What can happen next?

Situation Awareness is a perception of the elements of the environment, within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future. (Endsley 1995) Good situation awareness depends on three levels of mental activity all of which take place simultaneously, and all of which are subject to mental filters. These three levels are: (MCA; The Human Element, a guide to human behavior in the shipping industry 2010)

Perception comprehension projection

Terminal Instructional Objectives Given the information in this module and the full mission simulator the student will build an understanding of how much situation awareness affects every part of our actions and decisions. You must perform each and every simulation exercise.

Enabling Objectives To complete this assignment successfully, you must:

Understand the three levels of Situation Awareness Comprehend the Loss of Situation Awareness Define Individual Situation Awareness Explore Team Situation Awareness List the barriers To Situation Awareness Discuss methods of regaining and maintaining good Situation Awareness



Situation Awareness (cont)

Perception In making decisions, we must be able to pick out all the pieces of information in our environment that are relevant to our goals (MCA 20102

In complex situations, many different information sources may be relevant and all simultaneously competing for our attention.

). Some of these may be very subtle, such as small changes over time in what an instrument says. Some may rely on your memory, such as information passed on during watch handover. Some information will be very obvious, such as an engine alarm.

Information may also be hidden away, requiring a deliberate search to find them. So perception is:

What we see, hear and sense (Status of machinery, alarms, logs etc.) How we perceive these things will depend on our level of alertness

This level of Situation Awareness is our weakest point and we try to compensate for this perception gap by the use of automation



Situation Awareness (cont)

Comprehension It is here that we assign to the information that we gathered:

meaning significance priority

For example, if a chief engineer sees warning lights and hears unusual engine noises while under assisted tow in a restricted channel, the extent of the problem must be quickly evaluated to work out the implications for the ship and the accompanying tugs.

Projection Understanding the current picture is not enough for full situational awareness. Decision makers must also be able to project their understanding into the future. This enables them to make the decision they must take now and create the best options in the future. Projection requires us to have good mental models of the dynamic relationships between the relevant parts of our environment over time. Experts focus a lot on creating their own futures via present decisions. Good situation awareness takes immersion in the task, exposure to many different scenarios over time, and much practice and feedback in trying to deal with those variations.



Loss of Situation Awareness

The Consequences of Losing your SA When we lose Situation Awareness we increase the potential for human error mishaps. Analysis of navigational mishaps for cutters and boats revealed that 40% were due in part or wholly to a loss of situational awareness.

Clues you may have lost Situation Awareness The loss of Situation Awareness usually occurs over time and will leave a trail of clues. Be alert for the following clues (USCG3

A gut feeling that events are unfolding too fast ):

No one watching or looking for hazards. Use of improper procedures. Departure from regulations. Failure to meet planned targets. Unresolved discrepancies. Ambiguity. Fixation or preoccupation.



Loss of Situation Awareness (cont)

Look at the Clues and Trust your feelings!

A feeling that events are unfolding too fast The body is able to detect stimulus long before we have consciously put it all together.

Not Looking for Hazards Vessel operations require more than just taking a round or filling a log. The proper assignment and performance of tasks is essential to safe vessel operations.

Use of Improper Procedures This puts the individual or team in a gray area where no one may be able to predict outcomes with any certainty.

Departure from Regulations In addition to violating procedures, we are operating in an unknown area where the consequences of our actions cannot be predicted with any degree of certainty.

Failure to Meet Planned Targets During each evolution, we set certain goals or targets to meet. When they are not met, we must question why and systematically begin to evaluate our situation.

Unresolved Discrepancies When two or more pieces of information do not agree, we must continue to search for information until the discrepancy is resolved.

Ambiguity When information we need is confusing or unclear, we must clarify or to fill in the missing pieces before proceeding.

Fixation or Preoccupation When someone fixates on one task or becomes preoccupied with work or personal matters, they lose the ability to detect other important information. Early detection of both fixation and preoccupation is essential to safe vessel operations. The best way to identify these clues is by knowing the behavior of your team members and being alert to change. Preoccupation with personal matters can often lead to subtle changes in performance. (USCG3

)



Individual and Team Situation Awareness Types of Situation Awareness There are three types

1. Personal situational awareness

2.

: A crew members awareness of his or her own surroundings. Team situational awareness

3.

: A shared awareness of team members about what is happening in their collective surroundings. Incident situational awareness: A holistic awareness of the big picture and how the actions of teams are complimenting or impacting the performance of each other to the completion of the overall strategic objectives. (Gasaway6

)

A mariner would have personal situational awareness as clues and cues about his or her environment are captured and processed, including incident conditions and information about personal safety and perhaps information about fellow crew members abilities. Situational awareness during an incident is developed from understanding how individual and team performance impacts the overall incidents strategy and objectives with a keen awareness of the impact and consequence of failure and success. (Gasaway6

)



Team Situation Awareness Situation Awareness and the Teams Performance Effective team situation awareness depends on team members developing accurate expectations for team performance by drawing on a common knowledge base. This concept, known as maintaining a Shared Mental Model allows team members to effectively: (USCG3

Anticipate the needs of other team members. ):

Predict the needs of other team members. Adapt to task demands efficiently.

What Knowledge needs to be shared? To ensure a Shared Mental Model of the situation, team members must share their knowledge relative to:

The task and team goals. Their individual tasks. Team member roles and responsibilities.

For good team situational awareness, team members need to have information that will help them develop relevant expectations about the entire team task.

Crew Fixation and the Two-Challenge Rule The Two-Challenge Rule has been used effectively on the ship to detect fixation in a team member. If a team member fails to respond to two or more challenges regarding omissions or questionable actions, the individual is assumed to have lost situational awareness and some action is required. Apply this rule in daily operations. (USCG3

):



Regaining and Maintaining Situation Awareness Maintaining Awareness Maintenance of situation awareness occurs through effective communications and a combination of the following actions. (USCG3

Recognize and make others aware when the team deviates from standard procedures.

):

Monitor the performance of other team members. Provide information in advance. Identify potential or existing problems (i.e. equipment-related or operational). Demonstrate awareness of task performance. Communicate a course of action to follow as needed. Demonstrate ongoing awareness of task status. Continually assess and reassess the situation in relation to the goal(s). Clarifying expectations of all team members eliminates doubt.

Comment on Deviations When deviations are noted, effective team members comment in specific, assertive terms.

Monitor Performance of Others Be alert for changes in the performance of other team members caused by work overload, stress, errors, etc. When changes are noted, take action by speaking up.

Provide Information Dont wait to be asked. When you have information that is critical to team performance, speak up!

Identify Problems All team members are tasked to identify problems before they affect task accomplishment. (USCG3

):



Regaining and Maintaining Situation Awareness (cont) Maintaining Awareness (cont)

Demonstrate awareness of task performance Know how your job and those of other team members contribute to overall team goals. EXAMPLE: It may not be necessary to know the technical aspects of other team members jobs, but you must be aware of what actions, information, etc. they need from you to do their jobs effectively. (USCG3

Communicate a Course of Action

):

Effective communications may be the most important factor in achieving and maintaining situational awareness. To ensure a Shared Mental Model, speak up and verbalize any intended action. Understand that the level of situation awareness achieved is related to the level and quality of communication observed in team members.

Demonstrate Awareness of Task Status Ensure that your performance reflects an understanding and awareness of the task being performed. EXAMPLE: Effective team leaders plan ahead and communicate the plan to team members. This ensures that everyone is aware of the plan and builds a Shared Mental Model of the situation.

Continually Assess the Situation Continually assess and reassess the situation to determine if the team is still on track to safely and effectively accomplish the goal.

Clarify Expectations Understand that clear expectations lead to a Shared Mental Model of the situation and ensures high levels of situational awareness by all team members. (USCG3

):



Barriers to Situation Awareness The following barriers reduce our ability to understand the situation. Recognizing these barriers and taking corrective action is the responsibility of all team members. (USCG3

Perception based on faulty information processing.

):

Excessive motivation. Complacency. Overload. Fatigue. Poor communications.

Perception is our mental picture of reality. Insufficient information makes it difficult to ensure that our mental picture is always aligned with reality. Our mental picture is affected by: (USCG

Perception

3

Past Experiences: We act on information based on our knowledge. When something looks similar to what we are familiar with, we may react as if it were the same.

):

Expectations: We interpret information in such a way that it affirms the planned action. We may rationalize that the ship is being set by a current that was incorrectly computed, when in reality no one has compensated for bearing errors in the instruments.

Filters: We are provided with information, but we dont use it. We dont pay attention to information that doesnt match our mental picture.



Barriers to Situation Awareness (cont) Excessive Motivation This behavior imposes expectations and filters that affect our ability to assess the situation and any safety risks. It includes, but is not limited to, Can Do attitude and an overriding sense of task importance (e.g. you have to go into that tank. . .). Solution: Performing a risk management process, using an effective decision-making strategy and seeking feedback on judgments can reduce the potential for unsafe acts.

Complacency Assuming everything is under control affects vigilance. When things are slow, tasks are routine, or a project has been accomplished, complacency can occur. Solution: Challenging yourself and/or the team to be prepared for contingencies (e.g. planning or training) can deter complacency.

Overload Overload causes distraction; fixation; increased errors, and high stress. Solution: Prioritizing and delegating tasks and minimizing job distractions can improve safety in conditions of overload.

Fatigue Fatigue affects your vigilance. Solution: Adjusting work routine and imposing sleep discipline to prevent wake cycles longer than 18 hours and permit at least 5 and preferably 8 hours/day of sound sleep can minimize sleep deprivation.

Poor Communications Good situational awareness is related to the level and quality of communications observed in the team.



Situational Awareness Summary Situational awareness is dynamic, hard to maintain, and easy to lose. Knowing what is going on all the time is very difficult for any one person, especially during complex high stress operations. Therefore, it is important that we know what behavior is effective in keeping us situational aware.

Citations 1.

2. Maritime Coastguard Agency (MCA);

Endsley, Mica R. Human Factors: Toward a Theory of Situational Awareness in Dynamic Systems. Texas Tech University, Lubbock: 1995 PDF

The Human Element, a guide to human behavior in the shipping industry

3. USCG Team Coordination Training Student Guide (8/98) Module Five SITUATIONAL AWARENESS SITUATIONAL AWARENESS,

The Stationery Office (TSO) 2010 Electronic PDF (accessed April 4th 2013)

http://www.uscg.mil/auxiliary/training/tct/chap5.pdf (accessed June 12, 2013). 4. What is Situational Awareness? Wikipedia.com: (accessed 12th June 2013)

http://en.wikipedia.org/wiki/Situation_awareness 5. Gasaway, Richard B. Situational Awareness Matters (accessed 4th April 2013)

http://www.samatters.com/2012/02/28/tracking-of-personnel/



Module 6

Engineroom Organization And Company

Policy



Policy and Procedure

Terminal Instructional objectives In this module, we will go over the reasons and necessity of having Engineroom and company policies. We will also contrast policy/procedure done well and done poorly.

Enabling Objectives The goal of this module is to identify why well written policies & procedures allow employees to understand their roles and responsibilities within predefined limits. (AMEinfo1

The Student will complete the following objectives:

) In order to do this, we will examine sample company policies and procedures. Then, in teams, we will write a procedure which the other team must use to accomplish a job. We will then analyze if the procedure was effective and why.

Defining Policy and Procedure Understanding the Signs of ineffective Policy or Procedure Analyze a sample Policy and Procedure

Description Analyses of casualties show that weaknesses in the engineering department and/or company organization can be a contributory cause to a casualty. Policies and Procedures are the strategic link between the Company and Chief engineers vision and day-to-day operations. Basically, policies & procedures allow management to guide operations without constant management intervention. .



Defining Policy and Procedure

What is the difference between policy and procedure? In order to understand why policies & procedures are so important we need to know what they are and differences between them.

Policy Policies identify the key activities and provide a general strategy to decision-makers on how to handle issues as they arise. This is accomplished by providing the reader with limits and a choice of alternatives that can be used to "guide" their decision making process as they attempt to overcome problems. A policy is guidance on company goals. (AMEinfo1

Procedure

)

The ultimate goal of every procedure is to provide the reader with a clear and easily understood plan of action required to carry out or implement a policy. A well written procedure will also help eliminate common misunderstandings by identifying job responsibilities and establishing boundaries for the job holders. Good procedures actually allow managers to control events in advance and prevent the organization (and employees) from making costly mistakes. You can think of a procedure as a road map where the trip details are highlighted in order to prevent a person from getting lost or "wandering" off an acceptable path identified by the company's management team. (AMEinfo1

)



Defining Policy and Procedure The major differences between policies & procedures are identified below:

Policies Procedures: Are general in nature Identify company rules Explain why they exist Tell when the rule applies Describe who it covers Show how the rule is enforced Describes the consequences Are normally described using simple

sentences & paragraphs

Identify specific actions Explain when to take actions Describe alternatives Show emergency procedures Includes warning & cautions Give examples Show how to complete forms Are normally written using an outline

format (AMEinfo1

Policies & procedures are required when there is a need for consistency in your day-to-day operational activities. Policies and procedures also provide clarity to the reader when dealing with accountability issues or activities that are of critical importance to the company, such as, health & safety, legal liabilities, regulatory requirements or issues that have serious consequences (AMEinfo

)

1

Consistency ). To sum up we need:

Clarity Priority

Engineering Procedures The purpose of the Engineering Procedures Manual is to establish standardized procedures that adhere to the practice of good ERM principals in order to achieve a sound, efficient engineering organization. Clearly defined procedures laid down in company instructions, in the form of checklists, procedures, and Chief Engineers standing orders are essential.



Checklists A checklist is a written memory aid used to accomplish a series of tasks. The International Safety Management Code (ISM) and The International Organization for Standardization (ISO) require the use of ship and company specific checklists for a wide variety of tasks. It should be short, simple and checked for accuracy.

It serves as a memory aid, helps prioritize tasks, performs the task in the right order and cuts down on errors of omission or guesswork.

A checklist is not a substitute for thorough knowledge of the ship or procedures.

How should I write a policy and a procedure? Take a look at a procedure on writing a policy for the Safety Management System.

Note that the content refers to what a policy should contain, but it is written in the outline format of a procedure

The responsibility and authority for the SMS must be clear. The following items should be included:

1. appropriate details of the ship operator(s) a. the full name and details of the entity responsible for the operation of the

ship, if other than the owner, must be reported to the U.S. Coast Guard and included in the SMS manual

b. an organizational chart showing the lines of responsibility and the 2. allocation and interrelation of authority in the SMS (See Figure 1)

a. the person(s) or position(s) with the highest authority in the development, implementation, and maintenance of the SMS and how they can be contacted

b. the person(s) or position(s) with the overall operational responsibility and authority for safety and environmental protection

c. the person(s) with routine responsibility for safety and environmental protection



Signs of Inefficient Policy and Procedure

Critical Signs If your organization already has established Policies & Procedures, how can you determine if they are meeting your needs? A few critical signs indicating your policies and procedures need to be reviewed and updated would include:

An increase in the number of accidents. Higher failure rates. Costly overruns. (Welling 3

Clues

)

The workforce can also provide important clues to indicate a company's policies and procedures need to be reviewed. These clues could include:

Increased staff questions on "normal operations". A feeling of general confusion within a department or division. Employees demonstrating inconsistency in their job performance. An increase in the workforce's stress levels. Additional clues provided by customers in the form of increasing complaints.

Safety It's easy to see that well-written policies & procedures benefit the company as well as the employee. From an employee perspective, the guidelines provided in policies and procedures allow workers to perform their jobs with respect, dignity and safety. Policies provide guidance on how to handle issues properly as well as clearly identifying their job constraints. The organization benefits by allowing managers the freedom to concentrate on strategic issues because policies and procedures are in place to guide the normal-day-to-day operations. (Why? 4

)



Sample Policies and Procedures

Sample Policy Where hotwork is to be conducted in a confined space;

A confined Space Entry Permit and a Hotwork Permit are required. The atmosphere within the confined space must be tested for flammable vapor

prior to commencing hotwork and at frequent intervals throughout the hotwork activity. If any readings above 1% of the LEL are obtained, the hotwork activity must cease.

If welding on the boundary of a confined space, then, where possible, the confined space should be made Safe for Entry so that a fire watch can be posted on both sides of the boundary bulkhead as required. If the confined space cannot be made Safe for Entry, and if it is suspected that explosive vapors might be generated by the hotwork activity, then the confined space should be filled with water.

Sample Procedure Enclosed Space Entry Procedures

1. Is the space thoroughly ventilated? 2. Has the atmosphere been tested and found safe? 3. Is the space prepared for entry? 4. Is there sufficient rescue and resuscitation equipment available at the enclosed

space entrance? 5. Is there a suitably experienced person in attendance at the entrance? 6. Have communication arrangements been agreed between the person at the

entrance and those entering? 7. Is there safe access and sufficient illumination? 8. What personal protective equipment is to be used? 9. Breathing apparatus 10. Is a Permit to Work in place?( Enclosed Space Entry Ship owners Club5

)



Sample Policies and Procedures

Team Exercise (to be performed in the simulation exercise) Now put your knowledge to the test. Using the full mission simulator engine please perform the following actions:

1. The team will write a procedure from the sample list. 2. The team then will attempt to perform this task by faithfully following the

procedure as written 3. Afterwards the team will observe and appraise the usefulness of the procedure 4. Afterwards there will be a discussion about lessons learned

Sample Procedures List Fire Blackout procedure Flood Running the OWS Equipment lock-out, tag-out procedures Departure and/or Arrival

Summary In this Module we:

Examined the definitions of Policy and Procedure. Looked at the signs of ineffective policy or procedure. Looked at a Sample Policy and Procedure. Constructed a procedure and put it to the test.

Citations 1. Why are policies & procedures so important? | HR and Training

http://www.ameinfo.com/55422.html (accessed June 13, 2013). 2. USCG Safety Management System Manual Guidebook,

http://atcvantage.com/docs/US_CoastGuard_SMSGuide.pdf (accessed June 13, 2013). 3. Welling, Grant. Are your Policies and Procedures a Barrier to Growing Your Company? pcg-

services.com (n.p.) Web http://www.pcg-services.com/resources/policies-procedures-barrier-growing-company (accessed June 13, 2013).

4. Why is it important for an organization to have an information Policy? http://wiki.answers.com/Q/Why_is_it_important_for_an_organization_to_have_an_information_policy_What_are_some_important_things_an_organization_must_consider_when_creating_information_policies (accessed June 13, 2013).

5. Enclosed Space Entry - Shipowners Club, http://www.shipownersclub.com/media/198090/enclosed_space_entry.pdf (accessed June 13, 2013)



Module 7

Team Building



Team Building

Terminal Instructional objectives In this module we expect the student to join in a discussion on the elements required for building and maintaining an effective team.

Enabling Objectives This lesson will provide you with the information you will need to know in order to build or maintain an effective team. In order to do this we shall:

Study the pros and cons of some Decision-Making Methods Analyze the Establishment of Team Trust List the Four Stages of Team Development Distinguish Team Roles and Responsibilities Conflict Management Discuss Risky Team Behaviors

Description As a Mariner, you will have the opportunity to serve on many different teams. Some teams are large, like the entire ships staff. Others may be smaller, like a watch team, or a work group. Regardless of the size, for any team to function effectively it must be filled by competent and committed members who are willing to play their part and keep the team working towards a common goal. This does not happen by itself. Team leaders must be able to build trust among team members and know how to leverage the talents of people working on a common task, in complementary roles. The successful execution of the ships goals relies on team leaders who can skillfully guide their teams towards outcomes greater than those possible by any one person working independently.



Team Building

Decision Making Methods When it comes to leading and managing teams the three decision making methods commonly used; see which one applies to you:

1. Leader-made - One person makes the decisions. 2. Leader-made with input - Input is provided by the team, but considered at the

discretion of the leader. 3. Team-made - All team members have a chance to provide input and to have a

say in the final decision. The advantages and disadvantages of each approach can be found in the table below

Advantages Disadvantages Leader-made Quick decisions are made

The decision is direct and to the point

The person making the decision knows what he/she wants

Lack of buy-in from the team may shut down some members

The single leader may not have all the answers, but often times think they do

No diversity of ideas or opinions

Leader-made with Input Group members have greater buy-in

Decisions are made quicker than team decisions

Decisions are made using more information

Decision making can become time consuming

Leader may not use input

Team-made Team members have a sense of empowerment in the decision making process

Team members have a sense of ownership into the process and the final decision

More ideas are generated by the team

Better end product is achieved by considering all possible solutions

Diversity of ideas

Process is time consuming

Increase likelihood of conflict

Some team members may have limited knowledge or experience

Lack of ownership or responsibility may result when team members input is not considered in the final decision



Team Building

Establishing Trust Trust is a critical ingredient for creating and maintaining a high level of performance within a team. Mutual trust requires members of a team to believe they can depend on each other to achieve a common purpose. Trust is not a fact; rather it is a sense of confidence that develops over time. Trust requires time and effort to develop and can quickly be lost. The main elements of trust include a belief in a persons character and competence. (Apprentice Leadership Program1

)

The key ingredients for invoking trust include: Clearly communicate team goals Establish well-defined roles Support and encourage team cooperation Maintain well-defined decision-making procedures Seek balanced participation from all team members Create and follow mutually established ground rules Be aware of group processes and team dynamics Pay attention to peoples concerns and feedback Make team members feel valued Develop a sense of belonging and team pride Give team members a cause they can rally around Focus on short term goals Be Consistent Manage conflict directly Employ performance improvement plans Use action plans to set the course



Team Building

Group Development All group and teams go the through stages of development. Identifying and understanding these stages will help the team leader move through them and create a more cohesive team (Apprentice Program1

Forming

) by recognizing that each of these stages is a natural part of team building process. The four stages of team development identified by Dr. Bruce Tuckman include:

Storming Norming Performing

The table below provides a brief description of the four stages along with suggestions for how a team leader should manage their team at each stage:

Stage Description Forming Team members in the Forming stage will

usually appear tentative and unclear on what is expected of them. The team leader will need clearly communicate required standards and goals, and help to manage the teams expectations.

Storming In the Storming stage team members may become defensive and hostile toward one another as they attempt get consensus on group decisions or exercise personal power. During this phase the team leader must make sure conflicts do not get out of hand, and that individual team members do not become the teams scapegoat.

Norming The Norming stage is characterized by a sense of belonging and a share committed to mutual goals. At this stage the team leader should continue to provide direction and corrective feedback when required.

Performing Teams in the Performing stage are fully functional, self-organized and work well together. The main task of the team leader at this point is to offer support and encouragement and to reinforce and celebrate team achievements.



Team Building

Team Roles In order for teams to function effectively, it is important that everyone understands their roles and responsibilities. Team roles define who will be responsible for what. It is important that every team member is involved and knows the role they play in contributing to the teams goals. The two main roles include

1. team leader 2. team member

The responsibilities for both roles are listed in the table below:

Team Roles and Responsibilities Team Leader Team Member

Give clear directions Ensure team members are acquainted

with each other Create a positive atmosphere Assign simple straight forward tasks Be sensitive to members need for

direction Effectively manage conflict Move towards negotiation and consensus Encourage members to assume more

task responsibility Allow the team to assign their own tasks Encourage the team to review their own

goals and progress Listen and facilitate Participate, consult, inspire Be involved in tasks as needed No Micromanaging Keep communications and information

flowing Reinforce and celebrate achievements Provide vision Demonstrate Leadership

Work cooperatively and cohesively with

fellow team members Be an attentive listener Support each others efforts to do well Differ with others in a constructive manner

when needed Participate equally Be able to give and receive constructive

criticism Be able to negotiate Value others opinions Demonstrate ability to follow



Conflict Management

Conflict 101 A conflict is more than just a disagreement. It is a situation in which one or both parties perceive a threat (whether or not the threat is real). Conflicts continue to fester when ignored. Because conflicts involve perceived threats to our well-being and survival, they stay with us until we face and resolve them. We respond to conflicts based on our perceptions of the situation, not necessarily to an objective review of the facts. Our perceptions are influenced by our life experiences, culture, values, and beliefs. Conflicts trigger strong emotions. If you arent comfortable with your emotions or able to manage them in times of stress, you wont be able to resolve conflict successfully. Conflicts are an opportunity for growth.

When youre able to resolve conflict in a relationship, it builds trust. You can feel secure knowing your relationship can survive challenges and disagreements.



Team Building

Risky Team Behaviors Along with the existence of positive and constructive team roles, negative and destructive agendas can emerge that undermine the ability of individual teams to function and perform adequately (Bednarz2). In some cases these behaviors could cause injury or fatality. Some of these roles might at first appear positive. Lets review some risky mindset (Gasaway3

The New Guy (a.k.a., the new member) ):

The Subordinate (a.k.a., the loyal follower) The Expert (a.k.a., the expert or know-it-all) The Superior (a.k.a., the BOSS!) The Stubborn (a.k.a., the defiant) The Silent (a.k.a., the shy one) The Hero (a.k.a., the unstoppable) The Slacker (a.k.a., the complacent) The Instigator (a.k.a. the puppet master) The Synergist (a.k.a., the like-minded)

The New Guy This refers to the novice Engineer, just starting out in the maritime industry. Intimidated by a comparison of experience this person might not speak up if they doubt their skills. They might see a bad decision being made and not voice their concerns. This is very bad for the safety of the team If you are the starter, its simply a matter of discussing, in a respectful way, your concerns. If you are an officer, initiate the discussion. Be the one to open the dialog about how to speak up and make sure your followers know you genuinely appreciate them helping you by sharing their concerns for safety.



Team Building

Risky Team Behaviors (cont) The Subordinate Loyalty is a subordinate quality coveted by many leaders. Loyalty can be acquired by building trust or by instilling fear. The loyal subordinate who follows out of trust may not question the decision of the leader because there is a level of trust that inhibits the follower from questioning the decision of the leader. If the fear of retribution from the leader exceeds the fear of the consequence of performing the order, the order may be obeyed even if the consequences to the subordinate are catastrophic. (Gasaway3

The Expert ):

Smarty-pants, Know-it-all, Specialist. It is good to have intelligent team members and team leaders but sometimes the expert can be a detriment to situation awareness. An expert is a person who has devoted themselves to acquiring and using a narrowly defined knowledge or skill set. There are two types

1. Fake expert (inflated ego) 2. True expert

The Fake expert will let you down when you need them by possibly giving you wrong information that you use in a crucial decision. They might be just a self proclaimed expert, and if no one else is around to cross check their facts the information you base a decision on may be flawed and even have bad consequences. The true expert while having better information to give in their

specialty, may have a narrow field of vision may cause them to miss vital clues and cues, which is also a danger to their situation awareness. So it is important to check that your expert is a true expert and that the rest of the team is trained to a basic level in all specialty areas.



Team Building

Risky Team Behaviors (cont) The Expert (cont)

To help your expert/team member situation awareness, it can be very beneficial for the specialists to teach the non-specialists a basic level of the special knowledge and for the general team members to feed back to the expert the wider picture (Gasaway3

):

The Supervisor It would be rare for a supervisor with a balanced ego and a healthy self-esteem to possess a dangerously superior mindset. It is the boss who lets their authority get the best of their judgment or a boss who suffers from a feeling of inadequacy (inferiority) that results in a dangerous mindset. When this mindset is put under stress then one of two things could happen

A strong leader would want subordinates to tell them if they were getting things wrong. They know that they can miss things and want the members the team to know that their input and their willingness are valuable in helping to ensure the safety of the team as a whole. A weak leader might run under a paramilitary hierarchy. There is no place for debate or discussion about decisions and orders. They give the orders and the

subordinates job to follow the orders. And if they dont like the order, that is too bad.

The Leader who cannot say NO This Leader may take every project assigned by company or other department with no clear prioritization. They might agree to a project without checking to see if the ship has the correct resources or time to actually get the job done. This can cause the team to be placed under unfair and unrealistic deadlines.



Team Building

Risky Team Behaviors (cont) The Stubborn STUBBORN

1. Having or showing dogged determination not to change one's attitude or position on something, esp. in spite of good arguments or reasons

2. Difficult to move, remove, or cure Synonyms Obstinate - pertinacious - dogged - headstrong obdurate Being obstinate can be used for both good and for evil

Good Stubborn Bad Stubborn Takes no shortcuts on training Staying with proper procedures in spite of pressure to take a shortcut Confident

Cannot see any other perspective than their

Documents

17 ERM Student Manual REv 3 (1)