Human Factor and Organizational Issues (1)

Human Factor and Organizational Issues

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CONSTANTA MARITIME UNIVERSITY

Human Factor and Organizational Issues (Course support)

Constanta


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Content

Introduction .................................................................................................................... 5 1. Human factor ............................................................................................................. 6

Types of human factors ............................................................................................ 6 Human factors engineering ....................................................................................... 8 Human factors engineering/ergonomics model: Elements that enhance human performance and safety .............................................................................. 10

2. Human errors ........................................................................................................... 12 Human characteristics and the working environment ............................................. 12 Addressing human error ......................................................................................... 14

3. Human performance and limitations...................................................................... 18 Human process information .................................................................................... 18 The human senses ................................................................................................. 19 Memory and its limitations ...................................................................................... 20 Managing human performance limitations .............................................................. 21

4. Team development and teamwork ......................................................................... 23 Team types ............................................................................................................. 23 Team building ......................................................................................................... 24

5. Motivation ................................................................................................................. 27 6. Task analysis ........................................................................................................... 30

Action oriented approaches .................................................................................... 30 Cognitive task analysis techniques ......................................................................... 33 Evaluation of Task Analysis Methods ..................................................................... 35

7. Vigilence, checking errors and error recovery ..................................................... 37 The error making process ....................................................................................... 37 The error recovery process ..................................................................................... 37 Team errors and Performance Shaping Factors ..................................................... 38 Shared errors and Performance Shaping Factors .................................................. 39 Failures to detect and Performance Shaping Factors ............................................. 41 Failures to indicate/correct and Performance Shaping Factors .............................. 41 Summary on Team Errors and Performance Shaping Factors ............................... 42

8. Fatigue and workload .............................................................................................. 44 9. Social factors - organizational and group level .................................................... 50

People, technology, environment and organizational factors .................................. 50 Human factors issues in the marine industry .......................................................... 53


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10. Safety culture and situational awareness ........................................................... 55 Safety culture .......................................................................................................... 55 Situational awareness ............................................................................................. 57

11. Human decision making ....................................................................................... 59 12. Comman styles and leadership ............................................................................ 65 13. Organizational issues............................................................................................ 71 14. Organizational change .......................................................................................... 73 Bibliography ................................................................................................................. 79


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Introduction

Over the last 40 years or so, the shipping industry has focused on improving ship structure and the reliability of ship systems in order to reduce casualties and increase efficiency and productivity. Weve seen improvements in hull design, stability systems, propulsion systems, and navigational equipment. Todays ship systems are technologically advanced and highly reliable. Yet, the maritime casualty rate is still high. It is because ship structure and system reliability are a relatively small part of the safety equation. The maritime system is a people system, and human errors figure prominently in casualty situations. About 75-96% of marine casualties are caused, at least in part, by some form of human error. Studies have shown that human error contributes to: 84-88% of tanker accidents 79% of towing vessel groundings 89-96% of collisions 75% of allisions 75% of fires and explosions Therefore, if we want to make greater strides towards reducing marine casualties, we must begin to focus on the types of human errors that cause casualties. One way to identify the types of human errors relevant to the maritime industry is to study marine accidents and determine how they happen. Accidents are not usually caused by a single failure or mistake, but by the confluence of a whole series, or chain, of errors. In looking at how accidents happen, it is usually possible to trace the development of an accident through a number of discrete events. A Dutch study of 100 marine casualties found that the number of causes per accident ranged from 7 to 58, with a median of 23. Minor things go wrong or little mistakes are made which, in and of themselves, may seem innocuous. However, sometimes when these seemingly minor events converge, the result is a casualty. In the study, human error was found to contribute to 96 of the 100 accidents. In 93 of the accidents, multiple human errors were made, usually by two or more people, each of whom made about two errors apiece. But here is the most important point: every human error that was made was determined to be a necessary condition for the accident. That means that if just one of those human errors had not occurred, the chain of events would have been broken, and the accident would not have happened. Therefore, if we can find ways to prevent some of these human errors, or at least increase the probability that such errors will be noticed and corrected, we can achieve greater marine safety and fewer casualties.


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1. Human factors

1.1. Types of human factors

The latest studies on human factors proposed three categories for human factors that contribute to accidents in the offshore oil industry, including tanker operations: individual factors, group factors, and organizational factors (in Figure 1.1). Other researchers focus on individual vs. organizational causes. Researchers have found that although the majority of immediate causes are attributable to individuals (e.g. operating personnel), the majority of contributing, or underlying, factors can be attributed to the organizational context or group dynamics that influence the individual. Similarly, once an accident sequence has begun, organizational influences may allow the sequence to continue, resulting in an accident. Therefore, the culture, incentives, operating procedures, and policies of organizations have important effects on the safety of marine systems.

Figure 1.1. Human factors vs. human errors

Individual human factors. Although most researchers recognize the importance of the organizational safety culture, the role of the individual operator is critical. The competence, perceptual judgments, stress, motivation, and health risks (such as work over-load) of an individual operator are critical to the chain of events that may cause an accident or oil spill. Two of the most recognized and studied individual factors as related to the maritime industry are described here: inadequate knowledge and fatigue. Other individual factors. In some studies were contend that people are basically rational, but their goals and risk attitude may not always match those of the organization, due to policies that may inadvertently encourage undesirable behavior. People typically act to receive awards and avoid negative consequences, but more weight is generally given to potential negative consequences to themselves, such as being


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caught and punished, rather than how specific behaviors may contribute to catastrophic accident risks. Production pressures, an organizational factor, may contribute to risk-taking behaviors, because the potential for reward for high production may outweigh the consequences of the worst-case scenario, especially for activities where that risk seems particularly remote. Another component of individual human factors can be attributed to a lack of preparedness for crises. Operators may be extremely proficient in routine day-to-day operations; however, because crises occur so rarely and are not always well predicted, an operator may be poorly prepared to deal with such an event. Finally, people have a tendency to ignore information that is inconsistent with their beliefs until it becomes irrefutable. This has been cited as a cause for unrealistic optimism in a variety of industries where accident risks are characterized by uncertainty. Only when faced with inevitable, catastrophic consequences do people acknowledge the potential for disaster, at which point intervention may not be possible.

Figure 1 . 2 . Relationship between sleep loss, fatigue, and accidents

Inadequate knowledge. A United States National Research Council study cited inadequate general technical knowledge as the cause of 35% of marine casualties: Mariners often do not understand how the operation works or under what set of operating conditions it was designed to work effectively. In the same study, 78% of mariners ascribed a lack of understanding of the overall system of the ships they work on as a contributing factor to accidents. Moving among different sizes and types of vessels can cause confusion and compromise decision-making abilities if mariners are not familiar with the ship-specific systems. When people take actions that increase the risk of failure, it is often because they have encountered a rare event that is not part of their training or general awareness, and they are unaware of how their actions will affect the system or are unaware that they are contributing to accident risk.


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Mariners are charged with making navigation decisions based on all available information. Too often, we have a tendency to rely on either a favored piece of equipment or our memory. Many casualties result from the failure to consult available information (such as that from radar or an echo-sounder). In other cases, critical information may be lacking or incorrect, leading to navigation errors (for example, bridge supports often are not marked, or buoys may be off- station).

An human factors study by the United States Coast Guard identified the need for automated design approaches that incorporate human factors into the design and use of automated systems, so that operators will understand the concept of operations and form appropriate mental models during initial learning and routine use. The integration of existing equipment and skills with new systems, such as navigation electronics, was identified as especially important. While not having adequate information may cause an individual to make an error, the fact that he or she is not adequately trained for his or her position is reflective of an organizational human factor - in this case, an organizational failure. Group factors. At the group level, the relationships among individuals, the members of a vessel crew, for example, or between a supervisor and subordinate, may influence safety. Group factors may overlap with organizational factors, but in the marine oil transportation industry, the dynamics at the group level, such as crews or duty sections, can be extremely important to overall safety. An important group factor for vessel operations is the atmosphere that exists within operational units, such as a vessel crew. The maritime tradition of iron men on wooden ships has been cited as a contributor to risk-taking behavior. Overconfidence or bravado may contribute to actions that violate a companys stated safety policies. Pressure from the organization or company to meet unrealistic demands with the number and qualifications of available personnel may encourage irresponsible or risk-taking behavior as crew stretch to meet demands from supervisors. Reporting channels are also critical to safety considerations at the group level. Informal communication channels can be as important as or more important than formal ones for encouraging open and proactive communication of safety concerns. Direct communications between operators can be a powerful source of organizational memory and can contribute significantly to accident prevention, especially in regards to maintenance practices. In the marine transportation industry, this kind of organizational knowledge is best realized onboard vessels where crew members are retained long-term. With new crewmembers or trainees, it is extremely important that their work be subject to diligent oversight and inspection, as close supervision can have the dual benefits of educating employees while minimizing risks.

1.2. Human factors engineering

Understanding human capabilities and limitations is a primary means to overcome opportunities for human error. A significant amount of research has been conducted to identify the factors that shape and influence human behavior and performance in a work environment. These factors include such diverse issues as:

How the workplace is designed Human-system interfaces (e.g., ease of use and accessibility) How employees are selected for particular jobs (e.g., knowledge, skill, and ability

requirements)


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How job aids such as operational or maintenance manuals or procedures are written and/or illustrated

Human-computer interaction Physical, visual, and auditory access for maintenance and operation How company policies and practices are presented to, and enforced on, the work force Training personnel and a myriad of other human behavioral and psychosocial issues that

affect personnel performance. The application of the results of this research to the design of tools, equipment, tasks, workplaces, procedures, hardware, software, the working environment, and even to company/organizational design, is known as Human Factors Engineering (HFE). Those who practice in this discipline are called Human Factors Engineers, Human Factors Professionals, or Ergonomists. HFE is a unique and specialized engineering discipline that combines specific academic education and experience of the humans behavioral (i.e., social, physiological, psychological) and physical (i.e., size, strength, endurance) capabilities and limitations with that of the traditional engineering requirements to produce a human-system interaction that maximizes the best of both. This discipline allows for the human and system to work safely and efficiently. HFE has broad areas of specialization and applicability. Therefore, for the purpose of these Guidance Notes, the focus of HFE is a domain of specialization largely concerned with human anatomical, anthropometric, physiological, behavioral, and biomechanical capabilities and limitations as they relate to human activity and the human-technology environment. There are several formal definitions of HFE, including the following by the International Ergonomics Association:

The scientific discipline concerned with the understanding of the interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and methods to design in order to optimize human well-being and overall system performance

Ergonomics, which is often synonymous with HFE in Europe, tends to focus on the biomechanical, physiological, and anthropometric capabilities and limitations that humans possess as they relate to the design of systems. The general approach of HFE in mitigating human error in the workplace as a means to reduce risk to human performance and safety is as follows (in order of preference):

Design the workplace so that human error cannot occur. Design the workplace so that if an error does occur the consequences can be mitigated to

an acceptable level. Provide training to prevent the error. Provide hazard identification labels to warn personnel of possible hazard. Write a procedure or create a company policy to attempt to prevent the error from

occurring. Proper design is the preferred approach, as it is the most preventative measure to take for workplace design.

The driving force behind the inclusion of HFE in the design of any offshore installation is that efficient and safe operational performance starts with good design. To conclude, integrating HFE design practices and principles that reflect human capabilities and limitations into a design project, as discussed in these Guidance Notes, will help result in installations that are more cost-effective, safer, and easier to operate and maintain. The earlier that HFE is integrated into a design cycle, the more cost-effective the HFE effort will become and the greater the potential impact on overall business performance.


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1.3. Human factors engineering/ergonomics model: Elements that enhance human performance and safety

Figure 1.3 encapsulates four high-level elements that influence safety and efficiency in job performance:

o vessel or offshore installation design and layout considerations, o workplace ambient environmental elements, o management and organizational issues related to operations, and o the personnel who operate the vessel or offshore installation.

Insufficient attention to any of these elements may adversely affect safety, productivity, and efficiency. It is important that these elements be at the core of any HFE implementation effort. The structure and selection of activities described herein help promote this model and associated elements.

Figure 1.3. Human factors engineering/ergonomics model

Management and organizational considerations. This aspect of the model covers management and organizational considerations that impact human performance and safety throughout a systems lifecycle. The implementation of an effective design and safety policy that includes human factors engineering and ergonomics will help create an environment that helps to minimize risks and reflects a good corporate safety culture for both system operations and to personnel. The commitment of top management is essential if this policy is to succeed. This commitment throughout the lifecycle means that it begins in early development with adequate resources to address HFE in design as well as the policy and personnel management required once the installation is operational. A study performed by the University of California at Berkeley found that 80% of all offshore accidents in U.S. waters were due to human error, and 80% of those occurred during operations. In 1995, the USCG launched a major initiative, called Prevention-Through-People (PTP), to reduce human error as a causative factor in maritime accidents when its research found that from 75-90% of all at-sea accidents were human-induced. This report also introduced the term human element to describe those factors which cause or contribute to human error. The


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preceding statistics illustrate the importance of the management considerations and commitment to implementing a comprehensive HFE program from inception through operations in order to achieve the human performance and safety goals. Design and layout considerations. Design and layout considerations include those related to the interfaces between personnel (users, operators, maintainers) and equipment or systems. Examples of interfaces include: controls, displays, alarms, video-display units, computer workstations, labels, ladders, stairs, and overall workspace arrangement. Designers and engineers should consider the ultimate users cultural, psychological, and physiological capabilities, limitations, and needs that may impact work performance. In terms of cultural and regional influences on personnels behavioral patterns and expectations, this includes understanding that there are different cultural meanings with regard to color, control movement compatibility, or that bulky clothing is needed when using equipment in cold weather. As a result, hardware and software design, arrangement, and orientation must match the associated characteristics and expectations of the users. Awareness of potential physical differences (e.g., male/female, tall/short, Northern European versus Southeast Asian) is required so that the design, arrangement, and orientation of the work environment will reflect the full range of personnel given the characteristics of the users and the required tasks. The likelihood of human error may be increased if these factors are not considered in the workplace design. Additional training, operations and maintenance manuals, and more detailed written procedures cannot adequately compensate for human errors induced by poor design. Ambient environment considerations. The ambient environment addresses the habitability and occupational health characteristics related to human whole-body vibration, noise, indoor climate, and lighting. Substandard physical working and living conditions can undermine effective performance of duties, causing stress and fatigue. For example, working conditions that include high noise workplaces may lead to ineffective voice communications. Ambient environmental considerations also include the appropriate design of living spaces that assist in recovery from fatigue. Considerations related to people. Personnel readiness and fitness-for-duty are essential for safety. These are especially important as tasks and equipment increase in complexity, requiring ever-greater vigilance, skills, and experience. The following factors should be considered when selecting personnel for a task:

Knowledge, skills, and abilities that stem from an individuals basic knowledge, general or specialized training, and experience

Bodily dimensions (anthropometrics) and characteristics of personnel such as stature, shoulder breadth, eye height, functional reach, overhead reach, weight, and strength

Physical stamina; physiological capabilities and limitations, such as resistance to and freedom from fatigue, visual acuity, physical fitness, and endurance

Psychological characteristics, such as individual tendencies for risk-taking behavior, risk tolerance, and resistance to psychological stress.

Choosing the correct personnel for the job or task is critical to overall safety and performance. Selection of personnel who do not have the requisite skills, training, or tools can adversely affect safety by reducing personnel efficiency and increasing the potential for error.


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2. Human errors

It has been estimated that up to 90% of all workplace accidents have human error as a cause1. Human error was a factor in almost all the highly publicised accidents in recent memory, including the capsizing of the Herald of Free Enterprise, Chernobyl and Three-Mile Island incidents and the Challenger Shuttle disaster. In addition to these acute disasters some industries, notably health-care, experience long-term, continuous exposure to human error. The costs in terms of human life and money are high. Placing emphasis on reducing human error may help reduce these costs.

2.1. Human characteristics and the working environment

In order to address human factors in workplace safety settings, peoples capabilities and limitations must first be understood. The modern working environment is very different to the settings that humans have evolved to deal with. Below are provided details on the main factors involved, including:

Attention - the modern workplace can overload human attention with enormous amounts of information, far in excess of that encountered in the natural world. The way in which we learn information can help reduce demands on our attention, but can sometimes create further problems.

Perception - in order to interact safely with the world, we must correctly perceive it and the dangers it holds. Work environments often challenge human perception systems and information can be misinterpreted.

Memory - our capacity for remembering things and the methods we impose upon ourselves to access information often put undue pressure on us. Increasing knowledge about a subject or process allows us to retain more information relating to it.

Logical reasoning - failures in reasoning and decision making can have severe implications for complex systems such as chemical plants, and for tasks like maintenance and planning.

Attention. Attention on a task can only be sustained for a fairly short period of time, depending on the specifications of the task. The usual figure cited is around 20 minutes, after which, fatigue sets in and errors are more likely to occur. This is why air traffic controllers are obliged to take breaks from their attention-intensive work at regular intervals. However, there are a number of other reasons why the attentional system is responsible for errors. These include: Information bottleneck it is only possible to pay attention to a small number of tasks at once. For example, if an air traffic controller is focussed on handling a particular plane, then it is likely that they will be less attentive to other aspects of safety, or other warning signals (although this depends on the nature of the signal). Habit forming - if a task is repeated often enough, we become able to do it without conscious supervision, although this automatisation of regular and repetitive behaviour can force us into mistakes. Perception. Interpreting the senses - one of the biggest obstacles we face in perceiving the world is that we are forced to interpret information we sense, rather than access it directly. The more visual information available to the perceiver, the less likely it is that errors will be made. Bearing this in mind, systems that include redundant information in their design may cause fewer


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accidents. An example of this was the change in electrical earth wire colour coding in the 1970s to include not only colour, but also a striped pattern. Signal detection - the more intense a stimulus (such as a light or a noise), the more powerful the response elicited (such as brain activity or a physical movement). This has implications for the way danger signals are perceived at work. For instance, the order in which the severity of danger is signalled on rail tracks is single red (most dangerous), followed by single yellow, then double yellow and finally green (no danger). Research suggests there may be some merit in swapping the order of the yellow signals, as the double yellow is more intense and thus more noticeable than the single yellow signal. However, this point must be offset against the fact that the current system provides automatic mechanical failsafe if a yellow bulb blows, and the psychological notion that double yellow serves a useful role as a countdown to the single. Memory. Capacity - short-term memory has an extremely limited capacity. In general, people can remember no more than around seven individual items at a time. This has safety implications in areas such as giving new workers a set of instructions to follow from memory or attempting to remember the correct sequence of procedures within a new task. However, trained individuals are able to retain larger chunks of information in memory. For example, chess grandmasters can remember the location of more pieces on a chessboard than can a novice because they see the pieces not as single units, but as parts of larger conceptual units which form coherent wholes. Accessibility - even when items are stored in memory, it is sometimes difficult to access them. There has been much research into the ways in which recall of information can be improved. For example, research has shown that people are much more likely to remember information if they are in similar conditions to when they encoded the information. This was illustrated in a study involving divers who were given lists of words to learn on dry land and underwater. Words learned on the surface were best recalled on the surface, and those learned underwater best recalled underwater. This has implications for training programmes, where albeit under less extremely contrasting situations, staff trained in an office environment may not be able to remember relevant details on the shop floor. Levels of processing - another way in which information can be more reliably remembered is to learn it at greater depth. For instance, if it is necessary to remember lists of medical symptoms, then it helps to understand more about the conceptual framework behind the list. If only the surface features (such as the words on the list) are remembered, then there is a higher chance of information being forgotten. Logical reasoning. Humans are not very good at thinking logically, but in technological situations, logical procedures are often necessary (for example, troubleshooting a complex system which has broken down). Illogical behaviour is a common source of error in industry. During the Three Mile Island incident, two valves which should have been open were blocked shut. The operators incorrectly deduced that they were in fact open, by making an illogical assumption about the instrument display panel. The display for the valves in question merely showed that they had been instructed to be opened, whereas the operators took this feedback as an indication that they were actually open. Following this, all other signs of impending disaster were misinterpreted with reference to the incorrect assumption, and many of the attempts to reduce the danger were counterproductive, resulting in further core damage.


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2.2. Addressing human error

The types of problems caused by these factors are often unavoidable. In certain situations, human beings will always make mistakes, and there is a limit to what can be done to modify behaviour itself. As it is inevitable that errors will be made, the focus of error management is placed on reducing the chance of these errors occurring and on minimising the impact of any errors that do occur. In large-scale disasters, the oft-cited cause of human error is usually taken to be synonymous with 'operator error' but a measure of responsibility often lies with system designers. For instance, during the Second World War, designers attempted to introduce a new cockpit design for Spitfire planes. During training, the new scheme worked well, but under the stressful conditions of a dogfight, the pilots had a tendency to accidentally bail out. The problem was that the designers had switched the positions of the trigger and ejector controls; in the heat of battle, the stronger, older responses resurfaced. Recent research has addressed the problem of how to design systems for improved safety. In most safety-critical industries, a number of checks and controls are in place to minimise the chance of errors occurring. For a disaster to occur, there must be a conjunction of oversights and errors across all the different levels within an organisation. This is shown in the figure below from which it is clear that the chances of an accident occurring can be made smaller by narrowing the windows of accident opportunity at each stage of the process. Factors such as training and competence assurance, management of fatigue-induced errors and control of workload can eliminate some errors. But errors caused by human limitations and/or environmental unpredictability are best reduced through improving system interface design and safety culture. System design. A good system should not allow people to make mistakes easily. This may sound obvious, but all too commonly system design is carried out in the absence of feedback from its potential users which increases the chance that the users will not be able to interact correctly with the system. A set of design principles has been proposed which can minimise the potential for error. Accurate mental models. There is often a discrepancy between the state of a system and the user's mental model of it. This common cause of erroneous behaviour arises because the user's model of the system and the system itself will differ to some extent, since the user is rarely the designer of the system. Problems that can arise as a result of this discrepancy are illustrated by the Three Mile Island incident. In this incident, the system had been designed so that the display showed whether the valves had been instructed to be open or closed. The most obvious interpretation to the user was that the display reflected the actual status of the system. Designers need to exploit the natural mappings between the system and the expectations and intentions of the user.


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Figure 2.1. The Swiss cheese model of accident causation

Another example of the importance of user familiarity with the working system is demonstrated by a laboratory study which examined how useful it was to give staff an overview of a fictitious petrochemical plant's structure and day-to-day functioning. One group was given rules about which buttons to press if a dangerous situation arose; another was given the rules and an overview of the workings of the plant. Both groups were equal in their ability to deal with the expected problems, but when new problems arose, only the group which understood the plant's functioning were able to deal with the situation. Managing information. As our brains are easily distracted and can overlook necessary tasks, it makes sense to put information in the environment which will help us carry out complex tasks. For example, omission of steps in maintenance tasks is cited as a substantial cause of nuclear power plant incidents. When under time pressure, technicians are likely to forget to perform tasks such as replacing nuts and bolts. A very simple solution to this problem would be to require technicians to carry a hand-held computer with an interactive maintenance checklist which specifically required the technician to acknowledge that certain stages of the job had been completed. It could also provide information on task specifications if necessary. This would also allow a reduction in paperwork and hence in time pressure. Reducing complexity. Making the structure of tasks as simple as possible can avoid overloading the psychological processes outlined previously. The more complex the task specifications, the more chances for human error. Health-care systems are currently addressing this issue. With the that a leading cause of medical error in the United States was related to errors in prescribing drugs, a programme was undertaken to analyse and address the root causes of the problem. A computerised system of drug selection and bar-coding reduced the load on memory and knowledge on the part of the prescriber, and errors of interpretation on the part of the dispenser, resulting in an overall reduction in prescription errors. Examples such as this emphasise the fact that reducing task complexity reduces the chance of accidents. Visibility. The user must be able to perceive what actions are possible in a system and furthermore, what actions are desirable. This reduces demands on mental resources in choosing between a range of possible actions. Perhaps even more important is good quality feedback


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which allows users to judge how effective their actions have been and what new state the system is in as a result of those actions. An example of poor feedback occurred during the Three Mile Island incident; a poorly-designed temperature gauge was consistently misread by experienced operators (they read 285 degrees Fahrenheit as 235 degrees), which led them to underestimate the severity of the situation. Constraining behavior. If a system could prevent a user from performing any action which could be dangerous, then no accidents would occur. However, the real world offers too complex an environment for such a simplistic solution: in an industrial operation, a procedure which could be beneficial at one stage in the process may be disastrous at another. Nevertheless, it is possible to reduce human error by careful application of forcing functions. A good example of a forcing function is found in the design of early cash machines. People used to insert their card, request cash, take it and walk away, leaving their cash card behind. It was a natural enough response, as the main objective of the action had been achieved: obtaining money. The task was thus mentally marked as being complete before all necessary stages of the transaction had been carried out. After a great deal of thought, the systems designers came up with a very simple solution which has been effective ever since: as the target objective of the task was to obtain money, placing this stage at the very end of the transaction would avoid the problem. Hence, the card is now given back before the money is. Functions such as this relieve the user of the responsibility of deciding what actions are appropriate whilst interacting with the system, and are very effective in preventing dangerous incidents. Design for errors. In safety-critical systems, such as nuclear power plants, numerous safety systems are in place which can mitigate accidents. One approach is defence in depth (implementing many independent systems simultaneously); another is fail-to safe state system design. However, designers must assume that mistakes will occur, and so any useful system must make provision for recovery from these errors. Another consideration is that the design should make it difficult to enact non-reversible actions. Although this is an underlying principle of design, it needs to be applied carefully. For instance, most home computers have a recycle bin or trash folder, in which all deleted files are stored. They are recoverable from here, but when this folder is emptied, files cannot be recovered at all. Attempts to empty this folder result in a message asking the user to confirm deletion. The problem is that the user is often asked to confirm such requests, and, learns to associate the appearance of the warning message with the pressing of the 'OK' button. The result is that the pop-up messages may not be read, and on occasion, files are accidentally destroyed. A safer option would be to use this type of pop-up box less regularly, and to require different user input each time. Standardisation. When systems are necessarily complex but have been made as accessible and easy to use as possible and errors are still being made, then standardisation is sometimes used as an attempt to make the situation predictable. It has been suggested that medicine is one of the areas most amenable to standardisation. For instance, resuscitation units in accident and emergency hospitals vary considerably in their design and operation. This diversity, coupled with the movement of staff between hospitals, mean that errors can be made and delays occur. Another example where standardization might be of use in medicine is across different brands of equipment, since staff often do not have training in all the available designs. If all hospital equipment had standard placement and design, then all staff would be able to locate and operate equipment with ease. One problem with standardisation is that if any advances in design or usage are made, then it is a very costly process to re-implement standardisation across all departments of an industry. Also, a standardised system may be ideal for one set of tasks, but very inefficient for another set. Such


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practical considerations have tended to limit the application of standardisation as an approach for reducing human errors. User-centred design. Another basic principal of design is that it should be centred around the user at all stages from initial conception, through evolution and testing, to implementation. In practice however, systems designers are often given a brief, create the system and impose it upon the users without appropriate feedback. This can result in unexpected system behaviour and over-reliance on manuals which themselves have been written by the system designers from their own perspective. Systems designed in this way will be opaque to the end user, and this can hinder effective interaction. Designers of computer interfaces often fall into this trap. Safety Culture. Attribution of accidents to human failures at the sharp end of an industry may not provide a full picture of all the factors involved. The management of the organisation must also take responsibility for decisions which affect the safe functioning of the organisation as a whole. Unwise decisions at this level are more difficult to link directly to an accident, as they are often implemented well before an accident occurs, and they do not make their presence urgently felt. Good decisions at this level can create a culture of safety which can remove the precursor conditions for accidents or ameliorate their consequences. Safety Culture is a term that was first introduced after the Chernobyl disaster in 1986. The safety culture of an organisation is the product of the individual and group values, attitudes, competencies and patterns of behavior that determine the style and proficiency of an organisations health and safety programmes. A positive safety culture is one in which shared perceptions of the importance of safety and confidence in preventative measures are experienced by all levels of an organisation. According to the Health and Safety Executive (the statutory body that ensures that risks to health and safety from work activities are properly controlled), factors that create this positive culture include:

leadership and the commitment of the chief executive; a good line management system for managing safety; the involvement of all employees; effective communication and understood/agreed goals; good organisational learning/responsiveness to change; manifest attention to workplace safety and health; a questioning attitude and rigorous and prudent approach by all individuals.

If one or more of these factors is lacking, an organization may be prone to corner-cutting, poor safety monitoring, and poor awareness of safety issues. In these settings, errors are common and disasters more probable. Impoverished safety culture contributed to major incidents such as the Herald of Free Enterprise disaster and a number of recent rail crashes. It has also been found that workers in poor safety cultures have a macho attitude to breaking safety rules, and tend to ascribe the responsibility of safety to others. Human error is inevitable. Reducing accidents and minimising the consequences of accidents that do occur is best achieved by learning from errors, rather than by attributing blame. Feeding information from accidents, errors and near misses into design solutions and management systems can drastically reduce the chances of future accidents. Hence, studying human error can be a very powerful tool for preventing disaster.


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3. Human performance and limitations

To understand human performance fully, the way we attend to things, perceive, think, remember, decide and act, we first need to understand how human beings process information, how we use our brains. Operational personnel onboard make many decisions every day, and perform vital safety-critical tasks. Information processing is fundamental to doing these effectively.

3.1. Human process information

Human beings basically process information in five stages. Stage 1: Gathering information. First we must gather information. We do this by using our senses (sight, hearing, touch or smell) to collect information using our receptors, which transform information into sensations. Stimuli can either originate from an external source such as sound, or from an internal one, such as thirst or hunger. Stage 2: Perception or assessment. Once we have gathered this information, we must make sense of it. This involves perception and assessment, arguably the most important stage in the whole process. Our brain gives the information an initial once-over to see whether it is meaningful. At this point we must satisfy our human need to understand our environment. To do so we rapidly create an internal model (like a pattern) with which we are comfortable. The resulting model or pattern is influenced in two ways: by the raw sensory information we perceive; and either by previous experience, or our current expectations. Here we are most vulnerable to being fooled either by the information itself, or by our own expectations, our eagerness to make the input fit what we have seen before. So, depending on our interpretation, our brain takes preliminary steps to work out how the information is to be dealt with. If our brain has seen it all before and it is commonplace, the information is directed via the automatic program path. If the information is new or complex, our brain assigns it to the full conscious evaluation/decision route. Stage 3: Evaluation and decision making. If the information is complex or new, our brains will deal with it by giving it full and conscious attention. We may make the decision immediately, or store the information for a later decision. This will require the use of memory. Our initial evaluation may show that the input is familiar, so we can deal with it using well-known procedure or method that has worked before. Doing so will still require a small amount of our conscious attention, but for the most part of our response is directed automatically. On the other hand, our initial evaluation might be that this new information is complex or unfamiliar. When this occurs, we have to think more deeply (apply significant cognitive resources) to resolve the situation. Quite often this will require such a level of concentration and brainpower that our ability to attend to other matters will be reduced or even disappear. Stage 4: Action/response. Our action or response occurs either consciously, with full awareness, or subconsciously using our automatic programs. If it is performed consciously, we act and/or speak with full attention. If it is performed subconsciously, we act as if we are on automatic pilot. Visualize an automatic task you can perform while doing other things, for example, driving a car while maintaining a conversation. But if the driving task becomes more difficult, such as attempting to parallel park in a particularly tight spot, our brain will revert to the 100 per cent full-attention requirement, and we stop our conversation. So while we can do more than one thing at a time, our brain is limited by being able to process only one thing at a time.


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Stage 5: Feedback. The final stage is feedback, which allows us to confirm that what we are getting is what we are expecting. Feedback is not just a one-time deal. It occurs continuously throughout the various stages of information processing to ensure the information we are receiving continues to fit our expectations. The feedback stage provides the opportunity for:

Clarifying details of the information; If need be, seeking out additional information; Refining the information; Making small or large corrections with our actions and/or responses; Identifying emerging hazards.

The whole process is repeated as often as necessary, so that either the status quo is retrained, or necessary changes are implemented. When performing any skilled task we continuously monitor both environment and the consequences of our action to form a closed loop feedback system. This provides us with valuable opportunities to assess both emerging errors and hazards. Identifying errors in a timely manner means that corrections can be made, and ensures the action continues as intended. The mariners should have a basic awareness and understanding of how individuals process information. This helps to better understand and accept error in ourselves and in others. This understanding of information processing is particularly useful when analyzing errors, as it helps us to determine whether they are the consequence of one, or a combination of, the following:

Deficiencies in receiving stimuli/information through our senses (not enough information);

Deficiencies in perception/assessment of the information (not deciphering the information accurately);

Deficiencies in the evaluation and decision-making processes; Failure to monitor or respond to the feedback properly; Effect of external factors detrimental to the process overall, such as excessive workload

or fatigue. High workload, and periods with a high volume of information to be processes in a short timeframe, can cause information overload. This may lead to degraded performance and an increased likelihood of error.

3.2. The human senses

Vision. Vision is vital in maritime activities, think of the number of activities under visual supervision. Vision can be improved by ensuring you have appropriate environmental conditions, like illumination of working area, and ensuring that protective eyeware is clear and suitable for use when is necessary. An individuals lack of colour discrimination, or defective color vision, may make it difficult to distinguish between red and green. This can lead to error in tasks where color discrimination is necessary. Hearing. Continuous exposure to high levels of noise can be very fatiguing. It affects cognitive tasks such as memory recall. Whenever possible, you should try to remove or eliminate the source of noise, rather than attempting to reduce it by such things as wearing ear protection. In noisy environments, use appropriate communication headsets where possible, bearing in mind that ear plugs and headsets may restrict you from hearing warnings from other team members, or being aware of approaching hazards. If you are wearing headsets or ear defenders, exercise caution and keep a very good lookout.


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Touch. Touch is a vital sensory input especially for engineers, as components are often fitted and removed within very confined spaces, with limited visual cues. This means the engineer often has to rely on feel when fitting and /or removing components. Working in a confined space also increases the risk of error, because of reduced dexterity, lack of visibility, and limited space for tools and lighting. These tasks may also require the use of extensive personal protective equipment such as heavy gloves, which will reduce your sensitivity to touch.

3.3. Memory and its limitations

Memory is the ability to store and retrieve information, and is part of our normal learning process. It allows us to develop consistent responses to previously memorized data. We compare sensory data so that we can decide what to do, based on our previous experiences. Because of this, our memory stores are vital to the decision-making process. It is generally agreed we have three types of memory: sensory memory, short-term memory, long-term memory. Sensory memory. Our sensory memory only retains information for a second or two; for example, an image or photograph may be retained briefly before it is overwritten by something new. Short-term memory. Our short-term memory allows us to store information long enough to use it, hence why we often call it our working memory. Short-term memory holds information for about 15-30 seconds. Information in short-term memory can be lost very quickly through interference, distraction, or simply by being replaced with new information. The short-term memory can be improved by:

Mental repetition one way to increase our ability to recall information from short-term memory is to revise it regularly to keep it top-of-mind.

Chunking this involves putting gaps between, or grouping, three to four letters or digits. Chunks are much easier to remember than a long, unbroken string.

Linking link the data from short-term memory to something you know from your long-term memory.

Record the data the best way to be able to ensure accurate recall from short-term memory is to write information down for future reference.

Long-term memory. Our long-term memory enables us to store a vast amount of information. It stores general information, factual knowledge, and memories of specific events. Long-term memory is classified in two types, semantic memory and episodic memory. Semantic memory. Semantic memory is our store of factual knowledge about the world, such as learnt concepts and relationships. It does not relate to time and place, but rather refers to the rules by which we understand the things around us. This type of memory involves knowledge associated with data, skills, knowledge and things we are able to do for a purpose. It is our memory for meaning. It is generally believed that once information has entered semantic memory, it is never lost. Occasionally, it may be difficult to locate, but it is always there. Episodic memory. Episodic memory refers to our store of events, places and times, and may include people, objects, and places. It is almost automatic, allowing us to place our experiences in context. The improvement of the long-term memory can be done using:

Pre-active the knowledge think about the procedure before carrying it out. Go through it in your mind and mentally rehearse the steps you are going to perform.

Use visual imagery to learn new information information can be remembered by associating it with a familiar place or person. This might sound a little out there, but


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visual imagery is a powerful memory aid. In general, the weirder or more bizarre the association, the more likely you are to remember it.

Use physical context you remember information better if you learn it in the actual place in which you will apply this skills. This is why learning emergency evacuation drills is better onboard than in the classroom, and why practicing techniques using a simulator is more effective for knowledge transfer.

Ask questions do not just study material by re-reading it, but by asking yourself questions, so the information is more deeply encoded. For example, under what circumstances would I use this information? If I dont remember the information what could happen?

Information processing characteristics. Our information processing system is essentially a single pipeline where information goes in at one end; is processed sequentially; and eventually comes out at the other end. The information is processed centrally and in the sequence it is received. This means that high-priority or important information may not necessarily be processed first. All processing of information uses part of our limited capacity, so we can easily top out with information overload. In other words, we can take in only so much at any given time. New information can easily replace old information, particularly if the information is held in our short-term memory. Preoccupation, fatigue and stress can reduce information processing capacity and therefore performance. We tend to be most reliable under moderate levels of workload that do not change suddenly and unpredictably. When workload is excessive, the likelihood of human errors is increased. High workload and times when a high volume of information must be processed in a short time can cause performance to decrease dramatically.

3.4. Managing human performance limitation

The senses can be affected by personal protective equipment, or by extremes of stimulus such as low light or excessive noise. Before to begin any activity should consider how protective equipment might affect whether you complete the task successfully. Maritime activities require a reasonable standard of eyesight. To ensure good eye health, have frequent eyesight checks. Colour discrimination is also important, especially if the tasks are to be performed in low or poorly lit areas. Colds, flu and ear infections can affect our hearing capability. Generally, we have poor control over vestibular input. Use communication equipment such as headsets in noisy environments. Continued exposure to very loud noise leads to fatigue and therefore a higher potential for error. Our attention mechanism is limited, once its capacity is exceeded, performance will degrade. It is important therefore, that physical and mental workloads are maintained within reasonable levels. It can also be difficult to maintain attention for long periods on complex tasks. Think about scheduling appropriate breaks during the task, and ensuring workload is maintained at an appropriate level. It is very easy for our perception to be fooled, for example through visual illusions. Our assumptions can also lead us to an incorrect perception. One example of this is carrying out an inspection. The person in charge is normally checking to ensure that everything is correct. Because of this can sometimes see what expect to see. In reality, is expected to find something wrong, rather than simply checking that everything is as expect it to be. Effective decision making for seafarers starts with good situational awareness and a realistic assessment of the data and/or feedback. The next step is evaluating your available options and selecting and implementing the best/safest/most efficient option. This is not simply a one-off or stand-alone process, but rather a continuous cycle involving the updating of situational


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awareness, the evaluation of the appropriateness (or otherwise) of the decision, and coming up with, (and assessing) alternatives where necessary. Because our memory is fallible, it is vital that we refer to the manuals/data etc. rather than relying on recall from memory. This applies even if the information to be remembered or recalled is relatively simple. If you are at all ensure of the memorized information, check it. Noting something down temporarily can avoid the risk of forgetting, (or confusing) information, but using personal notebooks to store this information long term is dangerous, as that data is not amended and can rapidly become outdated. Use appropriate checklists to help with tasks requiring a number of independent steps and mentally rehearse the task before you start, that will help you recall its individual task elements. There is more chance of making errors if the task involves new steps. Error can also result from wrong perceptions of the available information or sensory input. To avoid this, carry out each task as if it were the first time, and before you start the task, mentally rehearse procedures and ask others how appropriate your plan is. If the task is difficult, or has an unusual and unexpected outcome, stop and review the situation and, where necessary, ask for help or clarification. Experience and regular supervision is also vital here in order to interpret feedback for personnel with limited experience, or those under training. In some activities, incorrect actions or errors may not give instant feedback. New tasks or incomplete feedback can lead to incorrect interpretation. To assess the feedback you have received accurately, you need an internal reference to a learnt standard. For this reason, inexperienced personnel, or personnel under training, require high levels of guidance and supervision, as they may not have the required store of experience in their long-term memory to accurately assess the feedback received. Take the time to evaluate all feedback during a task, especially when the feedback is different to what is expected. Regrettably feedback or poorly conducted activity may take the form of a catastrophic failure. Sometimes the fault can lie dormant in the system for a considerable time.


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4. Team development and teamwork

Many researchers state the importance of well-functioning teamwork in managing risk and error. A study conducted in maritime sector stated that the shipping industry is itself an error-inducing system, because of its distinctive characteristics (i.e. the structure of the industry, international regulations, economic pressure, and the social (hierarchical) organization on board the vessels). The potential for change lies in the human relations, and in the importance of facilitating teamwork. Teamwork is a crucial factor in affecting safe performance. The crew should be trained to work as a team, and the equipment should be designed to maintain teamwork. According to this study the key factors in teamwork that facilitates safety in the shipping industry are monitoring, speaking up when necessary, sharing and checking the teams mental models, and having a shared responsibility. But what constitutes a team, and what is teamwork? In the literature an inconsistency in definitions and explanations of team and teamwork is evident. One of the most common definitions of a team is: two or more individuals with specified roles interacting adaptively, interdependently, and dynamically toward a common and valued goal. In addition, a team is often characterized as having heterogeneous and distributed expertise. A team can also be a subgroup of a bigger team. Teamwork may be defined as a set of interrelated thoughts, actions, and feelings of each team member that are needed to function as a team and that combine to facilitate coordinated, adaptive performance and task objectives resulting in value-added outcomes.

4.1. Team types

Teams are complex in nature, and there is a lack of consensus around the typology of teams. Some researchers proposed integrated teamwork skill dimensions, that is supposed to be common for all types of teams. In general, previous research tends to share this focus on teams: that there are factors common for all team types. This research does not distinguish between the different types of work that teams perform, and act as if one common model is applicable for all. However, there is reason to assume that there are different types of teams working within the same organization or in different organizations and domains. Another study identified different team types based on the kind of work and tasks the teams are engaged in. In different team types, factors relevant for team performance will vary. Also was argued that there is a division between team specific factors, team generic factors, task specific factors, and task generic factors. Team and task generic factors are factors that can be applied across team types. Team and task specific factors, on the other hand, depend on team type characteristics and team members. The Big Five in teamwork Model. As previously mentioned, in different organizations there are various types of tasks and teams. Nevertheless, was claimed that there are several common features that facilitate teamwork across domains, team goals, and tasks. Based on this review they derived the Big Five in Teamwork Model (Big Five model), a model that consists of five core components of teamwork and three coordinating mechanisms (eight components). The three coordinating mechanisms are necessary to get the optimal value of the core components. The factors of teamwork in the Big Five model are team leadership, mutual performance monitoring, backup behavior, adaptability and team orientation. The coordinating mechanisms are shared mental models, mutual trust, and closed-loop communication. Some of these factors are very similar to the factors important for safe teamwork in the shipping industry.


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The following are the definitions of the five factors in the Big Five model: Team leadership: The ability to direct and coordinate the activities of other team

members, assess team performance, assign tasks, develop team knowledge, skills, and abilities, motivate team members, plan and organize, and establish a positive atmosphere.

Mutual performance monitoring: The ability to develop common understandings of the team environment and apply appropriate task strategies to accurately monitor teammate performance.

Backup behavior: The ability to anticipate other team members needs through accurate knowledge about their responsibilities. This includes the ability to shift workload among team members to achieve balance during high periods of workload or pressure.

Adaptability: The ability to adjust strategies based on information from the environment through the use of backup behavior and allocation of intrateam resources. Altering a course of action or team repertoire in response to changing conditions (internal or external).

Team orientation: The propensity to take others behavior into account during group interaction and the belief in the importance of team goals over individual members goals.

The definitions of the three coordinating mechanisms are as follows: Shared mental models: An organizing knowledge structure of the relationships among

the task the team is engaged in and how the team members will interact. Mutual trust: The shared belief that team members will perform their roles and protect

the interests of their teammates. Closed-loop communication: The exchange of information between a sender and a

receiver irrespective of the medium. In different studies was acknowledged that a teams engagement in the factors and the coordinating mechanisms (components) will vary in different tasks as the teams get the experience of working together over time. Nevertheless, they proposed that the coordinating mechanisms will have minimal variance across team type or team task. Shared mental models are considered especially important in teams experiencing stressful conditions. Also, communication is invaluable in teamwork, particularly in complex environments, such as emergency situations. However, this depends on the message being received and understood correctly, hence the coordinating mechanism of closed-loop communication.

4.2. Team building

With good team-building skills, you can unite employees around a common goal and generate greater productivity. Without them, you limit yourself and the staff to the effort each individual can make alone. Team building is an ongoing process that helps a work group evolve into a cohesive unit. The team members not only share expectations for accomplishing group tasks, but trust and support one another and respect one another's individual differences. Your role as a team builder is to lead your team toward cohesiveness and productivity. A team takes on a life of its own and you have to regularly nurture and maintain it, just as you do for individual employees.


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Team building can lead to: Good communications with participants as team members and individuals Increased department productivity and creativity Team members motivated to achieve goals A climate of cooperation and collaborative problem-solving Higher levels of job satisfaction and commitment Higher levels of trust and support Diverse co-workers working well together Clear work objectives Better operating policies and procedures

The first rule of team building is an obvious one: to lead a team effectively, you must first establish your leadership with each team member. Remember that the most effective team leaders build their relationships of trust and loyalty, rather than fear or the power of their positions. Consider each team member ideas as valuable. Remember that there is no such thing as a stupid idea. Be aware of team member unspoken feelings. Set an example to team members by being open with them and sensitive to their moods and feelings. Act as a harmonizing influence. Look for chances to mediate and resolve minor disputes; point continually toward the team's higher goals. Be clear when communicating. Be careful to clarify directives. Encourage trust and cooperation among your team. Remember that the relationships team members establish among themselves are every bit as important as those you establish with them. As the team begins to take shape, pay close attention to the ways in which team members work together and take steps to improve communication, cooperation, trust, and respect in those relationships. Encourage team members to share information. Emphasize the importance of each team member's contribution and demonstrate how all of their jobs operate together to move the entire team closer to its goal. Delegate problem-solving tasks to the team. Let the team work on creative solutions together. Facilitate communication. Remember that communication is the single most important factor in successful teamwork. Facilitating communication does not mean holding meetings all the time. Instead it means setting an example by remaining open to suggestions and concerns, by asking questions and offering help, and by doing everything you can to avoid confusion in your own communication. Establish team values and goals - evaluate team performance. Be sure to talk with members about the progress they are making toward established goals so that members get a sense both of their success and of the challenges that lie ahead. Address teamwork in performance standards. Discuss with your team:

o What do we really care about in performing our job? o What does the word success mean to this team? o What actions can we take to live up to our stated values?

Make sure that you have a clear idea of what you need to accomplish. That you know what your standards for success are going to be; that you have established clear time frames; and that team members understand their responsibilities. Use consensus. Set objectives, solve problems, and plan for action. While it takes much longer to establish consensus, this method ultimately provides better decisions and greater productivity because it secures every team member commitment to all phases of the work.


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Set ground rules for the team. These are the norms that you and the team establish to ensure efficiency and success. They can be simple directives (Team members are to be punctual for meetings) or general guidelines (Every team member has the right to offer ideas and suggestions), but you should make sure that the team creates these ground rules by consensus and commits to them, both as a group and as individuals. Establish a method for arriving at a consensus. You may want to conduct open debate about the pros and cons of proposals, or establish research committees to investigate issues and deliver reports. Encourage listening and brainstorming. As supervisor, your first priority in creating consensus is to stimulate debate. Remember that members are often afraid to disagree with one another and that this fear can lead your team to make mediocre decisions. When you encourage debate you inspire creativity and that's how you'll spur your team on to better results. Establish the parameters of consensus-building sessions. Be sensitive to the frustration that can mount when the team is not achieving consensus. At the outset of your meeting, establish time limits, and work with the team to achieve consensus within those parameters. Watch out for false consensus; if an agreement is struck too quickly, be careful to probe individual team members to discover their real feelings about the proposed solution. Symptoms that signal a need for team building:

Decreased productivity Conflicts or hostility among staff members Confusion about assignments, missed signals, and unclear relationships Decisions misunderstood or not carried through properly Apathy and lack of involvement Lack of initiation, imagination, innovation; routine actions taken for solving complex

problems Complaints of discrimination or favoritism Ineffective staff meetings, low participation, minimally effective decisions Negative reactions to the manager Complaints about quality of service


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5. Motivation

In a specialized manner, motivation is mentioned as a factor influencing consumer decision making, involvement and satisfaction. Motivation is also an underlying element to explore reasons behind individual decision of participating in a group event on board ship. The most common meaning of motivation is the reason or reasons one has for acting or behaving in a particular way and the general desire or willingness of someone to do something. The act of being motivated then can be described as being moved to do something. However the definition does not differentiate between intrinsic or extrinsic motivation; intrinsic being a motive born naturally from ones within, and extrinsic being the one originated outside oneself. Simply, if one has intrinsic motivation to perform a certain act, the act itself would be motivating. Then again, if one has extrinsic motivation, the end result would be the goal that motivates one to act. Though neither of these motivation types indicates that either process or goal will be the sole enjoyable aspect for the acting person. In tourism research the more frequently used motivation theory is the push and pull-theory. It was first introduced in 1977 and subsequently became most commonly used motivation theory in related literature. Was argued that there are push factors, which are embodiment of intrinsic needs to break off the stress or escape the routine. The pull factors then are those extrinsic appealing features that pulls individual towards a certain place or activity. Additionally, was stated that motivation and satisfaction are two factors, which should be observed jointly rather than separately, emphasising on the relationship between the two items. In addition to push and pull motivation theories, there are two psychological motivation approaches, behavioural and cognitive approach, which are both commonly used in consumer and psychology studies. In cognitive theories, motivation is the drive that individual has towards reaching a final goal, based on certain information. Whereas in the behavioural schools drive theories, a persons biological need produces unpleasant state of arousal: Individual wishes to reduce the tension, and motivation is thus engendered. The cognitive theories seem to relate to the pull motivation factor, which is external (extrinsic) to the consumer and involves cognitive process of information analysis rather than action based on deep emotions. The behavioural approach again resembles the effect of push factor, where one is trying to break off or improve from the current state due to stress or other internally formed needs. Additionally, it can be detected that push motivation is largely internal (intrinsic) and drive-based. This perspective gives a justification for deeper consideration of motivation formation process when making managerial decisions. In addition to making destinations more appealing or creating a place for escape, company should examine the sources of information search (cognitive theory) and possible internal needs of an individual to efficiently address his/her possible demands. One of the most well-known behavioural drive-motivation theories in the academic motivation research is hierarchy of needs, which will be used here to elaborate push motivation further. In indicated papers was stated that there are five basic need categories, which are hierarchical towards each other. On the lowest level is the physiological needs followed by the need to feel safe. Belongingness (or love) then tops the safety needs and it is followed by ego and self-actualisation needs, latter being the one on the top of the whole hierarchy. However it was stated that this need hierarchy is not a comprehensive theory on motivation. Additionally was claimed that multiple motivations could affect the behaviour of an individual, rather than a singular one.


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Though this hierarchy model is very rational, it has been criticised by many in academic fields. Another researcher argued that self-actualisation is not a basic need by concept and was identified the scarce amount of evidence existing for this type of hierarchy. In service environment, it might be likely that some basic needs exist for the services. Additionally, though the hierarchy is questioned, the theory still covers some basic needs of human nature, which can be utilised to differentiate motivation factors. Likewise, the pull motivation resembles cognitive schools expectancy theories, where expected desirable outcomes pull out the behaviour rather than push it from within. More clearly, the pull factors are motives aroused by the destination itself rather than being born within. Some of the pull factors are scenic attractions, cultural and historical attributes, as well as climatic characteristics. The push factors can be exempli gratia self-development, exploration and improvement of kinship. These motivation factors can influence each other.

Figure 5.1. The motivational model for hedonic tourism


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A classical interpretation of push and pull-motivation theory is found in Figure 5.1, where push factors are characterised as consumer dispositions, id est. internal needs, motives and drives. The push factors are then described as marketing stimuli that refer to the factors external to the consumer, which are advertising, destination and services.

Figure 5.2. Motivational dimensions

The two main motivational forces are approach (seeking) and avoidance (escape). Approach is described to be seeking intrinsic rewards, and avoidance to be escaping surrounding environments. The main aim of this model was to emphasise how it is ineffective to categorise factors into reasons and benefits. According to different researchers, it might be more sensible to analyse motivational factors and their means ends, rather than sort them into rigid motivation groups. However the basic idea behind theories is similar: They both declare tourism motivation as combination of two basic factors, escaping life (push) and seeking experience (pull). Moreover, there seems to be basic needs that push consumer to initiate decision-making process. Therefore despite the stiff motivation classification, categorising motivational factors into push or pull group might be beneficial for an overall understanding of consumer decision-making. However to gain a more comprehensive view on the motivational factors, the categorisation should integrate aspects from escaping and seeking, as well as cognitive and behavioural motivation to make the analysis constructive.


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6. Task analysis

Task analysis is a fundamental methodology in the assessment and reduction of human error. A wide variety of different task analysis methods exist, and it would be impracticable to describe all these techniques here. Instead, the intention is to describe representative methodologies applicable to different types of task. The term Task Analysis can be applied very broadly to encompass a wide variety of human factors techniques. Nearly all task analysis techniques provide, as a minimum, a description of the observable aspects of operator behavior at various levels of detail, together with some indications of the structure of the task. These will be referred to as action oriented approaches. Other techniques focus on the mental processes which underlie observable behavior, e.g. decision making and problem solving. These will be referred to as cognitive approaches. Task Analysis methods can be used to eliminate the preconditions that give rise to errors before they occur. They can be used as an aid in the design stage of a new system, or the modification of an existing system. They can also be used as part of an audit of an existing system. Task analysis can also be used in a retrospective mode during the detailed investigation of major incidents. The starting point of such an investigation must be the systematic description of the way in which the task was actually carried out when the incident occurred. This may, of course, differ from the prescribed way of performing the operation, and Task Analysis provides a means of explicitly identifying such differences. Such comparisons are valuable in identifying the immediate causes of an accident.

6.1. Action oriented approaches

Hierarchical Task Analysis. Is a systematic method of describing how work is organized in order to meet the overall objective of the job. It involves identifying in a top down fashion the overall goal of the task, then the various sub-tasks and the conditions under which they should be carried out to achieve that goal. In this way, complex planning tasks can be represented as a hierarchy of operations - different things that people must do within a system and plans - the conditions which are necessary to undertake these operations. Hierarchical Task Analysis commences by stating the overall objective that the person has to achieve. This is then redescribed into a set of sub-operations and the plan specifying when they are carried out. The plan is an essential component of Hierarchical Task Analysis since it describes the information sources that the worker must attend to, in order to signal the need for various activities. Each sub-operation can be redescribed further if the analyst requires, again in terms of other operations and plans. The question of whether it is necessary to break down a particular operation to a finer level of detail depends on whether the analyst believes that a significant error mode is likely to be revealed by a more fine grained analysis. For example, the operation charge the reactor may be an adequate level of description if the analyst believes that the likelihood of error is low, and/or the consequences of error are not severe. If the consequences of not waiting until the pressure had dropped were serious and/or omitting to check the pressure was likely, then it would be necessary to break down the operation charge reactor to its component steps. Unfortunately, until the analyst has broken down the operation further, it is difficult to envision how a sub-operation at the next lower level of breakdown might fail, and what the consequences of this failure might be.


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In practice, a consideration of the general quality of the PIFs (e.g. training, supervision, procedures) in the situation being evaluated will give a good indication of the overall likelihood of error in the specific operation being evaluated. Similarly, the consequences of errors can be evaluated in terms of the overall vulnerability to human error of the subsystem under consideration. By considering these factors together, it is usually obvious where the analysis should be terminated. Differing levels of detail may be necessary for different purposes, e.g. risk analysis, training specification or procedures design. There are two main ways for representing a Hierarchical Task Analysis description: the diagrammatic and tabular format. Diagrams are more easily assimilated but tables often are more thorough because detailed notes can be added. Advantages of Hierarchical Task Analysis:

Hierarchical Task Analysis is an economical method of gathering and organizing information since the hierarchical description needs only to be developed up to the point where it is needed for the purposes of the analysis.

The hierarchical structure of Hierarchical Task Analysis enables the analyst to focus on crucial aspects of the task which can have an impact on plant safety.

When used as an input to design, Hierarchical Task Analysis allows functional objectives to be specified at the higher levels of the analysis prior to final decisions being made about the hardware. This is important when allocating functions between personnel and automatic systems.

Hierarchical Task Analysis is best developed as a collaboration between the task analyst and people involved in operations. Thus, the analyst develops the description of the task in accordance with the perceptions of line personnel who are responsible for effective operation of the system.

Hierarchical Task Analysis can be used as a starting point for using various error analysis methods to examine the error potential in the performance of the required operations.

Disadvantages of Hierarchical Task Analysis: o The analyst needs to develop a measure of skill in order to analyze the task effectively

since the technique is not a simple procedure that can be applied immediately. However, the necessary skills can be acquired reasonably quickly through practice.

o Because Hierarchical Task Analysis has to be carried out in collaboration with workers, supervisors and engineers, it entails commitment of time and effort from busy people

Operator Action Event Trees. Are tree-like diagrams which represent the sequence of various decisions and actions that the operating team is expected to perform when confronted with a particular process event. Any omissions of such decisions and actions can also be modeled together with their consequences for plant safety. Each task in the sequence is represented by a node in the tree structure. The possible outcomes of the task are depicted as success or failure paths leading out of the node. This method of task representation does not consider how alternative actions (errors of commission) could give rise to other critical situations. To overcome such problems, separate OAETs must be constructed to model each particular error of commission. By visual

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