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7 A Human Systems Perspective on Marine Navigation and Piloting SUMMARY Lapses in human performance have contributed to most marine acci- dents, but the understanding of human systems needed to guide improvements in the marine navigation and piloting system is not well developed. The marine navigation and piloting system and its subsystems as they are organized and op- erated, particularly the traditional shipboard structure for command, control, communications, and information (C31), induces rather than reduces the poten- tial for human error. Recent innovations in the marine navigation and piloting system to improve C31 include changes in bridge organization such as bridge teams, the one-person bridge, and the pilot-copilot bridge configurations. Anoth- er important development is the application of marine simulation for profession- al development. To further reduce risk, a variety of issues must be addressed in the areas of Cal: error reduction, reaction time, automation of error-prone functions, and rationalization of tasks. Human systems in the marine navigation and piloting system could be improved through changes in structure, decision making, communication, and culture. The system could be restructured to better integrate interdependent decision making among its various components. Decision-making processes with- in organizations could be made more flexible to facilitate decision making at the organizational levels closest to available information about the decision and its implementation. Communications processes could be improved with regard to the development of interpersonal trust among personnel in all segments of the marine navigation and piloting system. Finally, appropriate cultural changes could be nurtured to improve attentiveness to safety considerations. i 271

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272 MINDING THE HELM The Coast Guard has initiated an improved data-collection methodology for human systems information and an integrated human factors research and development program to develop an empirical technical basis for technological advances and marine safety regulations. Modest research and development of technical systems to support bridge team and watch officer performance contin- ues to be undertaken by the Maritime Administration as well. INTRODUCTION Although human performance is recognized as a contributing factor in most marine accidents, the understanding of human systems (box /-1) and human- machine interactions that is needed to guide improvements in human perfor- mance as this pertains to marine navigation and piloting is not well developed (Box 7-23. Further, the understanding of organizational processes that contribute to unsafe operating practices in the system is very limited. This chapter examines human systems and organizational processes as they relate to the marine navigation and piloting system, and example of a large scale sociotechnical system. Interactions of the system's major components introduced in Chapter 1 navigation and piloting tasks, human systems, organizational cul- ture and structure, and technology (Figure 1-1) are analyzed with respect to human, organizational, and environmental imperatives. In keeping with the over- all focus of the report, emphasis is placed on navigation and piloting tasks. The opening section presents an organizational view of the marine naviga- tion and piloting system, especially the adequacy of communication in its man- agement. The heart of the chapter addresses navigation and piloting from a broad- er perspective by examining environmental and internal organizational contexts in which piloting and navigation take place. Human-machine interactions (also referred to as the man-machine interface) are also addressed. A............ .~ ........

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A HUMAN SYSTEMS PERSPECTIVE 273

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274 MINDING THE HELM AN ORGANIZATIONAL VIEW OF NAVIGATION AND PILOTING SYSTEMS Systems and subsystems usually are described in terms of their inputs, pro- cesses, and outputs (IPO). IPO analysis broadly describes the logic of how sys- tems work. The inputs to and elements of the marine navigation and piloting system include aspects of the operating environment such as markets, regulation, traffic, technology, and shipping company policies and tasks to be performed in this environment. The organizational processes of interest include decision mak- ing, problem solving, communication, conflict resolution, and the evolution of organizational structure and culture. The outputs or the effects of the marine navigation and piloting system include task and job performance; reliability; productivity; health and safety; and operator performance, satisfaction, fatigue, stress, boredom, and retention (in service). In any systems analysis, there is a danger of optimizing the performance of a single subsystem at the expense of other subsystems or the overall marine navi- gation and piloting system (that is, suboptimizing). This is a concern and a challenge with regard to the marine navigation and piloting system because the subsystems (such as a port or shipping company) are better understood and man- aged than the overall large system. Optimizing marine navigation and piloting subsystems also need to consider interactions with external influences such as port management and public policy in order to guide intended effects and to address unintended consequences of change. As an example of a discrete change that could have unintended consequences on the larger system, the U.S. require- ment for double hulls on oil tankers might reduce spillage, but this change also means less carrying capacity per ship if double hulls were installed in existing ships, thus creating a need for more ships (Bee and Moore, 1993~. Alternately, new vessels could be built with the same cargo carrying capacity. In this case, the vessel would be somewhat larger and depending on the magnitude of change, could in some port areas stress the limits of designed channel capacity if the vessels being replaced were previously operating with small maneuvering clear- ances in constricted waterways. In other words, the safety benefit could poten- tially be reduced by an increase in shipping activity or vessel size. The Operating Environment Maritime shipping has undergone dramatic changes in recent years. Sub- stantial increases in operating costs in the 1970s and the early 1980s motivated shipping companies to adopt more efficient operating practices. During the late 1980s, interest intensified in reducing operating costs by way of smaller crew numbers (NRC, 1990a). Crew sizes on modern vessels have been reduced signif- icantly from 30 to 40 in the 1960s and 1970s to crews of 20 to 30 today in the United States and 9 to 14 in western Europe, Scandinavia, and Japan (Grove,

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A HUMAN SYSTEMS PERSPECTIVE 275 1989~. U.S. requirements have not permitted reductions as great as those of other flag states, a competitive disadvantage for U.S.-flag ships. At the same time, vessel size has increased and shipboard systems have become more complex. It has often been suggested that crew-size reductions may increase the risk of collisions and groundings, although this has not been proved or disproved (NRC, 1990a). On some vessels, reduction in crew numbers has been extreme. Some large Norwegian vessels sail with only eight to 12 crew members (Kristiansen et al., 1989~. The German Morass' series carries 16 crew members but is designed to operate with 12 (Gaffney, 19891. The Japanese Pioneer ships have crews of 11 (Grove, 1989; Yamanaka and Gaffney, 19883. Considerable changes also have taken place in the size and structure of marine traffic. Between 1960 and 1980, the number of tankers doubled, and their tonnage increased sevenfold (Kwik, 1986~. New types of ships evolved, such as liquified gas and car carriers. With each major development in hull form and superstructure configurations came different maneuvering characteristics. Major changes in vessel size also accentuated the effects of hydrodynamic forces in shallow and confined waters. In addition, numerous structures for oil and gas production have been erected in some coastal waters, complicating marine traffic routing in these areas. As a result of these developments, navigation and piloting tasks in pilotage waters and their approaches have become more difficult and complicated. Economic competition can also complicate navigation and piloting practic- es. Vessel scheduling may become volatile depending on how shippers respond to competitive carrier pricing. Intermodal door-to-door pricing means that the carrier chooses the ports and thus has leverage in negotiations; the result is vigorous port competition for the carrier's business. Traffic, therefore, becomes partly a function of carrier pricing, itself a function of intermodal technology. Because pilotage is so route-specific and there are few, if any, arrangements to shift pilots between pilotage jurisdictions for foreign trade vessels, major shifts in shipping business between competing ports could affect the near-term avail- ability of qualified marine pilots. Perrow (1984) identified maritime shipping as an "error-inducing" system. He found that the economic pressures on the captain, the authoritarian social structure that belies the interdependence and complexity of operator interactions and the system itself, the structure of the marine industry and marine insurance, and the difficulties of national and international regulation all combine to make accidents highly probable and almost unavoidable. If organizations are to prosper amid environmental uncertainty and rapid change, they need flexible and changing organizational strategies (Peters, 1987~. However, the more typical response to such an environment is to retrench, ad- here rigidly to outdated policies, and develop a "we/they mentality" (Janis and Mann, 1 977; Meyer and Starbuck, 1 993; Staw et al., 1 98 1 ).

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276 MINDING THE HELM The present focus on analyzing and identifying sources of risk in the marine navigation and piloting system is hardly new. Marine safety authorities have been conscious of this need for years, although the focus has been on subsystems (see Chapter 11. With increasing sea transport of hazardous materials, this issue has assumed much more importance (Wennick, 19921. Public awareness and concern about the possible impact of accidents on the environment, in the form of pollution and personal injury, have heightened awareness of corporate respon- sibilities and the need to assess operational levels of risk in ports, on vessels, and for different trades and technologies (see Davidson, 19903. Internal Organizational Processes A dynamic organizational structure is indicated for the safe and reliable operations of technologically advanced systems (Roberts, 1992, 19931. Effective use of these systems requires that operators develop a deep intuitive knowledge of their systems and be given training to develop a sophisticated understanding of organizational processes in which these systems are applied. Also indicated is a need for flexible decision making and the development of trust in system and operator performance. This can be developed through the training of all partici- pants (Roberts, 19931. How well the language and culture of the marine naviga- tion and piloting system reflect this more flexible approach affects the safety benefits that can be obtained from the use of high-technology systems and mea- sures to improve human performance. Shipboard Command and Control Organization Shipboard navigation and piloting tasks are affected by interactions through- out the marine navigation and piloting system, including the operating and man- agement practices of marine transportation companies. As discussed in earlier chapters, the ultimate authority in the operation of any ship is its master. But as the character of merchant ships and shipping have changed in the past decade, anecdotal reports suggest that the capability of the master to ensure a ship's safety is being eroded, although the degree of erosion is uncertain. Nevertheless, the traditional hierarchical structure for command, control, communications, and information (C3I) is entrenched in the shipboard organization of most vessels. Both the language and the culture of the system and its structure assume that the captain always has the last word in decision making and that these decisions are always correct. Yet in pilotage waters, it is the marine pilot who typically directs and controls the vessel, usually with very limited oversight by the master (see Chapters 1, 2, and 31. The traditional command and leadership relationship has been considered necessary to maintain order and discipline, especially when faced with operating conditions that threaten the vessel, officers, and crew. But the hierarchical struc

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A HUMAN SYSTEMS PERSPECTIVE 277 lure results in unidirectional, top-down communications. Marine language and practices that derive from this traditional structuring leave little room for the development of a culture that encourages bottom-up communication or the pro- vision of rewards when it happens. No provision is made for bottom-up commu- nication, a major objective of bridge team training. This may be an important deficiency in the marine navigation and piloting system (no empirical research was examined). Communication of problems detected by subordinates and solu- tions they may propose can be stifled by the rigidity of the traditional bridge organization and culture unless the operating company, through the master, has fostered a more receptive bridge team communications environment. Interrelationships OF the Navigation Bridge Each member of the bridge team in confined waters has specific levels of access to information and duties to process that information with respect to C3I. While there is some overlap, no one has complete access to all information on a traditionally configured navigation bridge. Even on high-technology ships that are ergonomically designed to support one-person operations, sharing informa- tion and support among bridge team members is still desirable in order to safely navigate the full range of hazards and conditions that affect the passage in pilot- age waters. The safety of the passage depends on the ability of bridge personnel, including the marine pilot, to function as a team, the pilot's traditional role notwithstanding (see Chapters 1, 2, and 31. In almost every maritime accident involving the interactions of bridge team members, while specific errors can be assigned to individual members, it is the loss of smooth functioning of the team as a whole that leads to the accident. This is a common difficulty with airline cockpit crews involved in accidents as well (Fouschee and Helmreich, 1988~. Access to information is divided among all members. The officer of the watch has most of the radio, navigation, and chart information, as well as the information from the radar or ARPA and miscellaneous instruments and instru- ment indicators about the bridge. The officer of the watch also keeps the logs. The master picks up bits and pieces of information of interest but is usually most informed of the visual navigation elements and the radar or ARPA information. The pilot has most of the local knowledge information about the port and, as does the master, picks up information as needed, including that derived from radio transmissions (often by using portable transceivers). Because most ships do not have a 360 unobstructed view or bridge configurations designed to sup- port one-person operations, the master, pilot, and officer of the watch move about the bridge as necessary to perform their tasks. The helmsman has informa- tion from the instrument panel normally located above the windows on the for- ward bulkhead of the bridge and the steering stand about the rudder movements, ship's heading, and rate of turn. Thus, while each has access to different pieces

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278 MINDING THE HELM of information, none has continuous access to all the information needed for safe passage. Because navigation and piloting are shared tasks, communication is a key element in ensuring that each team member has all the information needed for assigned parts of the job. Beyond the sharing of information, other vital commu- nications take place during passage. Outside communications with other ships, and with vessel traffic services (VTS) where available, are very important. These external communications are typically carried out using a VHF radio with a bridge speaker to disseminate transmissions from other vessels and shore sta- tions. Both sides of the conversation can be heard if the other personnel on the bridge are positioned to hear the voice of the person operating the installed or portable radio and the bridge speaker. A complicating factor is that pilots often use portable transceivers to communicate with other vessels, often while the pilot is positioned on the bridge wing. Sometimes errors are made based on the assumption by bridge team members that everyone has heard the same informa- tion. Communications with the engine room are frequent and vital. The bridge team needs to know of any engine problems that might limit ability to maneuver at will. Engineers, too, need to know of any unusual anticipated maneuvers that might require adjustments to the propulsion system. Possibly the most important communications, though, are the orders given for maneuvering the ship in pilotage waters. These are normally given by the pilot, but they are sometimes given by the master or the officer of the watch. Most of the time, the orders are relatively easy to hear on the bridge, but at times such as docking or when meeting or overtaking another vessel, the orders may come from the bridge wing. Frequently, these must be relayed by one or more persons some of whom may not be fluent in English. All these communica- tions can be hindered further by ship or wind noise, radio transmissions from bridge speakers, and nonessential conversations. The level of interference in- creases in stressful situations, when timeliness and correctness of orders are most important. Command on the bridge is not as clear as it might seem. By law, the master is in command; however, in pilotage waters the pilot normally directs and con- trols the vessel's movements and gives maneuvering commands. Sometimes, the officer of the watch also gives or relays orders. Even in court decisions, naviga- tional command-and-control, particularly as it applies to the master-pilot rela- tionship, depends on the situation (see Chapters 2 and 3; Parks, 1982~. This rather fuzzy division of authority and responsibility has contributed to some accidents (NTSB, 1988b,c, 1989a, 1993~. Given the organization of the marine navigation and piloting system, the dominance of traditional bridge configura- tions, and legal precedents, it is likely that this peculiar relationship will contin- ue indefinitely. Miscues in these communications chains have also contributed to many accidents. Vessel control with respect to steering and propulsion is an example

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A HUMAN SYSTEMS PERSPECTIVE 279 of error-prone practice. Normally, steering is accomplished by a helmsman who has no command authority. The helmsman has direct control of the ship's rudder and, thus, its course through the water. The information available to the helms- man is usually limited to that directly related to steering, including rudder angle, gyro heading, and automatic pilot setting. Steering orders are received directly from the master or pilot if they are on the bridge or by relay through the mate when conning is being conducted from the bridge wing. On ships designed with bridge control of the propulsion system, shaft revolutions and direction are usu- ally controlled by the watch officer under orders from conning officer (normally the pilot or master). If bridge control is not available, the ship's engineer (or engineering watch officer) controls the engines based on orders relayed by en- gine order telegraph or voice tube from the watch officer. Opportunities for Human Error in Traditional Practices A typical risk-analysis fault tree of the traditional mode of bridge operation discussed above would reveal an unusually large number of opportunities for human error. Most of the problems stem from reliance of the operation on accu- rate and timely communications; many result from the wide distribution of re- sponsibilities for C3I. For example, the number of possibilities for error in a simple order for a change in engine speed is alarming. First the order must be formed correctly by the pilot, then understood and relayed correctly through as many as three persons on the bridge (pilot, master, and mate). If it reaches and is understood correctly by the engineer, it must then be executed correctly. If exe- cuted properly, the throttle control, engine, gears, shaft, and propeller must oper- ate correctly. Given that a large number of such commands may be necessary during a transit of pilotage waters, the chances for human error are multiplied substantially. This is offset to some extent by monitoring and cross-checking that has evolved as a practice of good seamanship. APPLYING ORGANIZATIONAL SAFETY STRATEGIES TO MARINE NAVIGATION AND PILOTING Changes in risk and economic conditions have already prompted innovation in marine navigation and piloting subsystems. This section reviews some of these ongoing developments from a humans systems perspective, including in- novations in training systems. Human systems concepts for reducing risk in performing tasks are then presented. These are followed by an examination of organizational approaches for improving safety. The section closes with a sum- mary overview of recent human systems research and development initiatives undertaken by the Coast Guard and the Maritime Administration.

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280 Bridge Teams MINDING THE HELM Recent Innovations in Navigation and Piloting The most widely used of the recent innovations has been the "bridge team" concept. Ideally under this concept, the master, pilot, watch officers, and the unlicensed helmsman and lookouts would be trained to operate as a team with a more cooperative structure than that found in the traditional hierarchical-bridge C3I model. In practice, team training usually involves licensed ship's officers. Marine pilots sometimes participate in bridge team training, usually in coopera- tion with specific shipping companies, for example, in advance of port calls by a new class of ships. A variant is "bridge resources management" in which indi- viduals such as pilots are instructed how to improve personal interactions in order to most effectively use the human resources that are available on the bridge. The bridge team and bridge resources management concepts, similar to cockpit resources management In aviation, have the advantage of encouraging more open discussion and constructive questioning of orders and actions, and they might provide for better communication among all participants (Crooks and Douwsma, 1989; Douglas and Wass, 1993; Koning, 1993; Wahren, 19933. Because coordi- nation of bridge teams does not require a substantive change in most staffing and procedural aspects of the traditional bridge model, acceptance is more likely than is acceptance of more radical change. There is some concern that excess questioning and discussion may lead to delay in carrying out required actions in emergencies. However, most advocates of the bridge team model think that this would not be a significant problem so long as training is adequate and that the benefits of the team concept outweigh the drawbacks. Pilots tend to prefer bridge resources management, because they do not consider themselves to be a member of a ship's bridge team, per se. One-Person Bridge The concept of a one-person bridge organization is far more radical than the bridge team. Here a single person has total control of the navigation and maneu- vering of the ship at sea. However, the master and a pilot may still be required by need or regulation to be on the bridge while in pilotage waters. Several classifi- cation societies have published, or are in the process of publishing, requirements for bridge layout and equipment for this type of operation, and the International Maritime Organization (IMO) has approved testing of the concept with the ap- proval of the flag states involved. The United States has not, to date, approved such tests in its waters. Proponents point out that most ship accidents result from human error and, particularly, from errors in communication among members of the bridge orga- nization. They contend that reducing the number of people involved will, given a

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A HUMAN SYSTEMS PERSPECTIVE 281 properly designed bridge and integrated equipment, reduce the chances for error and thereby the number of accidents. They also cite the good safety record of integrated tug and barge combinations and small coastal tankers that operate in this fashion, even without the benefit of the proposed bridge design and equip- ment. Further, they note that because a pilot is taken in pilotage waters (for foreign trade vessels), there are at least two people on the bridge in the region of highest risk. Opposition to the one-person bridge is focused on the additional task load- ing of the operator and the need for a proper lookout. Opponents contend that a single officer is not able to maintain an adequate lookout and still conduct all other duties effectively. Some concern has been voiced about the possibility of the watch becoming incapacitated or falling asleep. However, this concern might be mitigated by the availability of "dead man" alarms and other technologies that have proven effective for ensuring alertness in one-person operations ashore. Some commercial maritime research has been conducted investigating one person bridge concepts (Iijima et al., 1991; Kristiansen et al., 1989; Schuffel et al., 19891. In addition, the U.S. Navy has been evaluating such concepts from a defense perspective for a number of years. One published report found signifi- cantly improved track keeping and reduced stress and fatigue for one-person bridge operations as compared with traditional bridge manning and operational models (Schuffel et al., 19891. Pilot-CoPilot Model The pilot-copilot model is based on the arrangement used on the flight deck of commercial aircraft. To function properly, this model requires a bridge layout similar to the one-person bridge but has a two-position console. Each position is similarly configured and includes all controls and displays needed for one-per- son operation. Certain indicators and controls may be shared on a central console between the pilot and copilot. The consoles are located so as to allow essentially all operations to be performed while seated there. During passage, only one watch/conning officer controls the ship at any given time. To reduce fatigue, the officers regularly alternate control, in the same manner used on airliners. When not controlling the ship, the off-duty offic- er assists by handling communications, scanning secondary indicators, providing lookout, keeping logs, and handling other tasks not directly involved in ship control. Most importantly, this officer acts as a supervisor, or second pair of eyes, observing the officer in control to help eliminate the possibility of error. In times of low risk and minimal work load, such as in open waters and good weather without traffic, the bridge may be operated by one person. Use of the latter practice must, however, consider the fact that marine accidents often occur during such favorable operating conditions. Among the earliest proponents of this pilot-copilot operation was the

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286 Reaction Time MINDING THE HELM The "left 15 degrees rudder" illustration also suggests another problem in- herent in the traditional bridge model: reaction time. The example includes a number of processes that take considerable time to perform. If anything is done incorrectly, significant time is required for the conning officer to recognize and confirm the error and to formulate, communicate, and carry out the corrective action. Again, this process must be compared with the near-instantaneous brain- to-motor function of the single person reacting to visual feedback. The delays inherent in plotting position on a paper chart were discussed in Chapter 6. This process, which can only reveal the vessel's position in real time if the vessel is not moving "over the ground," can introduce significant delays in reaction time, because plotting is not normally continuous. To detect a position error, the conning officer must either wait for the next plot to be made and then wait to receive it from the person performing the plot or estimate the vessel's position from visual or radar cues (a marine pilot is supposed to be capable of precise position estimates from such cues). If there is a discrepancy, the conning officer usually asks that the plot be confirmed, which introduces yet another delay in determining actual position (at the time lines of position were taken i. Electronic charting systems, which incorporate real-time positioning informa- tion, are intended to be more accurate and timely for determining position. In addition, such systems eliminate time-consuming plotting tasks and another per- son-to-person communications link and source of human error. Another impediment to quick reaction is the arrangement of the traditional bridge, which requires an officer to roam the bridge as necessary to gather and process data. This task can be time-consuming and can distract from other tasks. Roaming can delay reaction to problems, introducing the possibility of errors in interpretation of data and communication of information. Integrated bridges place all important data in view of the conning officer and often, through data fusion and automated processing, reduce the time and space needed to receive and react to information. Automating Error-Prone Functions Many of the routine administrative tasks performed on the traditional bridge can be automated relatively easily using available technologies. In traditional approaches to human-machine allocation decisions, tasks are assigned based on functional analyses of the capabilities of humans and machines, and of the re- quired tasks. For instance, tasks primarily requiring motor skills are often desig- nated for machine support, while those requiring perceptual skills are often best supported by humans, or by combinations of humans and machines. In piloting and navigation systems, much research and development has focused on the design and evaluation of systems and decision aids which provide

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A HUMAN SYSTEMS PERSPECTIVE 287 support for the perceptual and motor activities involved in controlling a vessel. Typically, these aids used enhanced graphics and visual representations of actual and expected ship's position, in addition to steering assistance. Such systems provide good support for the lower-level cognitive skills of piloting trackkeep- ing and maneuvering but provide little help in supporting the higher level cog- nitive tasks which are an important component of good piloting and navigation, specifically collision avoidance and qualitative ship management skills known collectively as the "practice of good seamanship?' (Grabowski and Wallace, 1993~. Support for the full range of cognitive shills motor and perceptual in order to anticipate and avoid errors is currently a research goal. To the extent that machines can do a job at least as accurately and reliably as can people, technology has the potential to make bridge operation safer and more efficient, while freeing those involved in navigation and piloting to do the thinking, anticipating, and other intuitive tasks that machines currently cannot do. To the extent that technology reduces the need for interactions and commu- nications among bridge personnel, it can reduce the probability of human error. Microcomputers and processors already are very powerful and relatively inexpensive, and they promise to provide even more power at less cost in the near future. Software-based systems to automate appropriate bridge functions are being developed. These developments warrant a new and critical review of the traditional bridge operations model to the extent that they can provide cost- justified improvements in safety and efficiency. Rationalization of Tasks To derive maximum advantage from technology, a new model for bridge operations needs to be developed. The key to this effort is determination of which tasks are best done by the machines and which are more appropriately done by people. While there will not be a clear distinction in all cases, a clear vision of the desired bridge model would facilitate decision making. Some tasks are easily assigned to machines, simply because a machine al- ready has proven to be significantly faster, more accurate, and more reliable than people. Such functions are primarily the simple mathematical computations re- quired for navigation. A well-programmed computer virtually never makes an error in computing a mathematical function, while humans err frequently. Clear- ly, this fact suggests that the simple and repetitive calculations required to deter- mine position, set and drift, and "course made good" can be given over to com- puters. With direct inputs from electronic navigation instruments and radar, such calculations can be done several times a second with very good accuracy, and they can be compared with alternative inputs and displayed in real time on an electronic charting system. Similarly, the positions and tracks of other vessels in open water can generally be computed more accurately and faster with modern ARPA systems than they were by people; interactive positioning systems in

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288 MINDING THE HELM conjunction with VTS operations has the potential to provide the same capability for pilotage waters (see Chapter S'. In cases where tasks can be accomplished with significantly greater timeliness, accuracy, and reliability through automa- tion, continued requirements for manual performance can work against improve- ments in safety performance. Some tasks will be difficult to automate but still can be automated, with thoughtful technology development. Data fusion and information display is one very important task of this type. Much work has been done in this area by the aircraft electronics industry, which has developed cockpit displays that in only a few seconds of instrument scanning convey all necessary information to the pilot. Lessons learned from these advances could be incorporated into develop- ment of integrated bridge consoles that could free the mariner from the time- consuming process of having to gather, process, and interpret all the information necessary for understanding the condition of the vessel and its environment. Other tasks that can be performed accurately and reliably by machines are steering and track keeping. Current-generation auto pilots are more accurate an consistent in maintaining course than are the typical helmsman. The capabilities of microprocessors offer the promise of even better performance by allowing the use of more-complex ship models. These new models are under development, including those with neural networks which can adapt continually to changes in the navigation situation (see Chapter 6~. By combining these new autopilots with real-time information on cross-track error from electronic charting systems, a level of track-keeping precision can be achieved that argues for replacing the helmsman with technology. If the helmsman position is eliminated, the trade-off is that either the master, a mate, or a qualified crewmember may have to hand- steer under some operating conditions, adding to task loading. Humans, on the other hand, do a better job of performing cognitive tasks that cannot be fully automated. Supervision of other humans and oversight of automated operations to detect malfunctions or to override systems to compen- sate for unplanned operating conditions are such tasks. While a person does not necessarily perform very well in recognizing his or her own mistakes, well- trained operators seem well able to spot errors committed by machines and other humans. This performance is particularly good if the supervisor is not burdened by other, nonsupervisory tasks. Assuming this is the case, the ideal bridge oper- ations model is a fully automated vessel operating under the supervision of a full-time human supervisor, assisted by computerized expert systems, whose principal task would be to oversee the operation of the ship's systems. The operator would also need to be capable of overriding subsystems and operating them manually. Implementation of such a model is being explored by several nations the United Kingdom, Germany, and the Netherlands (Grove, 1989; Schuffel et al., 19891. The model sets a standard that might be approached to the extent that available technology, cost considerations, and mariner professional development allow.

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A HUMAN SYSTEMS PERSPECTIVE Organizational Approaches for Improving Safety 289 Safety in organizations can be improved in a number of ways. In addition to traditional human factors engineering approaches, such as attention to appropri- ate system and organizational design and operations, recent efforts have also focused on changes in organizational structure, decision making, communica- tions, and organizational culture. The following section discusses these ap- proaches as applied to the marine industry. Structuring Military organizations have determined that one way to control operations in uncertain environments is to exert tight local control. They also have learned that, as situations become increasingly fluid and dangerous, decision making at the local level is essential. This tension between centralization and decentraliza- tion is a paradox of modern military operations. Most theorists interested in effective organizational design sooner or later note that when organizations are tightly coupled (that is, they have well-defined, rigid decision-making processes) and consequently are fairly centralized, they become brittle and unable to respond to changing environments (see Daft and Weick, 1984; Perrow, 1984; Weick, 19761. These researchers often call for loos- er coupling, noting that organizations tend to experience operational or adminis- trative problems when the coupling becomes too tight. Perrow expands on this notion of tight coupling with specific reference to the marine industry. He notes that many systems are so complex in structure that small changes cannot make the system safe: The problem, it seems to me, lies in the type of system that exists. I will call it an "error inducing" system; the configuration of its many components induces errors and defeats attempts at error reduction. Discrete attempts to correct this or that will be defeated by something else; only a wholesale reconfiguration could make the parts fit together in an error-neutral or error-avoiding manner. Much of the marine system is perversely inverted. The identifiable victims are primarily low status, unorganized, or poorly organized seamen; the third party victims of pollution and toxic spills are anonymous, random, and the effects delayed . . . it seems to be the combination of system components that promotes error inducement, such that improving or changing any one component will either be impossible because some others will not cooperate, or inconsequential because some others will be allowed more vigorous expression. (Perrow, 1984) Perrow's analysis focuses on the system's complexity and assumes tight coupling in potentially dangerous situations; however it does not address the loose coupling within the marine industry, much less within the marine naviga

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290 MINDING THE HELM lion and piloting system. Although some tight couplings do exist, such as on the ship's bridge (this can be a detriment because of the lack of bottom-up commu- nications, discussed earlier), the overall system is very loosely integrated. An example of tight coupling might be an oil shipping company that, in response to the Exxon Valdez accident, required specific behaviors on the part of masters bringing ships into port. Such specifications, if too rigid, could constrain the use of judgment or intuition in responding to novel situations. Thus, loosely coupled or entirely disconnected systems can cause accidents as readily as can tightly coupled systems. This point is missed in the organiza- tional literature. The challenge to marine safety and pilotage authorities, trans- portation companies, industry trade associations, and researchers is to identify the degree of coupling and interdependence appropriate to the safe and effective performance of navigation and piloting tasks. No studies on large-scale organi- zatiorlal systems exist that could aid in determining this optimal structure. Decision Making Masters, mates, and pilots navigating in confined waters are inundated with data from a variety of sources and must make crucial decisions quickly (see Chapters 5 and 6; NAS, 19813. These decisions are made in stressful environ- ments, often after lengthy cargo watches, by an ever-smaller bridge team. Card et al. (1983) and Grabowski and Wallace (1993) offer a model of information processing and decision making that helps explain the decision-making situation faced by mariners. In a simple transit scenario, the pilot relies on a mental construct of the chart. In the words of the model, these data are stored in the pilot's perceptual processor and memory. Lines of position, deviations from channel centerline, and track-keeping information are held in the sensory system's buffer memory while the data are coded symbolically. The cognitive system takes sensory imag- es and knowledge from long-term memory past experience with deviations from the present track, procedures from the nautical rules of the road, courses to steer, how to align the vessel in the waterway, and how to compensate for cur- rent set and drift. The pilot's motor system executes the results of the decisions made as commands are vocalized (Grabowski and Wallace, 1993~. Problems arise when the cognitive representation fails to map reality. For example, a serious maritime accident occurred when the captain of a large ship misinterpreted a flashing red light as a net buoy marker (Roberts et al., in press). The captain gave the wrong order, and the ship hit a rock. Problems can also occur when orders are misinterpreted or carried out incorrectly. For example, the pilot may order a rudder turned 10 degrees to the right, but the helmsman turns left 10 degrees. The resulting situation can worsen rapidly when no one is avail- able to question the maneuver or when the organization's culture restricts any questioning.

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A HUMAN SYSTEMS PERSPECTIVE 291 Individual decision making exists within the context of the system. It is apparent that such a loosely federated system creates a situation in which deci- sion making also is uncoupled (that is, the affected parties do not communicate). Since the days of Henry VIII, maritime nations have recognized the need for some kind of connection between the port authority and the ship to transfer local navigation knowledge. This need led to establishment of the piloting industry, which has changed little over time. Viewing the ship and pilot as a system unit, the notion of a pilot as a navigation aid introduces the opportunity for checks and balances. The social-psychological research on decision making focuses primarily on how individuals make decisions in response to group characteristics (Scott, 1992; Simon, 19563. Some attention has been devoted to distributed decision making, which in many ways is characteristic of the marine industry. However, this con- cept makes an assumption that decisions are tied together across a system- that does not hold true for the marine system. For the most part, in any port, individual decisions made aboard yachts, tugs, ferries, and other vessels are totally independent of one another. Distributed decision making is a neologism that has been deliberately chosen to capture the cumulative change in the nature of multi-person decision making that has been wrought through advances in technology. Those advances have increased the distance over which individuals can maintain contact, the speed with which information and instructions can be shared, the amount of informa tion being created and the accompanying information load, the opportunities for monitoring operators' behavior, and the possibilities for automating instruc tions (for example, through expert systems, computerized pattern recognition). (NRC, l990b) To the extent that truly distributed decision making exists in the marine industry, existing research could be integrated to illuminate inherent characteris- tics of that decision making. If a feature of distributed decision making is the interdependence of the parts of the system, then it would be useful to have an understanding of the cognitive maps held by the various operators. Cognitive maps vary depending on knowledge of the system, status within it, and so on. An important characteristic of individuals in the marine system is trust- trust in the expertise of other operators, trust in the behavior of each vessel, and trust in the system itself. While trust has long been a major issue in the organiza- tional literature, there is no systematic research on its place in the marine indus- try. Clearly, if a ship's master cannot trust the knowledge, skills, and intuition of a local pilot, the master is handicapped severely in operating the ship in unfamil- iar waters. No research exists on decision making involving multiple individuals in the marine environment. Only one study is related even tangentially. Roberts et al.

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292 MINDING THE HELM (in press) studied decision making aboard two nuclear-powered aircraft carriers. (No attempt was made to tie the carriers to shore installations or to navigation aids such as a VTS or the GPS.) These authors found that the decision locus migrated within the organizations. Important decisions could be made by a num- ber of individuals, even at the lowest organizational level. Factors such as ac- countability, responsibility, uniqueness of the problem, and characteristics of the external and internal environment affected decision dynamics. A model was developed to account for movements of the decision locus in these organiza- tions. Many other important issues concerning multi-individual decision making require research. System designers and users need to know how shared knowl- edge develops, what knowledge requires sharing, and the nature of barriers to sharing knowledge (Bowers et al., 19911. The distribution of responsibility and accountability also could be examined, particularly with regard to pilots and other navigation aid services. Research designs could be adapted from those used in aircraft cockpit team research (for example, by the National Aeronautics and Space Administration) and from research conducted by the U.S. Navy on team decision making (Dr~skell and Salas, 19911. At the organizational level, a number of other issues warrant attention. An organizational analysis may focus either on one organization (such as a shipping company) or on the network of organizations constituting the marine system (such as tugboat companies, passenger ferry companies, shipping companies, and recreational users). Because no investigations of larger systems have been conducted to guide everyday operations, it can only be assumed that at least some factors thought to be important in organizational behavior also are impor- tant at the larger system level. Myriad issues could be the focus of study. Recent- ly, some research has been devoted to understanding how organizations learn (Attwell, 1992; Huber, 1991; March et al., 19911. How they learn certainly influ- ences how they approach multiparticipant decision-making tasks. Communication In his analysis of the Tenerife air disaster, in which 583 people on a Pan American 747 and a KLM 747 were killed, Weick (1993) males the following points: First, part of any job requirement must be the necessity for talk. Strong, silent types housed in systems with norms favoring taciturnity can stimulate unreli- able performance because misunderstandings are not detected. Of the four im- plications for managerial practice derived by Sutton and Kahn (1987) in their influential stress review, three concern talk: be generous with information, ac- knowledge the information functions of the informal organization, do not hold back bad news too long. Rochlin, LaPorte, and Roberts (1987) find that reliable performance and amount of talk exchanged co-vary.

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A HUMAN SYSTEMS PERSPECTIVE What our analysis of Tenerife has uncovered is the possibility that with commu- nication a complex system becomes more understandable (you learn some miss- ing pieces that make sense of your experience) and more linear, predictable, and controllable. The recommendation that people should talk is not as simple as it appears, because one of the problems at Three Mile Island was too many people in the control room talking at one time with different hunches as to what was going on. The din created by tense voices plus multiple alarms, however, would malice it all but impossible to single out talk as uniquely responsible for confusion, mix-diagnosis, and delayed responding. The crucial talk at Three Mile Island should have occurred in the hours before the control room got cluttered, not after. If things do not malice sense, speak up. This is the norm that needs to be created. 293 Multiple distributed decision making is impossible without communication, and communication is the vehicle through which the culture of an organization is conveyed. It has long been known that in situations where there is a lack of trust, communication is distorted (Gibb, 1961; Mellinger, 1956; O' Reilly and Roberts, 1974, 19763. Maintenance of trust in organizations is an ongoing process (Schul- man, 1993), and mechanisms need to be in place to ensure that this process is sustained. Other variables are also important in the communication process. For exam- ple, the nature of desirable feedback, and how to make best use of it, is not defined clearly within the marine industry. At the organizational level, to the extent that distributed decision making is desirable, it is important to understand existing communication networks in ports and along waterways. The various roles individuals play in networks determine what they say and the response they receive (Monge and Eisenberg, 1987; Tichy and Frombrun, 19791. As discussed in Chapter 5, marine traffic regulation, particularly with regard to VTS systems, is voice-communication intensive. Because of reliance on voice radio for virtually all information, from routine through emergency situations, VTS operations can compound communications problems. Information satura- tion can compromise rather than increase safety. So too can selective screening of information, transmission of important information at inopportune times (such as when two vessels are engaged in bridge-to-bridge communications to avoid or alleviate "in extremis" situationsJ, and reliance on the inefficient means of radio monitoring to provide a complete traffic picture to each vessel's pilot. Electronic data links, already available in the military and beginning to make a debut in commercial marine operations, provide a technological capability that could be used to give more complete information to a vessel for onboard interpretation and use (see Chapters 5 and 6~. The airline industry and its regulator, the Federal Aviation Administration, have developed a communication system employing a highly stylized vocabu

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294 MINDING THE HELM lary that is understood clearly. (As discussed in Chapter 1, a similar vocabulary is available for marine operations but is not widely used.) Even private users must conform to certain standards. The network is fairly well integrated, linking more organizations across a larger geographical area (the entire United States and Pacific Ocean region, for example) than is evident in the marine industry. Some of the aviation industry's characteristics may be appropriate for the marine industry, as discussed in Chapter 5. Culture Ideologies and values (that is, culture) determine behavior (Beyer, 1981~. The development of a culture of safety and reliability along the waterways has become increasingly important to the public. The various cultures of the various segments of the marine industry are the glue binding these segments together (J. Martin, 1992;Ott, 1989;Smirchich, 19831.Public outcry andlegislation,suchas the Oil Pollution Act of 1990, place external pressure on the various segments to develop cultures in which safety is a priority. Furthermore, when pilots find themselves potentially liable for large sums of money, their behavior may be different and perhaps too rigid to be safe than it would be under more realis- tic liability conditions. The United States no longer can afford a marine industry in which participants see themselves as "iron men in wooden ships." The grow- ing interdependence of participants, the pace of technological development, and the sheer size of some vessels (particularly those carrying toxic chemicals and petroleum products) combine to demand a culture of reliability, because the skills and knowledge of teams rather than individuals increasingly are required. In the research literature on safety and culture, very few studies focus on the safety aspects of culture (Koch, 1993~. These aspects are poorly understood in organizations generally and not at all understood in the marine industry. Howev- er, because of the growing interdependence of individuals in this industry, it is clear that authoritative attitudes cannot be tolerated. It is also clear that when large shipping companies downgrade shipboard jobs and pay little attention to crew skill or quality of life, a negative message about the importance of ship- board jobs is sent to crews. The various cultures in the marine industry may vary too widely in nature and be insufficiently understood to ensure the safety of the system. A challenge to the industry is to decide how best to develop reliable and safe organizational cultures. Recent Human Factors Research and Development The Coast Guard, responding to recommendations to improve its capabili- ties to address human performance in marine safety and the Exxon Valdez acci- dent, initiated a human factors program. The agency developed a comprehensive

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A HUMAN SYSTEMS PERSPECTIVE 295 taxonomy to guide data collection (Dynamics Research Corporation, 1989) and then upgraded its marine casualty data collection program to better collect hu- man systems information. This effort includes the training of field personnel to achieve this objective. Data collection under this revised program has only re- cently begun, so the availability of improved human systems data pertaining to marine casualties is several years away, depending upon program success. The agency has also developed an integrated plan for human factors research and development. Research protocols have been identified in the areas of: (1) man- ning, qualifications, and licensing; (2) automation design; (3) safety procedures and data; (4) communications; and (5) organizational practices. The objective of the program is to establish an empirical human factors technical basis for devel- oping technologies and regulations (Sanquist et al., 1993~. The agency is also sponsoring an ongoing assessment of ship-bridge simulation training. Although the research and development budgets of the Maritime Adminis- tration have been severely reduced over the past decade, the agency has contin- ued to sponsor research in advanced navigation technology relevant to human performance. The administration's most significant recent research was develop- ment of the Shipboard Piloting Expert System, which drew heavily on techno- logical developments in the aerospace and defense sectors. The agency also initiated efforts to establish an interagency cooperative research program to ad- vance national capabilities in marine simulation. Maritime Administration-spon- sored research and development during the past five years includes: (1) develop- ment of a shipboard piloting expert system, (2) investigation of the feasibility and applicability of fitness-for-duty monitors to determine readiness to stand watch, (3) development of a computer-based shipboard system to optimize ves- sel passage planning to avoid heavy weather, (4) development of an onboard ship maneuvering simulator, and (5) co-sponsorship of an ongoing examination of ship-bridge simulation training.

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