2

Assessment of Program Documents

The subcommittee reviewed and critically discussed the Coast Guard 's quality action team (QAT) report, the Prevention Through People (PTP) implementation plan, and the Human Factors R&D Program plan. It conducted an overall assessment of each of the three relevant documents (Sanquist et al., 1993; U.S. Coast Guard, 1995, 1996) and identified development activities and R&D projects to strengthen and advance the technical basis and principles of the PTP program. By development activities, the subcommittee means activities outside the realm of basic and applied research, but within the realm of formal R&D, that offer stronger technical support to the prevention effort.

The subcommittee used a number of criteria to assess the Coast Guard objectives that support the PTP program. For each PTP goal and objective (see Table 1-1), the subcommittee discussed whether there was (1) technical and/or scientific support for the objective; (2) a known methodology that could be used to achieve the objective; (3) a development activity that could improve the technical foundation of the objective; (4) a R&D component of the objective; and (5) a gap in the R&D component and, if so, how this could be remedied. Based on its assessment using these criteria, the subcommittee identified a number of both development activities and additional human factors R&D projects that could strengthen and support the goals and objectives of the PTP program. These results are presented in Chapter 3 and Chapter 4, respectively.

CURRENT HUMAN FACTORS R&D PROGRAM

The scope of the subcommittee's study did not include an in-depth review of all specific, ongoing R&D projects and the interim reports that are available. Such a review should be undertaken by the Coast Guard if the end products of the R&D projects are to be aligned to the extent possible with the goals and specific objectives of the PTP program. However, the subcommittee 's review of documents yielded the following important points.

  1. The focus of ongoing human factors research projects is on deep draft commercial vessels and large passenger vessels. Although this focus is a legitimate effort, the PTP program also gives explicit consideration to a full range of high-risk sectors (e.g., the towing/barge industry, fishing vessels, and other operations in which the greatest safety problems exist in terms of accidents, fatalities, injuries, and spills), which the current Human Factors R&D Program plan does not specifically target. This difference implies that the Coast Guard 's human factors R&D effort should be expanded to be commensurate with the scope of the PTP program.

  2. One of the guiding principles of the PTP program seems totally lacking from the Human Factors R&D Program: Honor the mariner. It is important to honor the mariners not only because they have to be partners in the process if they are to readily accept the results of the process but also because the mariners themselves are being studied. The definition of the



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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM 2 Assessment of Program Documents The subcommittee reviewed and critically discussed the Coast Guard 's quality action team (QAT) report, the Prevention Through People (PTP) implementation plan, and the Human Factors R&D Program plan. It conducted an overall assessment of each of the three relevant documents (Sanquist et al., 1993; U.S. Coast Guard, 1995, 1996) and identified development activities and R&D projects to strengthen and advance the technical basis and principles of the PTP program. By development activities, the subcommittee means activities outside the realm of basic and applied research, but within the realm of formal R&D, that offer stronger technical support to the prevention effort. The subcommittee used a number of criteria to assess the Coast Guard objectives that support the PTP program. For each PTP goal and objective (see Table 1-1), the subcommittee discussed whether there was (1) technical and/or scientific support for the objective; (2) a known methodology that could be used to achieve the objective; (3) a development activity that could improve the technical foundation of the objective; (4) a R&D component of the objective; and (5) a gap in the R&D component and, if so, how this could be remedied. Based on its assessment using these criteria, the subcommittee identified a number of both development activities and additional human factors R&D projects that could strengthen and support the goals and objectives of the PTP program. These results are presented in Chapter 3 and Chapter 4, respectively. CURRENT HUMAN FACTORS R&D PROGRAM The scope of the subcommittee's study did not include an in-depth review of all specific, ongoing R&D projects and the interim reports that are available. Such a review should be undertaken by the Coast Guard if the end products of the R&D projects are to be aligned to the extent possible with the goals and specific objectives of the PTP program. However, the subcommittee 's review of documents yielded the following important points. The focus of ongoing human factors research projects is on deep draft commercial vessels and large passenger vessels. Although this focus is a legitimate effort, the PTP program also gives explicit consideration to a full range of high-risk sectors (e.g., the towing/barge industry, fishing vessels, and other operations in which the greatest safety problems exist in terms of accidents, fatalities, injuries, and spills), which the current Human Factors R&D Program plan does not specifically target. This difference implies that the Coast Guard 's human factors R&D effort should be expanded to be commensurate with the scope of the PTP program. One of the guiding principles of the PTP program seems totally lacking from the Human Factors R&D Program: Honor the mariner. It is important to honor the mariners not only because they have to be partners in the process if they are to readily accept the results of the process but also because the mariners themselves are being studied. The definition of the

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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM Human Factors R&D Program should involve those in the Coast Guard and associated marine industries who have current and daily responsibilities for marine safety. Without this involvement, the Human Factors R&D Program could become irrelevant to current and future problems in the field. Identification of efforts that can provide important and near-term benefits will be missed without such involvement. This involvement can improve dissemination of knowledge to the field and to the office. The reliance of the program on interviews with personnel at the Coast Guard Headquarters seems to limit the recommendations emerging from the program to Coast Guard application (Sanquist et al., 1993:13). The subcommittee believes that this should be revised to be inclusive of the entire maritime industry. The human factors development projects could be directed toward effective dissemination of knowledge to seamen, first through pilot demonstration projects and then through workshops, courses, symposia, and conferences. It is important to involve individuals who have daily responsibilities for marine safety and those who want to learn and help improve human factors and safety in the marine industries. The focus of the Human Factors R&D Program could then be broadened from individual seamen to include crews and teams and the organizational influences that have major and dramatic influences on the incentives, attitudes, behaviors, and performance of seamen. Incentives are a key to attitudes and behavior. Behavior is a key to performance. Development of positive incentives (e.g., social, monetary) can provide important resources for application of the principles of and knowledge about human factors. U.S. business management decisions regarding expected economic benefits are not always based on data or knowledge, but are often based on what is “acceptable” or “necessary” for success. The incentives that motivate management behavior are often clearly economic, but the results have important social consequences. However, downsizing and outsourcing, re-engineering, total quality management and International Standards Organization certification have demonstrated the importance of non financial incentives for companies as well. The Human Factors R&D Program could focus on ways to better utilize existing knowledge of human factors within the Coast Guard and its associated activities. Coast Guard demonstration or pilot projects could be used as “show pieces” to illustrate the benefits and challenges associated with implementation of human factors principles (e.g., see McCormick and Sanders, 1982, or other human factors and ergonomics texts). It could also focus on the enhancement of communications within the Coast Guard and within industry. These communications range from individual seamen (with minimal reading skills), to crew communications (e.g., multiple languages and cultures within crews), to interagency, company, and group communications. The means to enhance communication exist and others could be developed to overcome punitive and legal barriers to such communications. The Federal Aviation Administration and the commercial air transportation industry have developed useful and effective, though not perfect, models (e.g., the Aviation Safety Reporting System (ASRS); see Chapter 3 for more information on the ASRS) that could be adapted to the marine industry. Through closer coordination with related R&D activities being conducted by industry, classification societies, other private and government research agencies, and academia—for example, in meetings to discuss developments and exchange information and views—the Human Factors R&D Program could take better advantage of the scarce intellectual

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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM and monetary resources that are now available for investment in improved safety and operations. Cooperative multisponsor projects could combine the input and efforts of industry, government, and academia. One particular outcome of having limited resources and time has been the overutilization of sole-source expertise and a lack of peer review, a situation in which the organization that identifies research needs is the same organization that conducts the research. The Coast Guard Research and Development Center should be provided with the mandate and resources to take advantage of best practices of openness and competitive bidding with peer review. This is essential to the credibility and quality of the R&D that is conducted.1 Establishing priorities in the Human Factors R&D Program is a key issue. Careful choices need to be made to balance both short-term objectives and long-term goals and to balance what can be done and what should be done. Such prioritization could leverage the talents and backgrounds that are available, especially by taking advantage of participation and monetary support accruing through coordinated efforts with classification societies, industrial organizations, and academia. One way to make more informed and balanced choices among competing priorities would be to utilize an external advisory committee composed of individuals from academia and industry. This may give greater credibility to the work conducted under the auspices of the R&D Center. Similar external advisory groups currently exist that support the efforts of numerous other government agencies, including the Department of Defense's Air Force Office of Scientific Research, the Department of Transportation, the National Institutes of Health, and the National Science Foundation. The subcommittee believes that reporting arrangements should be such that the Human Factors R&D effort is directly responsive to Coast Guard operational needs in an ongoing manner and to the PTP effort in particular. More specifically, an ongoing and institutionalized mechanism could be devised between the Coast Guard's line offices and the R&D Center to coordinate their activities on a regular basis, especially in developing requests for proposals. PREVENTION THROUGH PEOPLE PROGRAM In the executive summary of the QAT report and elsewhere in the document, it is stated that, “Human error causes more than 80 percent of marine casualties” (U.S. Coast Guard, 1995:1). The subcommittee believes that this statement tends to “blame the operator” to a greater degree than is justifiable. Although there clearly are some cases in which humans are the direct cause, more often there are error-inducing characteristics in maritime systems that result in human error. This QAT statement appears to blame the individual for maritime accidents and injuries. Because there is a common tendency to “blame the operator,” the subcommittee suggests that this statement be reworded carefully to give the correct intent (as is 1   It should be noted that the committee did not assess in-house Coast Guard expertise because it was beyond the scope of this study.

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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM supported by the documentation in the report and research findings within the discipline of human factors and organizational studies). Although it was noted in the QAT report that the greatest safety improvements can be realized in the high-risk sectors,2 these sectors were not clearly targeted in the PTP implementation plan. For example, the Coast Guard has prepared a PTP pamphlet, which briefly describes the PTP program, for distribution to the maritime community; but the pamphlet does not target particular sectors. To further strengthen the Coast Guard's position that sector-specific efforts can be made to improve safety, the subcommittee suggests that inserts tailored to each sector be prepared for inclusion in the PTP pamphlet. It is the subcommittee's belief that this will both clarify and help gain acceptance for the PTP program within the respective sectors. SUMMARY The subcommittee's review of program documents did not encompass a detailed review of individual projects, but the subcommittee believes that the Coast Guard must institute such a comprehensive review of current R&D projects to ensure that each one is compatible with the goals and objectives of the PTP program and to determine if they need to be or can be refocused to more directly support PTP goals. Assessing the Human Factors R&D Program in very broad terms, the subcommittee notes the lack of targeting of high-risk sectors; an absence of the “honor the mariner ” principle, whereby the vital importance of the individual seaman as both recipient and source of information should guide the process of improving safety; and a need for more effective utilization and dissemination of knowledge about human factors at all levels. Recommendations for specific activities that the Human Factors R&D Program could undertake are presented in Chapter 4. With respect to the PTP program, the subcommittee emphasizes that the wording “human error” is misleading because one tends to interpret this as meaning that the human is the cause of the error, rather than that there are often error-inducing characteristics in the system that result in people making errors. This often leads to a “blame the operator” (i.e., blame the person who made the “error”) mentality, which needs to be overcome. Keeping this point in mind, the PTP program is an important advance in its approach to safety, and significant improvements can be realized in the high-risk sectors that have been largely ignored, particularly by the Coast Guard's Human Factors R&D Program, in the past. Ways of strengthening the PTP program through development activities are discussed in Chapter 3. 2   The high-risk sectors are: towing vessel/barge operations, tankship operations, fishing operations, passenger vessel operations, and offshore supply vessel operations.

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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM REFERENCES McCormick, E.J., and M.S. Sanders. 1982. Human Factors in Engineering and Design. 5th ed. New York: McGraw-Hill. Sanquist, T.F., J.D. Lee, M.B. Mandler, and A.M. Rothblum. 1993. Human Factors Plan for Maritime Safety. Technical report no. CG-D-11-93. Washington, D.C.: U.S. Department of Transportation. U.S. Coast Guard. 1995. Prevention Through People Quality Action Team Report. Washington, D.C.: U.S. Department of Transportation. U.S. Coast Guard. 1996. Prevention Through People Implementation Plan Draft Report. Washington, D.C.: U.S. Department of Transportation.

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