3

Improving the Technical Basis for the Prevention Through People Program

On the basis of its assessment of the Prevention Through People (PTP) program, the subcommittee identified a number of activities that, although outside the realm of traditional basic and applied research, is within the realm of formal R&D and could strengthen the technical foundation of the PTP program and provide insights for expanding the program. The suggested “development activities” are as follows: near-miss/incident reporting, evaluation, and dissemination; PTP information dissemination strategies; accident reporting and evaluation; organizational self-assessment instruments; risk analysis and management; annual PTP conferences; data utilization; and cooperative best practices.

The subcommittee assessed the potential contribution of these activities to the PTP program. Consistent with its charge, the subcommittee does not make any recommendations concerning the undertaking of these development activities because they are not based on direct scientific evidence; however, the subcommittee believes that these activities are essential if the PTP program is to have industry support and a long-term impact on maritime safety. The observations and comments of the subcommittee on each activity are presented below.

The PTP program, as noted in Chapter 1, has five goals, each with accompanying objectives. The goals emphasize “more” (e.g., “do more,” “train more,”). Interpreting “more” to imply “better” or “smarter,” the subcommittee discussed ways to achieve each goal. Each activity discussed below is listed under the goal it most directly supports; however, in the accompanying boxes additional goals and objectives supported by each activity are also included. In addition, Table 3-1 indicates the degree to which each suggested activity supports each PTP goal. At the end of each goal section, comments the subcommittee has on specific objectives within that goal (see Table 1-1) are presented.

KNOW MORE

The “know more” goal may be the hardest of all the PTP goals because of potential legal barriers (discussed below) that may have to be imposed to protect the civil and potentially criminal rights of both licensed individuals and vessel owners. However, meaningful progress in the understanding of the human element in maritime operations and accidents would be unlikely without improvement in this area.



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM 3 Improving the Technical Basis for the Prevention Through People Program On the basis of its assessment of the Prevention Through People (PTP) program, the subcommittee identified a number of activities that, although outside the realm of traditional basic and applied research, is within the realm of formal R&D and could strengthen the technical foundation of the PTP program and provide insights for expanding the program. The suggested “development activities” are as follows: near-miss/incident reporting, evaluation, and dissemination; PTP information dissemination strategies; accident reporting and evaluation; organizational self-assessment instruments; risk analysis and management; annual PTP conferences; data utilization; and cooperative best practices. The subcommittee assessed the potential contribution of these activities to the PTP program. Consistent with its charge, the subcommittee does not make any recommendations concerning the undertaking of these development activities because they are not based on direct scientific evidence; however, the subcommittee believes that these activities are essential if the PTP program is to have industry support and a long-term impact on maritime safety. The observations and comments of the subcommittee on each activity are presented below. The PTP program, as noted in Chapter 1, has five goals, each with accompanying objectives. The goals emphasize “more” (e.g., “do more,” “train more,”). Interpreting “more” to imply “better” or “smarter,” the subcommittee discussed ways to achieve each goal. Each activity discussed below is listed under the goal it most directly supports; however, in the accompanying boxes additional goals and objectives supported by each activity are also included. In addition, Table 3-1 indicates the degree to which each suggested activity supports each PTP goal. At the end of each goal section, comments the subcommittee has on specific objectives within that goal (see Table 1-1) are presented. KNOW MORE The “know more” goal may be the hardest of all the PTP goals because of potential legal barriers (discussed below) that may have to be imposed to protect the civil and potentially criminal rights of both licensed individuals and vessel owners. However, meaningful progress in the understanding of the human element in maritime operations and accidents would be unlikely without improvement in this area.

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM Near-Miss/Incident Reporting, Evaluation, and Dissemination BOX 3-1 Near-Miss/Incident Reporting, Evaluation, and Dissemination This activity supports objectives 1.2, 1.4, 1.5, 2.3, 2.4, 3.1, 3.2, 3.4, 3.5, 3.6, 3.7, 4.2, 4.3, 5.1, 5.3, and 5.4 (see Table 1-1 for a description of each objective). All five PTP goals and many of their accompanying objectives, to varying degrees, would be supported and reinforced by a development project on near-miss/incident reporting, evaluation, and dissemination. In fact, developing this type of reporting system is requisite to pursuing many of the PTP objectives because these objectives require data that would emerge from the reporting system. A high-quality near-miss reporting system would benefit the marine industry for many reasons. For example, it could provide early warnings of potential degradation in the system safety provide symptomatic indications of the causes and sources of system safety degradation promote understanding of initiating, contributing, and compounding causes derive benefits from the Aviation Safety Reporting System (ASRS) (a near-miss reporting system for the aviation industry) and related developments heighten awareness of and reinforce PTP principles provide feedback on the effectiveness of strategies and procedures for risk management A near-miss reporting system is complex, having several aspects that must be considered carefully. First, a near-miss reporting system should incorporate information gathered throughout the life cycle of a marine system including design, construction, operation, and maintenance. Second, as learned during the development and implementation of the ASRS over the past 10 years, an effective near-miss reporting system should include a definition of the following processes: reporting, investigation, information encoding, information analysis, reporting and information dissemination, and system administration and organization. Further refinement of these processes can be expected to emerge from current efforts to revise the ASRS that are aimed at identifying contributing and propagating events and factors, organizational influences, and database fields so the “richness” of the original near-miss reports and investigations (i.e., call backs—phone calls made to the individual reporting an

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM incident to obtain additional information and clarifications before the identifying information such as the person's name and phone number is removed to assure anonymity) can be maintained. TABLE 3-1 Development Activities and Their Capacity for Strengthening the Technical Basis for achieving PTP Goals

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM Third, a near-miss reporting system should encourage information collection from all sectors responsible for the safety of marine systems. As was learned in the aviation industry, for such encouragement to inspire widespread participation, the system must provide anonymity and timely, accurate, meaningful feedback. As was found in the case of the ASRS, congressional protection against litigation is necessary for the reporting system to be successful. A database with limited immunity for individuals reporting incidents, equivalent to the immunity provided by the ASRS, would be essential. Fourth, a near-miss reporting system requires an agreement about the responsibilities and accountabilities to the system by all sectors —including the Coast Guard, classification societies, industry associations, owners and operators, manufacturers and builders, maintenance service (inspection, repair), unions, insurance companies, and legal representatives. A particularly important question is who would undertake to adapt a reporting system to the marine environment and serve as its custodian. The ASRS appears to have worked well for the aviation industry and could be studied for potential adaptation to the marine industry. Its success may be due in part to the efforts of the major air carriers. Several airlines have begun to operate their own private reporting systems that are shared to a limited degree with the Federal Aviation Administration (FAA) but not with other airlines. These Aviation Safety Action Programs(ASAPs) have been formalized and defined by the FAA and are described in the FAA Advisory Circular 120-66, January 8, 1997. The ASAP was an outcome of a Department of Transportation safety conference held January 9–10, 1995. The ASAP is modeled after the original ASAP, which was developed by American Airlines. The individual airline approach allows each airline to analyze its problem areas in greater depth because they can then relate the reports to their specific operating environments. It also allows them to make immediate changes if necessary to increase the safety of their operations. Because the data remain the property of the airline, the reports are protected from Freedom of Information Act requests. The American Airlines ASAP creates an official ASRS report for anyone reporting to the airline's system, thereby ensuring federal protection from legal enforcement action provided by the ASRS and, in addition, allowing for system-wide problems to be tracked by the ASRS. Instituting a near-miss reporting system in the marine community, although in the opinion of the subcommittee is virtually a requirement for implementing the PTP program, will be difficult, partly because of the relatively small size of marine companies compared with commercial aviation companies. Perhaps the most troublesome issues would be those in the legal area. However, legal or regulatory obstructions that could prevent the immediate implementation of an ASRS-like system within the marine community could be anticipated early in the development process and the required corrective actions identified, using the ASRS experience as a guide. Regardless of the obstacles, given the large number of individuals and vessels operating under the International Safety Management (ISM) Code (a total quality management (TQM) program) or similar program, this seems the appropriate time to develop a near-miss reporting system that would provide one means of monitoring. If such a system is implemented, a follow-up evaluation of effectiveness and fine-tuning should be conducted as necessary.

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM Strategies for Disseminating PTP Information BOX 3-2 Strategies for Disseminating PTP Information This activity supports objectives 1.1, 1.2, 1.3, 1.4, 1.5, 2.1, 2.2, 2.3, 2.4, 3.2, 5.1, 5.2, 5.3, and 5.4 (see Table 1-1 for a description of each objective). Strategies for disseminating PTP information to Coast Guard personnel and industry, including mariners, will be critical to the success of the PTP program. In aviation and various other industries, organizations share safety information (National Research Council, 1980; U.S. General Accounting Office, 1990). This type of sharing could greatly benefit organizations within the marine industry. One current objective of the “do more” goal is to create avenues for sharing information (objective 3.2) that will directly impact the “do more” goal, and there are a number of activities that could provide support for this objective. Dissemination to mariners is critical. For example, the fishing industry is comprised of a full range of vessels from small, undocumented inshore vessels to large factory ships. Among the maritime industries, corporate entities are much easier to target than small, independent operators. Coast Guard policy letters, the Federal Register, and navigation and vessel inspection circulars are not effective in disseminating information because of the limited number of people they reach. Providing information through trade organizations and trade journals, as well as through government agencies, training organizations, technical schools, and marine suppliers, may be the best way to reach marine audiences. (For specific examples of successful dissemination strategies, see The Economist, 1994; SEMATECH, 1992; SEMI, 1993; SIA, 1993a,b;) PTP information dissemination strategies could provide essential feedback access to data and information notice of data and information to all participants (from CEO level to seamen)

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM General Comments Objective 1.2. Improve marine safety investigation processes so as to develop more timely, accurate, and comprehensive determinations of causes, with emphasis on the contributions of the human element. To improve marine safety investigations, the Coast Guard could collect success (and failure) reports and determine their potential applicability in the marine industry. Also, a methodology using root cause (or root factor) analysis, tailored for the marine industry and taking legal issues into account, could be developed. This objective is related to organizational and work system design factors and contains two parts: (1) development of appropriate methodologies and (2) development of a practical plan to implement a root cause analysis that falls within legal constraints. Objective 1.3. Show how PTP is cost effective. To demonstrate the cost effectiveness of the PTP program, case history data for similar initiatives in other industries could be compiled (e.g., Hendrick, 1996). The data should include direct and indirect costs. There should also be evidence available from companies that have put training programs, TQM programs, and other programs into effect to show empirical evidence of cost savings. This is especially true of companies with TQM programs in which “price of nonconformance ” is measured routinely. The subcommittee notes, however, that the way a TQM is implemented is critical to its usefulness (Druckman et al., 1997; Hackman and Wageman, 1995). These data should also be available from the classification societies and the American Waterways Operators (AWO), which as part of its AWO Vision 2000 strategy is developing industry-wide data on safety. Objective 1.5. Gain a better understanding of safety from the mariner 's perspective. This objective has yet to be addressed. The subcommittee believes that the mariner is a resource that the Coast Guard has not tapped adequately. The mariner could be the source of much of the best information about issues and solutions in the area of human factors, particularly with respect to design and layout. Pursuit of the mariner's perspective, which is participatory ergonomics, could be made more effective by training mariners (in a one- or two-day seminar) in principles of human factors. Demonstration studies should be conducted to show that such training is feasible in different sectors of the industry. TRAIN MORE The “train more” goal focuses on identifying the skills that people need to do their jobs and the best means of providing these skills. Marine simulation at all levels could be promoted as one tool for training and measuring proficiency (National Research Council, 1996). Large

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM simulators facilitate training and testing people in teamwork on the bridge, in the pilothouse, in cargo handling, and in engine room operations. Use of simulators should be considered as an addition to the PTP objectives for the “train more” goal. The Coast Guard should closely follow developments of industry-sponsored simulator facilities such as those at the Raymond T. McKay Simulation Training and Research Center at Dania, Florida, and Toledo, Ohio; and at the Maritime Institute of Technology and Graduate Studies in Linthicum Heights, Maryland. There is also a facility under construction in Paducah, Kentucky, that will focus on inland operations. Perhaps the Coast Guard, working in conjunction with the companies who have invested in these facilities, could lay the groundwork for pursuing the several “know more” and “train more” objectives by participating in training sessions with the practitioners at these facilities. Objective 2.1. Implement the Standards for Training, Certification, and Watchkeeping Convention (STCW). Implementation of the STCW does not apply uniformly to all sectors. The Coast Guard should foster adoption of the principles embodied in the STCW. Such an approach may result in safety improvements that otherwise might not occur because of the perceived inapplicability of the STCW. To the extent that the maritime community needs a better understanding of the underlying principles of the STCW before adopting them, the Coast Guard's role could be to aid in this increased understanding. Furthermore, the subcommittee believes that a corollary objective to “develop and promulgate understandable STCW implementation guidance to the field” (U.S. Coast Guard, 1996) should be expanded to read “STCW and International Safety Management (ISM) implementation,” because the STCW and ISM are critically connected. Objective 2.2. Increase the human element focus in Coast Guard education, training, and job recruitment. The subcommittee believes that this objective could be broadened or supplemented to be inclusive of the entire maritime industry. Training in such areas as leadership, professional responsibility, and participatory ergonomics could be taught at all entry-level institutions, whether federal, state, company, or union. Many companies, particularly large firms, have been conducting such training for all levels of seagoing personnel for several years, and these programs should be recognized. The now-defunct U.S. Navy Correspondence program1 could be reviewed to determine if its contents are applicable, and, if so, a similar program of correspondence courses could be designed for mariners. 1   The U.S. Navy Correspondence program was a service-wide correspondence course under the auspices of the Chief of Naval Education and Training Command, headquartered at the Naval Air Station, Pensacola, Florida. The courses were administered from the Navy Correspondence Course Center at Scotia, New York.

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM Objective 2.3. Develop continuing education professional training program for mid/senior management and officers in human element causes and prevention of accidents. The subcommittee questioned whether this objective should be directed at the Coast Guard only or whether it should be extended to include industry as well. This objective is related to the annual conferences on PTP best practices and experiences, which the subcommittee suggests as a Coast Guard initiative (see discussion below under “Cooperate More”). Objective 2.4. Infuse human element issues into all maritime training and education courses. The subcommittee recognizes that the objective of infusing human element issues into all maritime training and education courses is very broad, but the subcommittee believes that this objective is worthwhile and that there are a number of steps that can be taken to achieve it. For example, basic ergonomics training programs in other industries may be adaptable to the maritime industry. In addition to these basic programs, more extensive, tailored safety ergonomics training packages could be developed. However, follow-on field studies would need to be conducted to determine the training impact for each training program. DO MORE The “do more” goal requires implementing what is known. It requires partnerships, comprehensive risk assessments, open sharing of information, and other efforts to establish an atmosphere that encourages safety. Reporting and Evaluating Accidents BOX 3-3 Reporting and Evaluating Accidents This activity supports objectives 1.2, 1.5, 2.3, 2.4, 3.1, 3.2, 3.4, 3.5, 3.6, 3.7, 4.2, 4.3, 5.1, 5.3, and 5.4 (see Table 1-1 for a description of each objective). A system of analysis to trace the chain of events and identify root causes or factors of accidents in the maritime transportation system could be developed to further strengthen the

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM PTP program's goal for improved safety (i.e., fewer and less consequential accidents). (An example of such a system is presented and illustrated for the case of the Piper Alpha accident in Paté-Cornell, 1993, 1995.) This effort would provide support in varying degrees for all five PTP goals (see, for example, the discussion above on objective 1.2 regarding the “know more” goal). Improved accident investigation, analysis, and reporting is necessary for a number of reasons. High-quality near-miss information systems can provide essential “real-time” information on the safety of marine systems, and this information can be used in the development of proactive strategies for managing risk. On the other hand, high-quality accident information systems can provide “reactive” information on the safety of marine systems. Understanding the causes of accidents can aid in the identification of future risk management measures. High-quality near-miss and accident reporting systems provide important information and data for risk analyses. High-quality accident information systems can provide opportunities to learn from past mistakes in-depth understanding of failures in systems (i.e., hardware, structure, operators, organizations, procedures, environment) dissemination of lessons opportunities to conduct trend analyses and indications indices of relative performance of industry sectors and components feedback on the effectiveness of processes and measures of risk management For an undertaking of this magnitude, it might be beneficial to create a standing group whose mission is to continually improve the measurement and analytical techniques of accident review and root cause analysis. Active participation of industry members and classification societies, as well as representatives from the marine insurance community, would be useful. Organizational Instruments for Self-Assessment BOX 3-4 Organizational Instruments for Self-Assessment This activity supports objectives 1.1, 1.1,1.2, 1.4, 1.5, 3.1, 3.2, 3.4, 3.5, 3.7, 3.8, 4.2, 4.3, 5.1, 5.2, 5.3, and 5.4 (see Table 1-1 for a description of each objective.)

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM Organizations may be unaware of how they impact the safe performance of their operations; thus, it would be helpful to develop means by which organizations can obtain feedback on their impact so as to make necessary changes. A self-assessment instrument for assessing organizational influences on the safety process, based on evaluations and modifications of existing validated instruments, is one type of instrument that could be developed. These instruments could provide feedback from organizational participants identification of strengths and weaknesses in system safety early warnings of emerging error-inducing elements that contribute to and compound organizational developments information on the effects of policies, procedures, and regulations Risk Analysis and Management BOX 3-5Risk Analysis and Management This activity supports objectives 1.2, 1.5, 2.2, 2.3, 2.5, 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 3.7, 3.8, 4.1, 4.2, 5.1, 5.2, and 5.4 (see Table 1-1 for a description of each objective). Risk analysis and management is a key activity in support of the PTP program. Risk analysis is an attempt to understand the potential strengths and weaknesses of a system. Once the weaknesses are understood, effective strategies for managing risk can be identified and implemented. Marine risk analysis should address, in an integrated and realistic manner, all relevant components of a marine system—including the operating personnel, organizations, procedures, hardware and equipment, environments—and the interfaces and interactions of these components. The risk analysis should address the life-cycle phases of marine systems, including design, construction, operation, and maintenance. Risk management should address evaluations of costs and benefits; consequences; trade-offs; safety targets; and effective, efficient procedures and processes for applying the insights developed from risk analyses. Procedures and processes for risk management must be linked with the procedures and processes associated with risk analysis. A body of literature on this issue is available in the nuclear industry and published by the U.S. Nuclear Regulatory Commission on this issue (e.g., Apostolakis, 1982, 1990; Apostolakis and Wu, 1995; Apostolakis et al., 1990; Dougherty and Fragola, 1986; Gertman

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM and Blackman, 1994; Humphreys, 1988; Meshkati, 1991a,b; Meshkati, et.al., 1993, 1994; Orvis et al., 1993; Reece and Gertman, 1991; Swain, 1982; Swain and Guttman, 1983; Wells and Ryan, 1991; Wu et al., 1991). A comparable body of literature and background is available from the military (e.g., U.S. Department of Defense, 1989, 1995), aviation (e.g., Pidgeon and O'Leary, 1994; Wiener and Nagel, 1988), chemical refining (e.g., Center for Chemical Process Safety, 1989, 1994; Chemical Manufacturers Association, 1990; Kirwan, 1994), medical (e.g., Bogner, 1994; Cook and Woods, 1990; Henriksen et al., 1993), and offshore platform industries (e.g., Bea, 1992, 1994; National Research Council, forthcoming a,b). There is a wide variety of approaches to risk analysis that range from qualitative (e.g., Groeneweg, 1994; Hudson et al., 1996; Hurst et al., 1992) to quantitative (e.g., Center for Chemical Process Safety, 1989, 1994). Although quantitative methods have been highly developed for the hardware, equipment, and structural components of systems, they have not been highly developed for the operating personnel and organizational components. A study of the available literature represents an important starting point for making progress in PTP risk analysis and management. The Coast Guard is developing a set of integrated and comprehensive processes for risk analysis and risk management that includes systematic consideration of the human element and organizational factors. Experience from other industries could be studied to determine how best to integrate human and organizational factors into the risk analysis and risk management processes used by the maritime industry. The subcommittee notes the Coast Guard's initial use of risk assessment methods in the Marine Safety Evaluation Program for determining alternative regulatory compliance with Coast Guard regulations. The risk analysis and risk management processes should be meshed carefully with the accident and near-miss information systems to increase the reliability of the results and to provide information to help verify the analyses and the effectiveness of the management strategies. Different types of risk analysis and risk management processes should be developed to address different types of system safety hazards, life-cycle phases, and management strategies. The risk analysis and risk management processes should be verified with applications and field tests; they should include definitive guidelines for applications to help ensure veracity and consistency of results; and they should address the experience, training, and qualifications of those who perform the analyses. General Comments Mid-level and senior level managers in organizations often do not know how to initiate changes, especially in the face of existing barriers imposed by governmental regulations, laws, company policies and procedures, union contracts, tradition, and lack of knowledge of alternatives. There is a need to identify and examine these potential barriers and develop strategies to overcome or accommodate them.

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM Objective 3.7. Focus Coast Guard preventive programs. The subcommittee suggests that this objective be extended to read, “focus Coast Guard preventive programs to avoid duplication and to implement PTP.” Objective 3.8. Apply PTP to the U.S. commercial fishing vessel industry. The subcommittee is pleased to note that this objective has been initiated recently by a Coast Guard fishing industry initiative called the “Fishing Vessel Human Factors Study.” Its objectives are to develop a standard stability aid (i.e., a “best practices” guide) conduct an assessment of program development improve public relations The subcommittee questions, however, why other high-risk sectors have not yet been targeted as well and suggests that the Coast Guard consider doing so. OFFER MORE The PTP program encourages cooperation and active participation so that more than minimum safety standards will be met. Incentives and reward programs are one means of encouraging high-quality safety management systems. General Comments Objective 4.2. Evaluate ongoing and future projects and policies to support program emphasis on PTP. In support of this objective, the subcommittee suggests implementation of a criterion-based system of performance appraisal for safe work methods. This involves tangible measures for work methods, such as frequency and severity of back injuries, slips and falls, and lacerations, to name but a few. Objective 4.3. Identify incentives to reward safety and human element-based prevention strategies and begin process to visibly implement the incentives. Concurrently, identify and address impediments to a safety culture. The concept of “safety culture” should be researched to provide support for the “know more” goal as well as the “offer more” goal. As part of this research, the impact of the

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM national (societal) culture on its components, within the context of the maritime industry, should also be clearly examined and determined. The research aspect of this objective is discussed in more detail in Chapter 4, where the subcommittee's recommendations for high-priority human factors R&D activities are set forth. Objective 4.3 has a corollary objective, which is to “revise the procedures for issuing CG-835s (repair requirements), issuing 835s only to quality operators while citing other operators or requiring compliance before further operation” (U.S. Coast Guard, 1996). Forms 835 and 2692 should be reviewed to determine if any revision is required in light of the PTP program or to allow for the reporting of human element and organizational factors. A form in addition to form 835 may be required because form 835 has some legal implications (for example, the captain is responsible for corrections and fixes required by form 835; however, if, for example, there is an organizational deficiency, this deficiency cannot be corrected by the captain). Objective 4.4. Institute a PTP award. This objective, associated with objective 4.3, is to identify incentives to reward safety and human element-based prevention strategies (discussed further in Chapter 4). A PTP award should include incentives from insurance companies (i.e., incentives in the form of reduced rates for taking preventive measures that have proved to reduce accidents and related costs). COOPERATE MORE The “cooperate more” goal encourages the sharing of information, such as lessons learned, that can benefit others in the marine community. One means of implementing this goal is to establish partnerships; as noted above, the formation of partnerships is one of the major thrusts of the PTP program and has much potential in terms of improved safety. Partnerships will encourage the sharing of information, such as might occur in conferences, and data and research results, which will speed and strengthen the development of safety improvements. Annual PTP Conferences BOX 3-6Annual PTP Conferences This activity supports objectives 1.1, 1.2, 1.3, 1.4, 1.5, 2.1, 2.2, 2.3, 2.4, 3.2, 3.4, 3.5, 3.7, 3.8, 5.1, 5.2, 5.3, and 5.4 (see Table 1-1 for a description of each objective).

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM Annual conferences on PTP best practices and experiences could be organized and conducted by the Coast Guard. An annual conference could be comparable to the by-invitation-only meeting hosted by the FAA annually, which involves representatives from each of the major commercial airlines, developers, and maintainers, and whose purpose is to share best practices. Another model for an annual conference is one with open attendance, such as the annual conference of the Center to Protect Worker Rights, which has stimulated ideas for reducing injuries and has led to action by some companies. The exchange of information is critical to the success of the PTP program. An annual PTP conference could support a constructive discussion of lessons learned. An annual conference might include discussions of near misses; accidents; development activities; implementation; emerging problems; and audits, assessments, and inspections. This conference could also be used to broadcast and celebrate successes, perpetuate momentum, identify new partners, identify development approaches, and provide feedback to government and industry. Data Utilization BOX 3-7Data Utilization This activity supports objectives 1.1, 1.2, 1.3, 1.4, 3.2, 3.3, 3.4, 3.5, 3.8, 4.2, 5.1, 5.2, 5.3, and 5.4 (see Table 1-1 for a description of each objective). Methods and other guidance for data capture and dissemination that exist outside the maritime industry can be adapted (e.g., the OSHA 200 Reporting System). Such an adaptation is needed because the methodology and necessary template for collecting data currently do not exist within the Coast Guard. Organizational, job, and individual factors need to be captured as well. Appendix B of the QAT (quality action team) report (U.S. Coast Guard, 1995) identifies shortfalls with current data analyses. Improvements in data and data analysis will help the PTP program establish a basis from which to measure its “successes.” For example, the numbers associated with casualty and pollution incident data in Appendix D of the QAT report (U.S. Coast Guard, 1995) are alarming for the fishing industry sector. Ratios related to volumes/numbers and types of vessels would be helpful, and there is need for a reliable database. The pie charts in Appendix D of the QAT report are for the period 1983–1993. The statistics shown by the charts may be misleading because they span a period of 10 years during which significant developments in the fishing industry took place. The commercial fishing industry was virtually unregulated until 1991, and the regulations that went into effect that

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM year (46 CFR Part 28) took several years to produce improvements in rates of injuries and fatalities. For example, in Alaska, through August 1996, where the highest level of fishing activity takes place, 15 lives were lost and 45 lives “saved.” The 17th Coast Guard District is doing a much better job of tracking the number of saved lives, which indicates that crews are better able to respond to emergency situations. Cooperative Best Practices BOX 3-8Cooperative Best Practices This activity supports objectives 1.1, 4.3, 4.4, 5.1, 5.2, 5.3, and 5.4 (see Table 1-1 for a description of each objective). A system for collecting and sharing information on best practices within the industry should be developed. This system could capture best practices from other industries that appear to be adaptable to the maritime industry. Toward this end, the Coast Guard could study other industries to identify successful partnerships, techniques, and methods that might be adaptable to the maritime industry. Successful methods from these industries can then be adapted and pilot tests conducted (National Research Council, forthcoming a,b). A follow-up mechanism to encourage and track implementation should be developed. The Coast Guard could then establish systematic partnership programs with industry. Insofar as reinforcing safe attitudes is a key to promoting safe behavior, the PTP program will benefit from greater recognition of partnerships and efforts to improve safe practices (e.g., partnerships with the Occupational Safety and Health Administration in the Volunteer Prevention Program); from the open exchange of information; and from the examination and adaptation, where appropriate, of lessons learned by others. Much has been learned about the role of human and organizational performance in system safety, and prevention programs that incorporate these factors could result in safer, more cost-effective operations. FINDINGS The subcommittee believes that there is tremendous value in the PTP concept, particularly in its balanced approach to risk management. The subcommittee finds, however, that a number of activities, which for convenience the subcommittee calls “development activities,”

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM will strengthen the technical basis for the PTP program. Important R&D efforts are identified in Chapter 4, some of which are not new or unique to any sector but should be undertaken in an attempt to realize dramatic safety improvements. REFERENCES Apostolakis, G.E. 1982. Data analysis in risk assessments. Nuclear Engineering and Design 71:375–381. Apostolakis, G. 1990. The concept of probability in safety assessments of technological systems. Science 250:1359–1364. Apostolakis, G., and J.S. Wu. 1995. A structured approach to the assessment of the quality culture in nuclear installations. In Proceedings of the International Topical Meeting on Safety Culture in Nuclear Installations. La Grange Park, Ill.: American Nuclear Society. Apostolakis, G.E., G. Mancini, R.W. van Otterloo, and F.R. Farmer, eds. 1990. Reliability Engineering and System Safety. London: Elsevier. Bea, R.G. 1992. Marine Structural Integrity Programs (MSIP). Ship Structures Committee report SSC-365. Washington, D.C.: U.S. Department of Transportation. Bea, R.G. 1994. The Role of Human Error in Design, Construction, and Reliability of Marine Structures. Ship Structures Committee report SSC-378. Washington, D.C.: U.S. Department of Transportation. Bogner, M.S., ed. 1994. Human Error in Medicine. Hillsdale, N.J.: Lawrence Erlbaum Associates. Center for Chemical Process Safety. 1989. Guidelines for Chemical Process Quantitative Risk Analysis. New York: American Institute of Chemical Engineers. Center for Chemical Process Safety. 1994. Guidelines for Preventing Human Error in Process Safety. New York: American Institute of Chemical Engineers. Chemical Manufacturers Association (CMA). 1990. A Manager's Guide to Reducing Human Errors: Improving Human Performance in the Chemical Industry. Washington, D.C.: CMA. Cook, R.I., and D.D. Woods. 1990. Operating at the sharp end: The complexity of human error. In M.S. Bogner, ed., Human Error in Medicine. Hillsdale, N.J.: Lawrence Erlbaum Associates.

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM Dougherty, E.M., Jr., and J.R. Fragola. 1986. Human Reliability Analysis. New York : John Wiley & Sons. Druckman, D., J.E. Singer, and H. Van Cott. 1997. Enhancing Organizational Performance. Committee on Techniques for the Enhancement of Human Performance, National Research Council. Washington, D.C.: National Academy Press. The Economist. 1994. Uncle Sam's helping hand: Sematech. April 2:77–79. Gertman, D.I., and H.S. Blackman. 1994. Human Reliability and Safety Analysis Data Handbook. New York: John Wiley & Sons. Groeneweg, J. 1994. Controlling the Controllable, The Management of Safety. Leiden University, The Netherlands: DSWO Press. Hackman, R., and R. Wageman 1995. Total quality management: Empirical, conceptual, and practical issues. Administrative Science Quarterly 40:309–342. Hendrick, H.W. 1996. Good Ergonomics Is Good Economics. Santa Monica, Calif: Human Factors and Ergonomics Society. Henriksen, K., R.D. Kaye, R.E. Jones, Jr., D.S. Morisseau, and J.J. Persensky. 1993. An examination of human factors in external beam radiation therapy: Findings and implications. In Proceedings of the U.S. Nuclear Regulatory Commission Twenty-First Water Reactor Safety Information Meeting, Vol. 1. Washington, D.C.: U.S. Nuclear Regulatory Commission. Hudson, P.T.W., W.A. Wagenaar, J.T. Reason, J. Groeneweg, R.J.W. van der Meeren, and J.P. Visser. 1996. Applications of TRIPOD to measure latent errors in North Sea gas platforms: Validity of failure state profiles. Paper no. SPE 23293. In Proceedings of the First International Conference on Health, Safety, and Environment Richardson, Tex.: Society of Petroleum Engineers. Humphreys, P., ed. 1988. Human Reliability Assessors Guide. SRD report no. RTS 88/95Q. Culcheth Warrington, U.K.: U.K. Atomic Energy Authority. Hurst, N.W., L.J. Bellamy, and M.S. Wright. 1992. Research Models of Safety Management of Onshore Major Hazards and Their Possible Application to Offshore Safety. Symposium series no. 13, EFCE pub. no. 93. Warwickshire, U.K.: Institution of Chemical Engineers. Kirwan, B. 1994. A Guide to Practical Human Reliability Assessment. London: Taylor & Francis.

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM Meshkati, N. 1991a. Critical human and organizational factors considerations in design and operation of petrochemical plants. Paper no. SPE 23275. Pp. 627–634 in Proceedings of the First International Conference on Health, Safety, and Environment in Oil and Gas Exploration and Production. Vol. 1. The Hague: Society of Petroleum Engineers. Meshkati, N. 1991b. Human factors in large-scale technological systems' accidents: Three Mile Island, Bhopal, Chernobyl. Industrial Crisis Quarterly 5:133–154 Meshkati, N., J.S. Garza, V.M. Morales, and A. del la Garza. 1993. The Use of Human Factors Methodology in Process Hazards Analysis: A Case Study of a Chemical Plant Accident. New York : American Institute of Chemical Engineers. Meshkati, N., B.J. Buller, and M.A. Azadeh. 1994.Integration of Workstation, Job, and Team Structure Design in the Control Rooms of Nuclear Power Plants: Experimental and Simulation Studies of Operators' Decision Styles and Crew Composition While Using Ecological and Traditional User Interfaces, Vol. 1. Grant no. NRC-04-91-102. Los Angeles: University of Southern California.. National Research Council. 1980.Improving Aircraft Safety. Committee on FAA Airworthiness Certification Procedures, Assembly of Engineering. Washington, D.C.: National Academy Press. National Research Council. 1996. Simulated Voyages: Using Simulation Technology to Train and License Mariners. Marine Board. Washington, D.C.: National Academy Press. National Research Council. Forthcoming a. Human Performance, Organizational Systems, and their Impact on Maritime Safety. Marine Board. Washington, D.C.: National Academy Press. National Research Council. Forthcoming b. Risk Assessment and Risk Management of Marine Systems . Marine Board. Washington, D.C.: National Academy Press. Orvis, D.D., P. Moieni, and V. Joksimovich. 1993. Organizational and Management Influences on Safety of Nuclear Power Plants: Use of PRA Techniques in Quantitative and Qualitative Assessments . NUREG/CR-5752. San Diego, Calif.: Accident Prevention Group. Paté-Cornell, E. 1993. Risk analysis and risk management for offshore platforms: Lessons learned from the Piper Alpha accident. Journal of Offshore Mechanics and Arctic Engineering 115:179–190. Paté-Cornell, E. 1995. Risk analysis and the probabilistic treatment of uncertainties. Report to the Electric Power Research Institute. Projects RP2955 and RP 3550.

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM Pidgeon, N., and M. O'Leary. 1994. Organizational safety culture: Implications for aviation practice . Aviation Psychology in Practice 52(3):21–43. Reece, W.J., and D.I. Gertman. 1991. NUCLARR: A Workstation Software Package to Support Risk Assessment . Report no. DE-AC07-76ID1570. Idaho Falls, Idaho: Idaho National Engineering and Environmental Laboratory. SEMATECH (Semiconductor Manufacturing Technology). 1992.SEMATECH Annual Report. Austin, Tex.: SEMATECH. SEMI (Semiconductor Equipment and Materials International). 1993.Safety Guideline for Ergonomics/Human Factors Engineering of Semiconductor Manufacturing Equipment. Draft document no. 2092. Mountain View, Calif.: SEMI. SIA (Semiconductor Industry Association). 1993a. Semiconductor Technology: Workshop Working Groups Reports. San Jose, Calif.: SIA. SIA. 1993b. Semiconductor Technology: Workshop Conclusions. San Jose, Calif.: SIA. Swain, A.D. 1982. A note on the accuracy of predictions using THERP. Bulletin of the Human Factors Society 25(4):1–2. Swain, A.D., and H.E. Guttman. 1983. Handbook of Human Reliability Analysis with Emphasis on Nuclear Power Plant Applications. NUREG/CR-1278. Washington, D.C.: U.S. Nuclear Regulatory Commission. 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. U.S. Department of Defense. 1989.Human Engineering Design Criteria for Military Systems, Equipment and Facilities. MIL-STD-1472D. Washington, D.C.: U.S. Department of Defense. U.S. Department of Defense. 1995. Formal Safety Program. MIL-STD-882C. Washington, D.C.: U.S. Department of Defense. U.S. General Accounting Office. 1990. How to Improve the Federal Aviation Administration's Ability to Deal with Safety Hazards. Report by Comptroller General of the United States, CED-80-66. Washington, D.C.:U.S. General Accounting Office.

OCR for page 23
ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM Wells, J.E., and T.G. Ryan. 1991. Integrating human factors expertise into the PRA process. Pp. 577–582 in G. Apostolakis, ed., Probabilistic Safety Assessment and Management. New York: Elsevier. Wiener, E.L., and D.C. Nagel, eds. 1988. Human Factors in Aviation. New York: Academic Press. Wu, J.S., G. Apostolakis, and D. Okrent. 1991.On the inclusion of organizational and management factors into PRA of nuclear power plants. Pp. 619–624 in G. Apostolakis, ed., Probabilistic Safety Assessment and Management. New York: Elsevier.