1

Introduction

In the marine industry, as in many other industries, regulations have often been based on engineering and technological research to improve safety and minimize the consequences of accidents and incidents (Bryant, 1991; National Research Council, 1990).1 An example is Section 4115 of P.L. 101-380, the Oil Pollution Act of 1990, in its provision for double-hull tankers. The intent of this law, in part, was to minimize future oil spills through preventive measures such as improved tanker design. However, certain double-hull designs, most notably those without longitudinal subdivision through the cargo tanks, can exhibit instability during loading and unloading operations (see National Research Council, 1996). Thus, despite improvements in quality and reliability, marine accidents and incidents continue to occur (National Research Council, 1990; U.S. Coast Guard, 1995). Therefore, it has been increasingly recognized that, for significant safety improvements to occur, attention must also focus on the people in the system and the factors that affect them, including management, regulations, and the work environment.

Given this recognition of the limitations of traditional regulation and the importance of a better understanding of the human role, the U.S. Coast Guard Assistant Commandant for Marine Safety and Environmental Protection established a quality action team (QAT) to develop the concept of prevention through people (PTP) into a long-term strategic program to that will focus prevention efforts on human behavior. Although many of the principles of the PTP concept are well known, an implementation strategy was needed to aid the Coast Guard in applying what is known and identifying research to fill existing gaps.

U.S. COAST GUARD PROGRAMS AND THEIR DEVELOPMENT

Prevention Through People Program

The PTP program, as developed through the work of the QAT, proposes a participatory, systematic approach to reduce both human injuries and fatalities and environmental pollution through collaborative relationships; the utilization of risk management tools; the utilization of techniques for detecting, assessing, and preventing human error 2; and the improvement of investigative methods, data collection, analyses, and feedback.

1  

The term “casualty” in this report refers to incidents such as groundings, collisions, allisions, or structural failures in which a vessel is damaged.

2  

The subcommittee has reservations about the phrase “human error” when its use may obscure human error as an effect of error-inducing characteristics in a system. This point is discussed in Chapter 2.



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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM 1 Introduction In the marine industry, as in many other industries, regulations have often been based on engineering and technological research to improve safety and minimize the consequences of accidents and incidents (Bryant, 1991; National Research Council, 1990).1 An example is Section 4115 of P.L. 101-380, the Oil Pollution Act of 1990, in its provision for double-hull tankers. The intent of this law, in part, was to minimize future oil spills through preventive measures such as improved tanker design. However, certain double-hull designs, most notably those without longitudinal subdivision through the cargo tanks, can exhibit instability during loading and unloading operations (see National Research Council, 1996). Thus, despite improvements in quality and reliability, marine accidents and incidents continue to occur (National Research Council, 1990; U.S. Coast Guard, 1995). Therefore, it has been increasingly recognized that, for significant safety improvements to occur, attention must also focus on the people in the system and the factors that affect them, including management, regulations, and the work environment. Given this recognition of the limitations of traditional regulation and the importance of a better understanding of the human role, the U.S. Coast Guard Assistant Commandant for Marine Safety and Environmental Protection established a quality action team (QAT) to develop the concept of prevention through people (PTP) into a long-term strategic program to that will focus prevention efforts on human behavior. Although many of the principles of the PTP concept are well known, an implementation strategy was needed to aid the Coast Guard in applying what is known and identifying research to fill existing gaps. U.S. COAST GUARD PROGRAMS AND THEIR DEVELOPMENT Prevention Through People Program The PTP program, as developed through the work of the QAT, proposes a participatory, systematic approach to reduce both human injuries and fatalities and environmental pollution through collaborative relationships; the utilization of risk management tools; the utilization of techniques for detecting, assessing, and preventing human error 2; and the improvement of investigative methods, data collection, analyses, and feedback. 1   The term “casualty” in this report refers to incidents such as groundings, collisions, allisions, or structural failures in which a vessel is damaged. 2   The subcommittee has reservations about the phrase “human error” when its use may obscure human error as an effect of error-inducing characteristics in a system. This point is discussed in Chapter 2.

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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM Quality Action Team Report The QAT considered issues of data analysis and marine operations from the systems perspective and laid the groundwork for the PTP program. The QAT issued the results of its work in a report (U.S. Coast Guard, 1995) that examines the role of humans in the maritime transportation system, particularly areas in which human error is prevalent. The report provides possible explanations for the prevalence of human error, offers a prevention strategy, and recommends an implementation plan. The QAT report characterizes the role of human error, and hence the importance of human and organizational performance, in marine safety across many sectors and stresses the need to incorporate changes in the marine industry based on what is known about people. The QAT report also notes the need for all participants in the maritime transportation system (e.g., government agencies, industry, classification societies, and mariners) to work cooperatively to increase system effectiveness and safety (U.S. Coast Guard, 1995). This change requires a redefinition of roles and relationships. The PTP program, as presented in the QAT report, is consistent with research on sociotechnical systems dating back to the 1950s (e.g., DeGreene, 1973; Emery and Trist, 1960, 1965; Trist and Bamforth, 1951; Trist et al., 1963) and on macroergonomics from the 1980s (e.g., Hendrick, 1986, 1991, 1997). For example, the PTP program has four components—management, the work environment, behavior, and technology —that are virtually identical to the four major system elements identified in the sociotechnical systems and macroergonomics literature, namely, (1) the technological subsystem, (2) the personnel subsystem, (3) the organizational structure (including management, policies, and procedures), and (4) the environment that permeates the organization and to which it must adapt and respond to survive and be successful. These elements are interdependent—a change in one affects the others, often in unintended and sometimes in suboptimal ways. The PTP program recognizes that safe and profitable operations require constant and balanced interactions. The QAT report identifies five high-risk sectors (i.e., areas in which human error persists): (1) towing vessel/barge operations, (2) tankship operations, (3) fishing operations, (4) passenger vessel operations, and (5) offshore supply vessel operations. The report recommends employing the PTP strategy in these high-risk sectors first because they can “offer the greatest potential to reduce maritime fatalities, injuries, and pollution” (U.S. Coast Guard, 1995:7). Prevention Through People Implementation Plan One of the PTP program objectives (see Table 1-1, objective 5.3) expresses a critical feature of the PTP approach in that it puts an emphasis on partnerships rather than the traditional regulatory enforcement as a means of improving safety. These partnerships have been given high priority by the Coast Guard in program development. For example, the Coast Guard and American Waterways Operators have established a partnership that has resulted in the formation of a number of steering committees to address various safety issues, such as

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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM towing vessel crew fatalities and tank barge transfer spills. In addition, the Coast Guard and the North Pacific Fishing Vessel Owners ' Association have a voluntary partnership that includes strong elements of the PTP program. Other comparable partnerships are proposed in the PTP implementation plan, some of which are currently being developed. TABLE 1-1 Objectives for Each Goal of the PTP Implementation Plan PTP Goal Objective Number Objective 1.0—Know more 1.1 In concert with stakeholders in industry, government, academia, and the public sector, develop a PTP R&D plan that identifies and addresses gaps in PTP strategic planning   1.2 Improve marine safety investigation processes so as to develop more timely, accurate, and comprehensive determination of causes, with emphasis on the contributions of the human element   1.3 Show how PTP is cost-effective   1.4 Develop a near-accident reporting system   1.5 Gain a better understanding of safety from the mariner's perspective 2.0—Train more 2.1 Implement the Standards for Training, Certification, and Watchkeeping Convention (STCW)   2.2 Increase the human element focus in Coast Guard education, training, and job recruitment   2.3 Develop continuing education professional training program for mid/senior management and officers in human element causes and prevention of accidents   2.4 Infuse human element issues into all maritime training and education courses   2.5 Include human element causal understanding in the license and document renewal process 3.0—Do more 3.1 Implement the International Safety Management Code   3.2 Create avenues to share information

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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM   3.3 Proceed with Coast Guard regulatory reform to make substantive improvements in the way that the Coast Guard regulates the U.S. maritime industry and the quality of Coast Guard regulations   3.4 Develop risk analysis (assessment, management, and communication) capability   3.5 Improve the capability to electronically capture and categorize data developed by marine safety investigations and to conduct comprehensive analyses of those data   3.6 Use risk tools in a practical application to assess and manage marine transportation system risks in concert with the affected members of the industry and public   3.7 Focus Coast Guard preventive programs   3.8 Apply PTP to the U.S. commercial fishing vessel industry 4.0—Offer more 4.1 Institutionalize the Streamlined Inspection Program (SIP)   4.2 Evaluate ongoing and future projects and policies to support program emphasis on PTP   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   4.4 Institute a PTP award 5.0—Coordinate/ cooperate more 5.1 Engage all sectors of the maritime community, including state marine-related agencies, to shift the focus of the culture from “reactive” to “preventive”   5.2 Work through IMO to focus on the human element   5.3 Establish partnerships and working agreements, as appropriate, with marine industry segments to address common concerns   5.4 Share best practices and lessons learned Source: [Adapted from] PTP Implementation Plan.

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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM The PTP implementation plan lays out a vision satement, presents a set of principles and goals, and for each goal identifies current and future objectives to be undertaken in support of the PTP program. The PTP vision statement is “to achieve the world's safest, most environmentally sound and cost-effective marine operations by emphasizing the role of people in preventing casualties and pollution” (U.S. Coast Guard, 1996:2). The program's set of principles and goals captures the values and philosophy that will be used to guide subsequent work. The five principles are Honor the mariner. Seek and respect the opinion of those who “do the work” at sea and ashore. Take a quality approach. Engage all elements of the marine transportation system to drive continuous improvements. Seek nonregulatory solutions. Emphasize incentives and innovation. Share commitment. Recognize and act upon the responsibility of government, management, and workers to foster a safe and environmentally sound marine transportation system. Manage risk. Apply cost-effective solutions to marine safety and environmental issues, consistent with the Coast Guard's shared public stewardship responsibilities. These principles have five accompanying goals: Know more. Significantly expand knowledge and understanding of the human element and its role in maritime operations and accidents. Train more. Give members of the marine community the necessary skills and knowledge to improve safety and prevent pollution. Do more. Improve professional performance through a practical application and open communication of human element knowledge within the marine community. Offer more. Provide incentives for improvement in safety management systems. Cooperate more. Work together to address the human element in transportation safety and pollution prevention. For each goal, a set of current and future objectives have been identified that explain how each goal will be achieved (see Table 1-1). Where possible, the PTP implementation plan specifies actions and tasks to be undertaken to accomplish the objectives. With one exception (commercial fishing), the PTP implementation plan does not target specific marine sectors but sets objectives that, if achieved, should reduce accidents across multiple sectors.

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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM Coast Guard's Human Factors R&D Program The Coast Guard's Human Factors R&D Program predates the PTP program. The current Human Factors R&D Program plan was developed in the early 1990s under contract with Battelle Human Affairs Research Centers and was finalized in a report published in February 1993 (Sanquist et al., 1993). Proposed R& D activities for FY95–FY97 are presented in U.S. Coast Guard Human Factors Project Plans 95–97 (U.S. Coast Guard, 1994). The focus of the Human Factors R&D Program is to contribute to insights into causes of casualties, safer operations, better understanding of problems, improved crew performance, technical bases for regulation, education, common language, and industry guidance. The R&D program currently focuses on deep draft commercial vessels and large passenger vessels. Sixty-eight research issues have been identified and classified into five categories: crewing, qualifications, and licensing automation and technology design safety methods and data communications organizational practices These five categories are reflected in the current Coast Guard Human Factors R&D Program areas, which include assessment of ship crews to perform; development of principles and strategies for incorporating human factors into the design and use of automated systems; identification of better information and procedures for defining and controlling safety problems; identification of improvements in person-to-person and equipment-to-person communications; and development of a better understanding of the organizational practices and policies that contribute to human error. Within these program areas, the following specific projects are currently funded: human factors in casualty investigations, human resource management for commercial vessels, human performance and safety in Coast Guard operations, qualifications and training and interactive testing, minimum manning standards and crew size modeling, and human factors guidelines for shipbuilders. Brief descriptions of these projects are included in Appendix B. SUMMARY The PTP program is a bold departure from traditional regulatory enforcement. It acknowledges the limitations of regulation, emphasizes partnerships, and recognizes that there is a potential for high return in safety improvement in the high-risk sectors. Human factors research contributes broadly to the first PTP goal to “know more.” It also can identify how safety improvements can be realized. The Coast Guard's commitment to human factors R&D is an opportunity to establish the missing research basis to realize the full potential of this approach to safety improvements. The Coast Guard's Human Factors R&D Program represents a human-centered approach to maritime safety, but, at present, it focuses largely on the Coast Guard's internal

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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM needs and commercial shipping (Sanquist et al., 1993; U.S. Coast Guard, 1995). The specific projects now under way have value but do not, by themselves, provide an adequate basis for the PTP program because the objectives of the R&D program are to increase marine safety in general, not to target specific high-risk sectors. REFERENCES Bryant, D.T. 1991. The Human Element in Shipping Casualties. London: Marine Directorate of the U.K. Department of Transport. DeGreene, K.B. 1973. Sociotechnical Systems: Factors in Analysis, Design, and Management. Englewood Cliffs, N.J.: Prentice-Hall . Emery, F.E., and E.L. Trist. 1960. Sociotechnical systems. In C.W. Churchman and M. Verhulst, eds., Management Science, Models and Techniques II. Oxford, U.K.: Pergamon. Emery, F.E., and E.L. Trist. 1965. The casual texture of organizational environments. Human Relations 18:21–32. Hendrick, H.W. 1986. Macroergonomics: A conceptual model for integrating human factors with organizational design. Pp. 467–478 in O. Brown, Jr., and H.W. Hendrick, eds., Human Factors in Organizational Design and Management II. Amsterdam, The Netherlands: North-Holland. Hendrick, H.W. 1991. Ergonomics in organizational design and management. Ergonomics 34(6):743–756. Hendrick, H.W. 1997. Organizational design and macroergonomics. Pp. 594–636 in G. Salvendy, ed., Handbook of Human Factors and Ergonomics, 2nd ed. New York: John Wiley & Sons. National Research Council. 1990. Crew Size and Maritime Safety. Marine Board. Washington, D.C.: National Academy Press. National Research Council. 1996. Effects of Double-Hull Requirements on Oil Spill Prevention. Marine Board. Washington, D.C.: National Academy Press. 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. Trist, E.L., and K.W. Bamforth. 1951. Some social and psychological consequences of the

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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM Longwall method of coal-getting. Human Relations4:3–38. Trist, E.L., G.W. Higgin, H. Murray, and A.B. Pollock. 1963. Organizational Choice. London: Tavistock . U.S. Coast Guard. 1994. U.S. Coast Guard Human Factors Project Plans 95–97. 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.