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2 Analogous Systems
Pages 28-53

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From page 28...
... These features are then described for each of the analogous systems of interest. Within the discussion of each system, relevant case studies are referenced illustrating how causes and contributing factors of an emergency or accident may be generalized, with caution, to the tank environment.
From page 29...
... A similar situation probably exists for air crews of commercial airliners. In contrast, shock trauma and hospital emergency room crews maintain a fairly continuous level of preparation for medical emergencies and accident victims, as they can be expected at any time.
From page 30...
... The conditions of the flight deck or nuclear power plant control room are relatively friendly temperature controlled, low to modest noise level, comfortable, and relatively free of vibration. This is in marked contrast to the tank environment, in which four operators work within cramped, noisy, and vibrating conditions, often under excessive temperatures.
From page 31...
... A number of airline accidents have been attributed to inadequate cockpit coordination and management (National Transportation Safety Board, 1985a)
From page 32...
... The environment is temperature controlled but noisy, which makes intracockpit communications difficult without the use of headsets and interphone (National Transportation Safety Board, 1980~. In addition, the cockpit is cramped, especially considering the number of displays and controls that are present.
From page 33...
... At the same time, the availability of air traffic control can often serve as a valuable asset to flight crews in time of crisis. Upon examination of Figure 2.1, it appears that tank crews and airline crews do not have a great deal in common.
From page 34...
... Local runs and passenger trains have more predictable schedules, and these trains, like the tank crews, have an average degree of team integrity. For example, passenger train crews typically work approximately 2 1/2 consecutive hours; freight train crews may work on trips that last anywhere
From page 35...
... In the railway industry, irregular schedules have been cited in numerous investigations as a contributing factor to railway accidents (National Transportation Safety Board, 1985b, 1989; Smiley, 1990~. One report notes (National Transportation Safety Board, 1989b:2~: The changing nature of railroad operations and competitive factors have materially increased the relative number of train crew members who must work irregular and unpredictable shifts on a long-term basis.
From page 36...
... Thus, the two systems are, dynamically, different and therefore may require different cognitive processes of the decision makers. In summary, the locomotive and tank environments share their greatest degree of similarity in the pretransition period, and here the common themes focus more on the efficiency of the individual operator, as influenced by vigilance, stress, and sleep disruption, than on the coordination of the team.
From page 37...
... Information, which is acquired mostly visually, comes from hundreds of instruments arranged on rather large control panels. Nuclear power plant control rooms normally operate in a semibuttoned-up mode, in that access to control rooms is controlled by locked doors and security badge readers.
From page 38...
... The one operational area in which nuclear power plant operating crews and tank crews differ greatly is in terms of the expectation of events that must be dealt with in a timely manner. Things do not often go wrong in nuclear power plants at least they don't go wrong to the extent that an emergency situation is encountered.
From page 39...
... flag vessels have a typical crew size of 20 to 24, in contrast with the 40 to 45 found aboard smaller ships of 30 years ago. Similarly designed foreign flag vessels currently have crew sizes ranging from 12 to 16, and in highly automated foreign flag ships, there may be as few as 8 to 12 crew members on board.
From page 40...
... . As in many of the other systems described in this report, including tank crews, this setup, in conjunction with watch organization, results in sleep disruption and deprivation, which often leads to fatigue and performance decrements.
From page 41...
... Fatigue and excessive workload were determined to have been contributing factors in a number of marine accidents (e.g., National Transportation Safety Board, 1988a, 1990~. Work-rest schedules are affected by the type of work being performed, and workload and shipboard operations vary drastically, depending on the stage of the voyage.
From page 42...
... (Ives et al., 1992~. Although human error is often cited as a factor in marine casualties, marine accident investigations primarily focus on proximate human causes of accidents rather than more subtle factors that underlie human performance.
From page 43...
... Some port-state nations have established VTS to improve order and predictability in waterway interactions. These capabilities are essentially interactive information sharing communications networks with, in some cases, very limited positive control.
From page 44...
... A somewhat dated review report has identified a set of prevailing conditions typically found at the time of many marine accidents (National Transportation Safety Board, 1981:183: the ships were outside an active vessel traffic service (communication control center) area, radar was not in operational use, there was no equipment failure, and the occurrence was during the 4 am to 8 am watch in clear visibility on a U.S.
From page 45...
... If situation awareness of this state is absent in a pretransition period, disaster may result. For example, if a grounding or collision occurs in a confined waterway, the time constant may be short, and unpredictable response types may be required.
From page 46...
... In addition, medics, like tank crew personnel, must be concerned about self-preservation, their personal safety, and what to do if there is a hostile environment. In the 1960s and early 1970s, emergency medical services were used almost solely to transport injured patients as quickly as possible to the nearest hospital.
From page 47...
... These paid ambulance crews work normal 8hour shifts, which may be extended depending on the requirements of the situation. EMS helicopter crews work on shift schedules, and the greatest number of calls are received at night, many times in bad weather (which may be one of the contributing factors of the accident that generated the need for medical services in the first place)
From page 48...
... . Of the 59 EMS helicopter accidents in the National Transportation Safety Board's data base between May 1978 and December 1986, 18 were weather-related.
From page 49...
... Like EMS teams, adult trauma centers (such as the Maryland Institute for Emergency Medical Services known as Shocktrauma) , pediatric trauma centers (such as the Children's Hospital National Medical Center)
From page 50...
... While working in the emergency rooms, the medical teams have a high level of integrity- they work closely together and on similar duty schedules. There appears, however, to be a large rate of turnover of personnel in emergency rooms, especially in the trauma centers, possibly due to the high level of stress inherent in the job.
From page 51...
... When the triggering event is complex or unstructured, then strong support for continuous situation awareness the state of the system and environment in the pretransition period will be likely to support more efficient and adaptive problem solving during the transition. Although this section has focused on what these analogous systems have to offer to the tank environment, one could also ask what conclusions drawn in the tank environment can be generalized to these other systems.
From page 52...
... National Transportation Safety Board 1980 Aircraft Accident Report Air New England, Inc., deHavilland DHC-6-300, N383EX, Hyannis, Massachusetts, June 17, 1979. Report No.
From page 53...
... 1989a Railroad Accident Report Head-End Collision of Consolidated Rail Corporation Freight Trains UBT-506 and TV-61 near Thompsontown, Pennsylvania, January 14,1988. Washington, DC: National Transportation Safety Board.


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