Week 5

Awareness of onboard situation

Human Error
and
Situational Awareness
STCW Table A-II/1 & STCW Table A-III/1
STCW Table A-II/1

Human Error
Human error has been cited as a primary cause or
contributing factor in disasters and accidents. Human
error means that something has been done that was "not
intended by the character; not desired by a set of rules or
an external observer; or that led the task or system
outside its acceptable limits".
STCW Table A-II/1

Human Error
STCW Table A-II/1

Human Error
In order to understand the basis for adverse events and develop
effective strategies for reducing risk it is necessary to appreciate
the role human error often plays as the cause of harmful
incidents.
An appreciation of the major types of errors and the omnipresent
"error chain" will help make your root cause analyses more
focused and effective.
STCW Table A-II/1

Human Error
Types of Error
Errors can be divided into three categories:

• Personal Error- An error comes into play because of faulty procedure

adopted by the observer.

• Systematic Error- error arises due to defect in the measuring device.

• Random Error- The error produced due to sudden change in experimental

conditions
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Human Error
Person approach
The longstanding and widespread tradition of the person
approach focuses on the unsafe acts errors and procedural
violations.
It views these unsafe acts as arising primarily from aberrant
mental processes such as forgetfulness, inattention, poor
motivation, carelessness, negligence, and recklessness.
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Human Error
Person approach
Naturally enough, the associated countermeasures are directed
mainly at reducing unwanted variability in human behaviour.
These methods include poster campaigns that appeal to people's
sense of fear, writing another procedure (or adding to existing
ones), disciplinary measures, threat of litigation, retraining,
naming, blaming, and shaming
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Human Error
System approach
The basic premise in the system approach is that humans are
fallible and errors are to be expected, even in the best
organizations. ( capable of doing mistakes )
Errors are seen as consequences (kinahinatnan) rather than
causes, having their origins not so much in the perversity (hindi
masama ) of human nature as in “upstream” systemic factors.
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Human Error
System approach

Countermeasures are based on the assumption that though

we cannot change the human condition, we can change the
conditions under which humans work. (Ex. Construction of
double bottom of ship)

A central idea is that of system defenses. All hazardous

technologies possess barriers and safeguards.
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Human Error
System approach
There are two major types of error that need to be
considered when conducting a root cause analysis. The
holes in the defenses arise for two reasons
a) active failures
b) latent conditions
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Human Error
System approach
Active Failures: errors that are committed by a person,
usually front-line direct support personnel. These types of
error are the most "noticeable" and are usually associated
with the proximate cause (malapit na dahilan ) of an adverse
event, i.e., they take place immediately before the incident.
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Human Error
There are three major types of active failures:
• Slips - unintended deviations from an established procedure, often due to
distraction or inadequate attention to the task at hand. 
• Mistakes - these are due to faulty reasoning and poor judgment. They are
not intentional and are often associated with a novel or new situation.
• Unsafe Practices - errors associated with an intentional or conscious
decision to do something "risky." Unsafe practices are direct violations of
rules and/or standards.
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Human Error
Latent conditions: errors in system design that set the stage for and

promote active errors. Latent faults have the following characteristics:

• Delayed impact - the fault or system design is usually not

immediately evident. They are identified only after one or more

significant adverse events and analysis of the system as a whole.

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Human Error
Latent conditions 
• Set the stage for failure - They set the stage for later errors
by staff and are often associated with confusing policy and
procedure, inadequate training, scheduling multiple
activities at the same time, punitive (maparusahan) work
environments that lead to stress and fear of failure,
inappropriate staff scheduling, unrealistic expectations, etc.
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Human Error
Error of Commission - mistake that consists of doing
something wrong, such as ​including a wrong ​amount, or ​
including an ​amount in the wrong ​place.
Error of Omission - mistake that consists of not doing
something you should have done, or not ​including something
such as an ​amount or fact that should be ​included.
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Situational Awareness
Situational Awareness is the ability to identify,
process, and comprehend the critical elements
of information about what is happening to the
team with regards to the mission. More simply,
it’s knowing what is going on around you.
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Situational Awareness
Example:
A fire broke out at night while the crew are
resting. They were called to their stations
and was able to combat the fire and
extinguish it within an hour. They know
what they are doing and kept in mind what
they learned.
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Situational Awareness
The loss of Situational Awareness usually occurs over a period of
time and will leave a trail of clues. Be alert for the following clues
that will warn of lost or diminished Situational Awareness:
• Confusion or gut feeling ( ex, sweaty palm )
• No one watching or looking for hazards
• Use of improper procedures
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Situational Awareness
• Departure from regulations
• Failure to meet planned targets
• Unresolved discrepancies
• Ambiguity (kalabuan)
• Fixation or preoccupation (natulala o napako)
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Week 6
Situational Awareness
Confusion
Disorder within the team or a gut feeling that things are not right. This clue is
one of the most reliable because the body is able to detect stimulus long
before we have consciously put it all together. Trust your feelings!
Ambiguity ( kalabuan )
When information we need is confusing or unclear, we must clarify or to fill in
the missing pieces before proceeding.
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Situational Awareness
No one Watching or Looking for Hazards
Vessel operations require more than just
driving the bow of the cutter or boat. The
proper assignment and performance of
tasks, particularly supervisory and lookout
ones, is essential to safe vessel operations.
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Situational Awareness
Use of Improper Procedures
This puts the individual or team in a gray area where no one
may be able to predict outcomes with any certainty.
Departure from Regulations
In addition to violating procedures, we are operating in an
unknown area where the consequences of our actions cannot
be predicted with any degree of certainty.
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Situational Awareness
Failure to Meet Planned Targets

During each evolution, we set certain goals or targets to meet, such as

speed of advance, waypoints, and soundings. When they are not met,
we must question why and systematically begin to evaluate our
situation.

Unresolved Discrepancies

When two or more pieces of information do not agree, we must

continue to search for information until the discrepancy is resolved.
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Situational Awareness
Fixation or Preoccupation
When someone fixates on one task or becomes
preoccupied with work or personal matters, they
lose the ability to detect other important
information. Early detection of both fixation and
preoccupation is essential to safe vessel
operations.
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Lack of Situational Awareness

A crew member has accidentally sprayed himself with chemicals.

He panicked and instead of using the diphoterine ( fire ext )which

is very effective in combating chemical reaction, he went inside

and splash himself with water. His actions worsen the effect of

chemical on his body wand he was rushed to the hospital.

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Lack of Situational Awareness

Modern electronic aids
It causes too much reliance on the
equipments thus making the user/officer on
duty complacent and eventually no longer
aware that the technology has limitations
and that it must be taken seriously.
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Situational Awareness
Maintenance of situational awareness occurs through
effective communications and a combination of the following
actions.
• Recognize and make others aware when the team deviates
from standard procedures.
• Monitor the performance of other team members.
• Provide information in advance.
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Situational Awareness
• Identify potential or existing problems (i.e. equipment-related or
operational).
• Demonstrate awareness of task performance.
• Communicate a course of action to follow as needed.
• Demonstrate ongoing awareness of mission status.
• Continually assess and reassess the situation in relation to the mission
goal(s).
• Clarifying expectations of all team members eliminates doubt.
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Situational Awareness
Barriers to Situational Awareness

The following barriers reduce our ability to understand the

situation. Recognizing these barriers and taking corrective
action is the responsibility of all team members.
• Perception (pang-unawa) based on faulty information
processing.
• Excessive motivation.
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Situational Awareness
Barriers to Situational Awareness
• Complacency. ( kasiyahan )

• Overload.
• Fatigue.
• Poor communications.

• Boredom
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Situational Awareness
Perception ( pang-unawa )

Perception is our mental picture of reality. The amount

and quality of information available limit all pictures of
our current operational state.
Insufficient information makes it difficult to ensure that
our mental picture is always aligned with reality.
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Situational Awareness
Excessive Motivation
This behavior imposes expectations and filters that
affect our ability to fully assess the situation and
any safety risks. It includes, but is not limited to an
overriding sense of mission importance.
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Situational Awareness
Fatigue
Fatigue affects vigilance. Adjusting work routine
and imposing sleep discipline to prevent wake
cycles longer than 18 hours and permit at least
5 and preferably 8 hours/day of sound sleep can
minimize sleep deprivation.
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Situational Awareness
Complacency ( Kasiyahan )
Assuming everything is under control affects vigilance. When
things are slow, tasks are routine, and/or when the vessel’s
employment objectives have been achieved, complacency can
occur.
Challenging yourself and/or the team to be prepared for
contingencies (e.g. planning or training) can deter complacency.
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Situational Awareness
Overload
Overload causes distraction; fixation;
increased errors, and high stress.
Prioritizing and delegating tasks and
minimizing job distractions can improve
safety in conditions of overload.
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Situational Awareness
Poor Communications
The level of situational awareness achieved is related to the level and
quality of communications observed in the team.
Boredom
Boredom can be a trap to situational awareness. We can miss what’s
going on in this cases. That’s why good habits are a real life-saver.
Professional diligence ( sipag ) and discipline helps you to stay aware
even when you’re bored.
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Actions subsequent to Near Miss

We can make a distinction between “near miss” and “unsafe
condition”. An unsafe condition can exist even when there is no
incident – making it a leading indicator.
Examples could be corrosion of steel walkways, uninspected
pressure vessels, PPE not worn, poor electrical grounding.
Near miss should be prevented but, whatever the incident was,
people should be congratulated for REPORTING a near miss.
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Situational Awareness
Automation or automatic control, is the use
of various control systems for operating
equipment. Too much reliance on equipment
leads to complacency for you put your trust
to it and put your critical thinking and
judgment to rest. This is when boredom
strikes increasing the risk of accidents.