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BRM QRH Full Booklet V1.5.2.1docx PDF
BRM QRH Full Booklet V1.5.2.1docx PDF
Glossary 1
Attitudes 12
Situational Awareness 14
Cultural Awareness 18
Workload 30
Team 35
Error Management 38
Leadership Styles 41
Decision Making 44
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Categories types
Challenge speaking up when something is or may be wrong
Channels methods, routes
Chat social talk
Circumstances situation, events
Clash crash
Clarifies makes clear
Climate feeling (atmosphere) between people
Coloured influenced
Committed in agreement to do it
Complacency false feeling of confidence (often not verbalised)
Compromise find a middle solution
Concepts mental picture
Conducting doing, carrying out
Facing meeting
Fixation getting stuck
Flee run-away
Flexible ways around
Flips switches, changes
Garbage rubbish
Gather collect
Guidelines help, advice, tips, company policies give advice
Margin area
Material success money, CD players, Swatches
Misinformation wrong information
Misunderstand not understand
Moderating calming
Monitoring watching and checking
Motivates makes people act the way they do
Motor movement
Mutual to each other
Receiving end the effect another person’s style has on you makes
Reinforces stronger
Reflex instant
Regard opinion
Rehearsal practice
Relevant useful
Resent do not like
Respect appreciation of worth, honour, esteem
Respond react, react to
Responding reacting
Responsibilities duties, trusts, obligations
Reptile like a dinosaur
Requested asked for
ABBREVIATIONS
Physical and psychological limitations on human performance and factors can lead to loss of
performance
Limitations on human performance can be divided into two main groups. These are:
Physical
Mental
Fatigue
Let us examine some aspects of fatigue and how our bodies work in regard to fatigue and
tiredness.
Daily Rhythm
• We all have a daily rhythm that regulates the different phases in our day:
• It’s maintained by a “biological clock” in the brain which controls physiological
activation.
o It provides high alertness & functional activity during the day.
o It promotes good sleep and poor functional activity during the night.
• Body temperature, stress hormones & metabolism follow the same pattern.
Adaptation to change
• The biological rhythm of most people adapts at a rate of 1-2 hours per day.
• The most important factor for adaptation is light (moving from the eye to the
“biological clock”).
Some areas of special concern with different working times are:
Night work
Evening work
• Usually no big problem of sleepiness or from a safety point of view since you are high
on your daily rhythm curve.
• Problem if you start early the next day.
Other factors
Countermeasures
Sleep Loss
Individual strategies
Day Workers
Motion Sickness
The balance centre of the inner ear then sends information to the brain that conflicts with
the visual clues of apparently standing still in the interior ship.
It has been found that fear or anxiety can lower the threshold for experiencing symptoms.
Symptoms generally consist of dizziness, fatigue and nausea, which may progress to
vomiting.
• reduce attention
• can cause slower reactions
• reduced the capability for creative problem solving
• cause difficulties in remembering data
• increase a tendency to deny negative messages.
One of the most challenging issues we must deal with is stress, but first we must be able to
identify stress.
Some symptoms are:
• Sleep disturbance
o Difficulty falling asleep.
o Broken sleep.
o Sleeping too much.
• Energy Disturbance
o Tiredness.
o Over activity.
• Mood disturbance
o Discontent.
o Worry.
o Depression.
Effect of Stress
• Degrades performance
• Degrades decision-making ability
• Can be dangerous to your physical and mental health.
If you don't come into contact with the source of your phobia very often it may not affect
your everyday life.
Types of phobia
There are a wide variety of objects or situations that someone could develop a phobia
about.
The most common type of phobia is the specific or simple phobia, these centre around a
particular object, animal, situation or activity.
They often develop during childhood or adolescence and may become less severe as you get
older.
Common examples of simple phobias include:
The most important of these is the third point the fact that “We make mistakes”.
It is a fact that humans make mistakes, it’s just part of the human condition. We must
develop systems, procedures and techniques to intercept these mistakes when they
happen.
Attitudes
Personality
Behaviour
Attitudes
Our personality and our attitudes lead to our behaviours. While there is not much we can do
about our personality we can control and change our attitudes particularly the hazardous
ones.
Attitude is defined as personal motivational predisposition to respond to people, situations
or events in a given manner.
Hazardous attitudes can create unnecessary risk and danger that can otherwise be avoided.
(Federal Aviation Administration, 2007).
This attitude is found in people who do not like anyone telling them
what to do. In a sense, they are saying, “No one can tell me what to Follow the rules.
do.” They may be resentful of having someone tell them what to do
or may regard rules, regulations, and procedures as silly or
unnecessary. However, it is always your prerogative to question
authority if you feel it is in error.
This is the attitude of people who frequently feel the need to do Not so fast. Think!
something, anything, immediately. They do not stop to think about
what they are about to do, they do not select the best alternative,
and they do the first thing that comes to mind.
People who are always trying to prove that they are better than
Why take chances.
anyone else think, “I can do it—I'll show them.” People with this
type of attitude will try to prove themselves by taking risks in order
to impress others. While this pattern is thought to be a male
characteristic, women are equally susceptible.
Factors that influence awareness, maintaining good awareness and spotting the signs of a
loss in awareness
“Knowing what’s going on around us. If you don’t know what’s happening around us how
can we make good decisions.”
“SA gives us the foundation for decision making in the operation of complex, dynamic
systems"
Having good SA cannot guarantee successful decision making, however having good SA does
support the process of good decisions making.
Collect The first step in achieving SA is to perceive the status, attributes, and dynamics of
relevant elements in the situation.
The most basic level of SA involves the processes of monitoring, cue detection, and simple
recognition, which lead to an awareness of multiple situational elements (objects, events,
people, systems, environmental factors) and their current states (locations, conditions,
modes, actions).
Interpret The next step in SA formation involves pulling together all the elements that have
been collected through the processes of pattern recognition, interpretation and evaluation.
The information can then be integrated to understand how it will impact upon the current
situation (goals and objectives). This includes developing a comprehensive picture of the
world, or of that portion of the world of concern.
Project The final step of SA involves the ability to project the future actions of the elements
in the environment and develop a short-term response to them.
Projection is achieved through knowledge of the status and dynamics of the elements and
comprehension of the situation, and then projecting this information forward in time to
determine how it will affect future states of the operational environment.
Time is an important concept in SA, as SA is a dynamic model, changing at a tempo dictated
by the actions of individuals or teams, task characteristics, and the surrounding
environment. As new inputs enter the system, the individual/team incorporates them into
The similarities between Team State1 and the Situational Awareness module show up when
compiling the list of factors that affect Situational Awareness shown below.
• Quantity of work
• Technical status
• Communication
• Unfamiliarity
• Improper procedure
• Weather
• Fatigue
• Night
• Speed
• Traffic volume
• Spatial awareness
• Position
• Time pressure
• Social environment for crew
• Company pressure, orders etc
• Personal situation / emotion
SA can be lost in several ways – failure to collect information (we just didn’t see it), failure to
interpret cues and failure to project future events.
Certain phases of a passage are more vulnerable than other to loss of Situational
Awareness.
Typical examples of loss of Situational Awareness occur at night, in long open water
stretches etc. minus team states2. Conversely loss of Situational Awareness can also occur
when there is high levels of activity corresponding to plus team states3.
Thus, loss of SA can occur in both minus and plus team states. It is not really a surprise that
underload, overload, stress or inattention can lead to loss of Situational Awareness.
1
See Team State
2
See Team State
3
See Team State
Additionally: Teams are more likely to lose Situational Awareness than individuals, and this
highlights the need to concentrate on such concepts as Shared Mental Models,
Communications & Briefings, Challenge & Response etc. that are clearly affected by loss of
Situational Awareness.
While crews are the most likely victims of Situational Awareness loss, they seldom detect it
until challenged – either internally or externally.
Some data from aviation: Frequency of Factors during loss of Situational Awareness Events:
Workload / Distraction 86
Communication 74
Improper procedure 54
Time pressure 45
Tech. Problem 43
Weather 32
Unfamiliarity 31
Fatigue 18
Night 12
The need for cultural awareness, different types of culture and how culture can affect behavior
Culture can be defined as the values, norms, and traditions that affect how individuals of a particular
group perceive, think, interact, behave, and make judgments about their world (Chamberlain 2005).
Culture is about how people make sense of experience and is not homogenous, static or a list of
traits or beliefs shared by a social group.
We all participate in multiple cultures which are linked to our ethnicity, nationality, social class, and
other aspects of our identity like gender, sexual orientation or religion.
Culture shapes the way we think, feel and experience our lives. We are also shaped by organisational
and professional cultures influence us.
The first stage in understanding culture is to look at the differences between us, we looked at three
key areas:
Power Distance
The power distance index expresses the degree to which the less powerful members of society
accept that power is distributed unequally.
In societies with a high-power distance individuals accept that everybody has a place and there is a
tendency to try to please superiors and not to challenge them.
In societies with a low power distance, individuals tend to see each other as equals irrespective of
the amount of power an individual holds.
Group or Individual
The group or individual index expresses how members of a culture relate to each other. Are they
part of an “I” culture, where they are expected look after themselves and their immediate family
only, or part of a “we” culture, where there is an expectation that relatives, the in-group and society
will look after them in return for loyalty?
The number “measures” the degree to which people in a society are integrated into groups.
Individualistic societies have loose ties that often only relates an individual to his/her immediate
family. They emphasize the “I” versus the “we.”
Uncertainty Avoidance
The uncertainty avoidance index is defined as “a society's tolerance for ambiguity,” in which people
accept or avoid a lack of certainty about the current situation or the future. Societies that score a
high value in this index opt for stiff codes of behaviour, guidelines, laws, and generally rely on
absolute truth, or the belief that one lone truth dictates everything, and people know what it is.
A lower value in this index shows more acceptance of differing thoughts or ideas. Society tends to
impose fewer regulations, ambiguity is more accustomed to, and the environment is more free-
flowing
In the unit the cultural wheel was introduced as a way to summarize the ways to deal with differing
cultures.
Here are the definitions from the cultural wheel.
Respect
You must respect other people’s culture. Without respect from both cultures, or good
communication will not even start.
Learn
Learn what motivates people as individuals and as members of their culture. They have reasons for
their behaviour. Pay careful attention to body language and their reactions.
Interpreter
You may need an interpreter, someone who can act as a link between the 2 cultures.
Explain
Explain your actions and give clear messages in simple language. Check understanding of actions
and instructions.
Procedures
Try to use procedures to reduce cultural misunderstandings, checklists can help.
Consistent.
Keep a consistent approach and attitude, so people know what to expect, consistency avoids
confusion.
Name
Use a person’s name or title, be sensitive to what they expect and want.
Understanding
Work at increasing your understanding of individuals. Keep an open mind. They’ll probably surprise
you.
Remember we can communicate despite our different cultures. Being more aware of culture can
help clear the fog and enrich your experience of other people.
Communication is not simple. We need to be constantly aware of the messages we are sending out
and receiving.
The leader creates the climate for communication. They must welcome an open interactive
communication style.
Closed Loop
Ensuring that the message has arrived is an important part of communication and the technique for
this is closed loop communication.
In closed loop communication the sender sends a message, the receiver acknowledges it by
repeating the main parts back to the sender, then the sender confirms the acknowledgement.
Send
Acknowledgement
The Confirm may appear simple and unnecessary, though it is very important. Confirming gives
positive feedback and reinforces the loop. It makes the communication channel more likely to stay
clear and open.
Briefings
A good briefing sets the climate for open interactive communication throughout the operation and
improves teamwork. It's a productive way of communicating the information among the team and
defining responsibilities. Without a briefing you can get confusion and negative feelings.
Briefing Guidelines
• Make time
o You need to make enough time so that people can pay proper attention, keep
everything open and friendly.
• Who should run the briefing?
o The team member with the most information (not necessarily the leader) should run
the briefing. By delegating the leader will not lose control.
• Keep it interactive,
o It’s not a one-way process.
o Ask for suggestions and comments - remember to include all team members.
• Shared Mental Model
o Make sure you're all on the same wavelength with the same mental model of the
situation.
• Assign tasks
o Who's doing what, and keep communication closed loop so that everyone agrees.
• Stick to the subject.
o Give an opportunity for questions at the end.
• Any questions?
o Finally confirm understanding
Checklists
A checklist is a type of job aid used to reduce failure by compensating for potential limits of
human memory and attention to ensure that critical items are not overlooked.
It helps to identify schedule, compare, or verify a group of elements or actions. It is also used as a
visual or oral aid to enhance short-term memory. It may also be referred to as an “Aide Memoire”
Almost all malfunction and emergency checklists use the Read-Do method.
• When beginning a checklist, the operator states the name of the checklist being used
• Checklist is actioned / completed
• When finished states the name of the checklist again, followed with the statement "...
Checklist Complete".
• Follow down the checklist with your finger so as not to lose you place.
• If interrupted during the checklist, and there is any amount of doubt as to where you are in
the checklist, simply restart from the beginning (and state you are starting from the
beginning).
Checklist Dos
• Checklists should be designed for independent use, so you don’t have to reference a manual.
• Designed so two checklists are not in use at the same time.
• Used to ensure that a particular series or specific actions or procedures are accomplished in
the correct sequence.
• Type size
• Type font
• Lighting conditions where it is used
• Legibility of print
• Readability
• Contrast
• Pictures and Illustrations
The need for a balance between authority and assertiveness and the dangers of extreme
combinations
Perhaps because of history and tradition, authority and assertiveness is a major hazard in shipping.
Understanding it can help to limit its negative effect.
Authority in this context comes from a legal and company responsibility, whether it’s shown or not.
Assertiveness is putting forward your ideas - right or wrong. It can come from confidence,
knowledge, skill, experience, or just personality.
Most people would agree that a balance between the authority and assertiveness of any two
members gives the safest situation. Everybody must be assertive enough to contribute and, if
necessary, challenge decisions.
We're all different. Our personalities affect our level of authority or assertiveness
Looking at the possible combinations of authority and assertiveness and their consequences.
A leader with high authority and a team / team member with low assertiveness.
This situation means that the whole team does not participate in decision-making - their
ideas and challenges are put down with little thought. This tends to be more dangerous
because the leader will take all decisions alone, giving a greater risk for one-man errors.
A leader with low authority and a team / team member with high assertiveness.
High assertiveness can compensate for low authority generally the least dangerous
combination because the leader will always be involved.
This could be very dangerous as the clash in personalities is a significant distraction and they
may miss critical events. It will also take time and emotional effort to repair the bad feeling
generated. There may be increased stress and higher than normal workloads on board.
A leader with low authority and a team / team member with low assertiveness.
This is perhaps the most dangerous combination because decisions may not be made, or
they may be made too late or incorrectly because of the lack of challenges.
We all think of ourselves as normal. It's others who are out of step. But we must learn to think
again and question our own actions first before calling others abnormal. If individuals are not
assertive enough, perhaps we haven't set the right environment. Are we giving them the
opportunity to participate or are we shutting them up by responding badly? Similarly, if they're too
assertive, are we using too little authority, and are they compensating by stepping into the gap
High Authority: Use humour and diplomacy. Lower assertiveness but not so much as to
threaten safety.
Low Authority: Stimulate or even provoke, so increase assertiveness, but within reasonable
limits.
High Assertiveness: Use humour and diplomacy but make the position clear (in private
conversations). You might lower your authority a bit.
Low Assertiveness: Stimulate - coach - build confidence. Use higher authority when needed but
be careful not to kill the last bit of assertiveness.
The importance of establishing a Challenge and Response environment, how to make a challenge
and how to respond to challenges
To improve safety everybody needs to operate as a team, monitoring, questioning, and supporting
each other. We need to set up a style of open communication in which we can challenge and
respond to challenges.
In a good challenge and response environment everybody feels free to question assumptions and
actions, and positive responses are normal.
Here we're dealing with challenging plans, understanding and assumptions, in other words our
situational awareness not the authority of team members.
It's the leader’s responsibility to set an environment that supports challenges. They should make it
clear that challenges are not only expected but welcomed. If the leader has not set the
environment, then the other team members should diplomatically persuade the leader to set it.
If the limits of the plan are not exceeded, then there may be no need for challenges. However, life is
not usually that simple…
Challenges can come from anywhere, including from within ourselves. We should continually
challenge our own plans and situational awareness.
Challenges will probably only happen if the environment is properly set. But you may have to
challenge even if not requested. In that case make the challenge as strong as necessary.
If challenged, the first response is always to check. If possible, use a third source of information to
check differences in situational awareness between the originator and the challenger. Remember to
welcome challenges even if they are incorrect.
The above may cause them to respond emotionally and negatively or not at all to any challenges
that are received.
Additionally, let us suggest a method of how to make challenges in the team environment.
Short Term Strategy is a structure for bringing the whole team into the problem-solving process.
It’s a common structure that saves time and increases situational awareness by building a shared
mental model and minimises misunderstanding and risk.
Short term strategy should be used when there are no rules or standard operating procedures to
support the decision. When you're not forced to make an instant decision, then you have time to
consider alternatives. These considered decisions need careful thought from the whole team.
Why short-term strategy? On the assumption that each of us has a percentage of the total relevant
knowledge to solve a problem, this knowledge may be experience, information, skills, attention or
ability.
When the team combines their relevant knowledge the combined knowledge increases. This
reduces the total unknown risk area considerably. Reducing the risk area means a major increase in
safety margin. Though it is only true if we work together as a team.
1. Identify the problem. Assess the situation - what are the risks and time available? And
gather information on the situation.
2. Each team member should judge the situation and build their own plan to solve the
problem, interacting with the others throughout the process. Plans will normally NOT be
written down. If everyone builds a plan it's less likely that one person will dominate.
3. Check the individual plans and produce a combined plan with the best parts of each. The
combined plan with the best ideas will be stronger.
Define and agree monitoring guidelines and assign tasks in the plan. They form the basis for
challenges when the plan is being carried out. And finally gain commitment that everyone
will actively participate in carrying out the plan. It helps motivation if each person can see
their contribution in action.
4. Brief everybody with a summary of the problem and the combined plan. Remember that
briefings will go on throughout the process.
This summary briefing occurs at the end of the analysis, before carrying out the plan.
It clarifies the situation and gets everyone committed… The whole process should be
interactive.
5. Monitor the plan as it's executed. Make sure that everyone knows their tasks. And adjust
the plan if the situation changes. Be flexible.
6. As soon as possible afterwards, take the opportunity to debrief the situation. What lessons
can we learn?
Short term strategy works best where there are good inter-personal communications - interactive
and closed loop and an environment where challenges can be made.
Short term strategy is a standard way of approaching problems, a formula we can follow consciously.
Use it to maintain situational awareness and to make sure that everyone makes an active
contribution.
Recognise different workloads, the importance of pre-planning, problems at the start and during
delegation and how to delegate correctly.
Controlling workload by pre-planning and delegation is one of your most important functions.
This is not just the leader’s job. Everyone is responsible for his or her own workload and should help
to share the total workload.
There's no real method of measuring workload. Even if there was, we're all different and respond
differently to the same workload. What's important is how we FEEL about our workload at a
particular moment in time. Our feelings and attitudes are the main influence on how we react.
• Demands
o Tasks to be done
▪ Easy,
▪ Difficult,
▪ Very difficult,
o Importance
▪ Unimportant,
▪ Important,
▪ Very important
• Resources
o Your fitness for the tasks - a combination
▪ Skills
▪ Training
▪ Experience
▪ Attitude
▪ Health
▪ Time available.
High Workload
When the number of tasks is large, and some may be important and difficult to handle.
If you're unfamiliar with the situation, and you're tired, you may not feel up to the tasks.
There may be time pressures and little time to take action.
This high workload may lead to an overload in which you cannot keep up with all the tasks.
• Duplication of effort
• Errors
• Focus on urgent tasks
• Tendency to overlook other important items
• Bad temper
• People stop listening
• Tunnel vision
This low workload can also be dangerous as a decrease in alertness and concentration can lead to
increased errors and increased time to perform tasks.
Recognising the level of workload is not usually a problem. But recognising unbalanced workload -
too little or too much is more difficult.
Pre-Planning
Let's look at pre-planning as one way of balancing workload. You can think of pre-planning as a long-
term strategy for example defining procedures, job functions, introducing new technology.
Everyone agrees that delegation is a good idea it has its challenges that come from within us that act
as blocks to delegation.
One of the main blocks to delegation is fear. The thoughts that can stop delegation are shown in the
table below, many of them are true, at least to begin with.
At the start of delegation, which tasks to delegate will depend on the difficulty or importance, and
the time available. Perhaps you should start from which tasks NOT to delegate and delegate the
rest.
Having overcome fear, you need to decide which task to delegate, to whom, how and when. We'll
introduce a simple checklist to help.
Don't forget to brief the others that the job has been delegated, otherwise they will keep coming
back to you and bypass the delegation process.
You need to keep a balance between monitoring progress and not trusting people. Be positive. Try
to stimulate them and give ideas rather than criticise. It's an art that you have to learn.
As an individual develops you should gradually withdraw support - give a lot at the start and less as
confidence grows. The best way is to ask how much support they feel they need. But sometimes
you should refuse to help and get them to find out for themselves.
Automation characteristics and dangers, people’s attitudes towards automation and the importance
of applying MCRM techniques to automation
Automation has been with us for a long time. The problem is that we don't often get enough
training with it so we're not familiar with all its behaviours.
Type Level of
Man / Machine interaction
of Automation Automation
Autonomous High The machines tell you what they're doing - if you're lucky
Managed The operator pre-programs instructions
Medium
Directed The machines command some systems
Guided The machine gives guidance only
Low
Manual The machines are disconnected
Humans Automation
Modes
A mode is a distinct setting within automation, where the same user input will produce different
results depending on the mode selected.
Observability
Observability of an automated system, - how easy is it to see what the system is doing when the
system moves to a new mode is set by the designer of the system and its human machine interface?
At one end, system status may be difficult to observe, or it may be silent, while at the other end
system status may be too observable with too many alarms, so that you immediately switch them
off.
Evolving Automation
As automation gets more powerful it can carry out longer sequences of actions without human
input, and even override human input.
Automation can be complex and difficult to control. It may be difficult to change mode, and there
may be delayed reactions to inputting commands.
As automation becomes more reliable it can be so good that we trust it, have confidence, maybe
overconfidence, in it, and become dependent on it.
The solution is to have a fall-back position. It may be to a medium level of automation or all the way
back to fully manual. This may depend on your company policy. If you're familiar with and practise
complex modes, then workload will be at a minimum.
Automation also affects the timing of errors - errors in pre-programmed actions may not be noticed
for hours.
There are dangers of missing things... misinterpreting, mistyping, (remember: garbage in garbage
out) mis-monitoring. Minor events can pass unnoticed and get more serious - the situation is going
sour and may end up in an automation surprise.
Automation Surprise
An automation surprise is an action that is performed by an automation system and is unexpected
by the user, this is usually due to a mode error.
Mode errors occur when the user forgets what mode the automation is in, then performs an action
that is appropriate to a different mode and gets an unexpected and possibly undesired response.
A mode error can be quite startling and disorienting as the user deals with an unexpected response
from the automation.
Problems occur if a change in the system mode happens unnoticed either initiated by the
automation, or by another person, such as a user who was previously using the automation, or if
after some time the user forgets about a mode change they have made.
One final comment on Automation. When you think about it automation it is really a member of the
team. It carries out delegated instructions. It communicates, and challenges you.
Six Team states, being able to recognise the “states” and the factors that affect them
Situational awareness tells us what's going on around us - the state of the instrumentation,
automation, speed, our position.
But we also need to continually check the human components - what's going on inside our heads,
that is our emotional situational awareness, which affects how we behave and perform.
This is not only our own emotional state but the state of the whole team.
We use the term Team State to indicate the state of the team
The indicator shows 6 team states ranging from plus 3 Alarmed to mins 3.
Team States
Normal
Everything is progressing as expected and anticipated.
+ 1 State Uncomfortable
If something happens to make you, or the team, feel concerned. It may not be clear what the
problem is, but the feeling is real and beginning to affect yours’s or the team’s performance.
Then the team moves to the + 1 state.
+ 2 State Concerned
If more problems occur, workload starts to increase. The situation is now getting more serious, you,
or the team, feel that the situation is getting serious, the workload or level of stress can increase.
The team state moves to the + 2 State
+ 3 State Alarmed
If the situation deteriorates further the workload increases further. If the situation is very serious,
the workload and/or level of stress can cause a strong sense of alarm, even danger – You, or the
team, are now in a critical + 3 state.
- 2 State Inattentive
You, or the team, can slip further into a minus two state - your brain slows even further, you get
sleepy and inattentive, errors can become frequent and serious.
In a – 2 state monitoring is not getting done. The instruments may be in control and you or the team
may be relying on them completely.
You, or the team, may disconnect from the situation or get hypnotised on minor details. Minor
mistakes can occur, or you or the team get bad tempered.
The most difficult thing is to recognise the danger even though all the physical factors appear Okay.
Inattention during a critical phase can be as dangerous or even more dangerous than a more
recognisable emergency.
Let's summarise. Your actions are affected by how you feel about your state. Whether you feel
happy with the situation, concerned, alarmed, bored, or inattentive. That feeling will effect
performance.
One particularly dangerous situation is when an emergency occurs in a minus three state. This can
cause confusion and panic at a critical time. Then you flip immediately to the alarmed state, when
someone recognises the danger.
To quote the NTSB;” Inadequate crew monitoring and cross-checking has been cited by a number of
sources as a problem for safety. 84 % of the accidents involved inadequate crew monitoring or
challenging”.
So, as part of our briefing and as part of creating a Shared Mental Model (SMM) we need to develop
a Monitoring strategy."
In thinking aloud, an individual verbalises their thoughts on both what they are perceiving and how
these fits in to the situation (their situational awareness) They also verbalise what their intentions
might be so that the whole team is aware and has the opportunity to challenge.
Types of errors (including “blunt” and “sharp end” errors), types of defences and countermeasures
and a policy for responding to and learning from errors
Some incidents and accidents are caused only by acts of god. But the sea is an error rich
environment and human error usually plays a major part. We need to understand the nature of
errors and apply defences and countermeasures.
Closer to the accident/incident are (Sharp End) errors related to the tasks or to the environment.
These include:
• Equipment faults
• Design faults
• Not enough training
• Individuals performing tasks can make errors because of lack of skill
Errors closest to the incident or accident are called Sharp End and furthest away are called Blunt
End.
In order to prevent errors, we introduce the error management tool Avoid Trap Mitigate
Long before operations you should set the environment and train the team to manage.
Trap
Mitigate
Lessons
After an event the most positive way is to look at it as a learning experience. Reporting and writing
down the lessons and feeding them back is in the best interests of maritime safety.
To summarise, there are so many sources of errors that we will never be able to guarantee absolute
safety. But there are many factors under your control. You can have a safety policy to reduce errors:
you can follow rules, discuss safety issues and use MCRM techniques.
When we or others make mistakes, we should have a policy of actively learning from them by
reading, debriefing and using personal experiences.
A debriefing is a meeting after an operation (good or bad). It is an investment in training and in the
future since the events have already passed.
• Try to debrief as soon as possible after a situation while it's fresh in everyone's mind.
o If this is impossible write notes for later.
• Cover the positive points as well as the negative. Each can provide a useful learning
experience.
• Consider areas of improvement for yourself first.
• Give them a chance to speak for themselves.
• How they felt about the operation is just as important as what actually happened.
• Don't blame individuals.
• Talk about the whole team.
o Even though one person may make a mistake it's the whole team's responsibility to
detect errors.
o Try to keep them relevant. Stick to the facts, in sequence.
One way of looking at leadership styles is to look at how people behave. Some people, because of
personality or personal philosophy, focus on goals, performance and results.
On the opposite side others instinctively believe that people are more important, motivate people
and they will take care of results.
So, one axis shows concern for performance and the other axis shows concern for people.
A person using only this style believes very strongly in performance and has little concern for people
and teamwork. They can be a tough authoritarian leader, possibly from the old school. They often
have a high regard for themselves, and a low regard for others.
But they’re usually a strong leader ready to make decisions and take responsibility for their actions.
And they can be loyal to their team and to the company.
On the opposite side a person using this style believes that performance is not so important, but
people are. They rely almost totally on their team. They may turn out to be easy going, and as a
result may not get much done. They are however a nice person to sail with and create a friendly
atmosphere. They are a good listener, but their own communication may not always be relevant to
the situation.
The low concern for performance, low concern for people style is typical of a person who's not
interested in his job. They do the minimum necessary to perform the task and hide from conflict.
In the middle the individual tries to adapt to the system and will compromise performance and team
relationships.
The individual has a high regard for performance and pays close attention to people. They apply the
best parts of the high on performance and high on people and are flexible enough to modify their
own style when necessary.
A person using this style is authoritarian. They only use one-way communication and avoid
discussions. They limit challenges from other officers and do not often accept them. They can be a
strong leader who sets an example and commands respect. You know where you stand with them.
The style is good in a crisis. The problem is that people using this style often try to do everything
themselves. They don't delegate tasks to make the best use of resources.
• Other team members may become quiet and defensive. They'll avoid active participation for
fear of getting bitten.
• Communication will decrease, and challenges will probably be avoided.
• Because all the team's resources are not fully used, there will be a decrease in performance,
this style will influence team morale.
The concern-for-people style believes that if you take care of people they'll be motivated, and things
will almost take care of itself. The Challenge and Response Environment could be unbalanced.
Maybe too few challenges - people don't want to spoil the good working relationship, or too many
challenges - officers are too assertive. Mistakes are forgiven and smoothed over to avoid conflicts.
Debriefings, if they occur at all, will focus only on positive aspects, so opportunities for learning from
mistakes are reduced. High performance standards may appear to be an attack on the individual so
lower standards are accepted. But they trust people and give them responsibility.
A person in the low-on-performance low-on-people position has a low opinion of his own ability.
They may look forward to retirement and try to be ignored by fading into the background. They set
low standards, are a poor communicator, and believe that authority is something to do with the
police.
• on morale
• on team standards
• On training.
People in this category can be hard to identify because they've learned to hide their weaknesses by
not sticking their necks out.
A middle of the road style is a compromise between performance and people. Results are usually
reasonable and there are normally no major concerns. Yet everybody has the feeling that there's
room for improvement.
An individual using the ideal style is very concerned with performance but at the same time makes
best use of their team. They use Maritime Crew Resource Management tools. Communications and
briefings are carried out in the correct way. They accept challenges and use short term strategies.
Even though they get good results they’re never quite satisfied and try to improve every voyage.
Now you may think that leadership style is unconsciously locked into your personality and cannot be
changed, but this isn't true. You can and should consciously adapt your style as circumstances
demand
Different categories of decision, how to classify decisions, influence of initial preference and hidden
pressure on decision-making.
We don't deliberately make wrong decisions. We make decisions based on personality, attitudes,
information, training and experience in what seems like the best way at the time. Much of our
decision making is not logical, but based on mental images, on experience and on intuition.
Skill Based
Skill based Decisions are for tasks which are very familiar. It can take a long time to learn these skills,
but you can use them fast without any conscious thought.
Rule Based
Rule based Decisions are for known situations where there are clear rules. Examples are standard
operating procedures and "go/no go" decisions.
Knowledge Based
Knowledge based Decisions are more difficult, complex and involve elements such as problem
solving and planning.
At the knowledge-based level, our decisions are also more sensitive to fatigue, stress and attitudes.
With increased automation, you'll be faced with more knowledge-based and fewer skill-based
decisions. Computers handle many of your skill-based decisions.
When faced with a problem our first instinct is to assess the situation by asking...What's the
problem? How much time have we got? What are the risks, now and in the future?
If we judge that time is limited and the risk is high, then even if we don't fully understand the
situation, we often apply rules or skills we know, appropriate or not.
The problem with decision making is that under time pressure and stress, and even when we have
time and think we fully understand the problem, we tend to pick the first action we think will work,
and don't investigate the rest.
Making decisions can be difficult, below are some factors that can affect the judgement process.
When things are uncertainty your personal feelings can have a major influence.
To start with you are not usually completely neutral. You may have an initial preference on
which option is best. To counteract this initial preference, you should first ask "What other
options do we have?". You may find a better solution.
As well as the initial preference bias our judgment can also be clouded by four major
factors... Fatigue, which affects our controlling brain's ability, complexity of the situation,
lack of time and often linked to time, stress caused by risk, or by high workload.
One important factor that affects judgement we'll call hidden pressure. Hidden because it
often goes unnoticed, and pressure because it forces us in one direction. It is not
immediately obvious, it's hard to detect and can be hard to cure.
When making decisions, we need to consider hidden pressure and take account of Risk and Threat,
especially in our planning.
How do you deal with hidden pressure? Be alert for it as a possible problem. And separate facts
from emotions.
The ART tool is a dynamic decision-making tool where you set the limits; these limits are specific to
the current situation and will vary through time.
It has 3 zones Aware, Risk and Threat the “objects” (such as an approaching ship or machinery issue)
will be allocated to a zone depending on the limits and situation.
In this zone there are “objects” that you need to be aware of as they may become a risk or a threat
in due course.
In this zone the “object” is moving up your attention scale and you are allocating more time and
resources to it.
In this zone the “object” has now become an active threat and you need to do something about it
you need to take action to reduce the threat.
Remember that you set the limits in the ART decision-making tool.