Executive Summary

In the marine industry, as in many other industries, regulations have often prescribed engineering and technological solutions in response to accidents to improve safety and to minimize the consequences. New engineering and technological approaches have resulted in tremendous safety improvements in the past; however, these approaches have also, at times, inadvertently resulted in less safe conditions because they cause unintended changes in one or more of the other system components, such as people's behavior.

The realization has been growing that human error is a contributing factor in a majority of marine accidents and that attention must be focused on the people in the system.1 Human errors have been attributed to factors such as fatigue, inattention, lack of training, inadequate communications and coordination, inadequate information, lack of clear-cut roles and work procedures, and design problems.

In view of the limitations of the traditional methods of enforcing regulations and the importance of a better understanding of the human role, the U.S. Coast Guard Assistant Commandant for Marine Safety and Environmental Protection developed the Prevention Through People (PTP) program, a long-term strategic initiative to focus preventive efforts on the human element. The PTP concept is founded on the premise that the components of a system that affect safety—human behavior, technology, management, and the work environment—are interdependent and that changes in one component are likely to bring about changes in the others. The Coast Guard established a quality action team (QAT) to identify implementation strategies for the PTP program.

The QAT report (1) examines the role of humans in the maritime transportation system, particularly in areas where human error has been prevalent, and provides possible explanations for this prevalence; (2) offers a preventive strategy; and (3) recommends a plan for implementation. In characterizing the importance of human and organizational performance in marine safety across many sectors, the QAT report stresses that changes in the marine industry must be based on what is known about people. A subsequent document devoted to elaborating the PTP implementation plan sets forth principles, goals, and objectives. Pursuing these objectives will require research and development (R&D) in human and organizational performance.

The Waterways and Marine Safety Division of the U.S. Coast Guard R&D Center, which is responsible for the Coast Guard's Human Factors R&D Program, has a variety of research activities under way at any given time; but the extent to which these activities are aligned with PTP program objectives has not been documented. Therefore, the Coast Guard requested that the National Research Council address this question. The Committee on Human Performance, Organizational Systems, and Maritime Safety, under the auspices of the Marine Board, was assigned this task. A subcommittee briefly reviewed and critically discussed the Coast Guard's QAT report,

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The subcommittee's reservations about the phrase “human error” are described later in this summary and in Chapter 2.



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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM Executive Summary In the marine industry, as in many other industries, regulations have often prescribed engineering and technological solutions in response to accidents to improve safety and to minimize the consequences. New engineering and technological approaches have resulted in tremendous safety improvements in the past; however, these approaches have also, at times, inadvertently resulted in less safe conditions because they cause unintended changes in one or more of the other system components, such as people's behavior. The realization has been growing that human error is a contributing factor in a majority of marine accidents and that attention must be focused on the people in the system.1 Human errors have been attributed to factors such as fatigue, inattention, lack of training, inadequate communications and coordination, inadequate information, lack of clear-cut roles and work procedures, and design problems. In view of the limitations of the traditional methods of enforcing regulations and the importance of a better understanding of the human role, the U.S. Coast Guard Assistant Commandant for Marine Safety and Environmental Protection developed the Prevention Through People (PTP) program, a long-term strategic initiative to focus preventive efforts on the human element. The PTP concept is founded on the premise that the components of a system that affect safety—human behavior, technology, management, and the work environment—are interdependent and that changes in one component are likely to bring about changes in the others. The Coast Guard established a quality action team (QAT) to identify implementation strategies for the PTP program. The QAT report (1) examines the role of humans in the maritime transportation system, particularly in areas where human error has been prevalent, and provides possible explanations for this prevalence; (2) offers a preventive strategy; and (3) recommends a plan for implementation. In characterizing the importance of human and organizational performance in marine safety across many sectors, the QAT report stresses that changes in the marine industry must be based on what is known about people. A subsequent document devoted to elaborating the PTP implementation plan sets forth principles, goals, and objectives. Pursuing these objectives will require research and development (R&D) in human and organizational performance. The Waterways and Marine Safety Division of the U.S. Coast Guard R&D Center, which is responsible for the Coast Guard's Human Factors R&D Program, has a variety of research activities under way at any given time; but the extent to which these activities are aligned with PTP program objectives has not been documented. Therefore, the Coast Guard requested that the National Research Council address this question. The Committee on Human Performance, Organizational Systems, and Maritime Safety, under the auspices of the Marine Board, was assigned this task. A subcommittee briefly reviewed and critically discussed the Coast Guard's QAT report, 1   The subcommittee's reservations about the phrase “human error” are described later in this summary and in Chapter 2.

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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM the PTP implementation plan, and the Human Factors R&D Program plan. The subcommittee assessed each relevant document and made findings and recommendations about ways to strengthen and advance the technical basis and principles of the PTP program. In its review of documents, the subcommittee noted that the term “human error” appears many times throughout the QAT report. Although the subcommittee recognizes that “to err is human,” the subcommittee believes that term “human error” is misleading: One tends to interpret “human error” as meaning that the cause of an error is most frequently a human being rather than error-inducing characteristics in the system that result in people making errors. This tendency often leads to a “blame the victim” mentality, which needs to be overcome. PREVENTION THROUGH PEOPLE PROGRAM The PTP implementation plan includes a vision statement and a set of principles and goals to be supported by a number of objectives, both current and future. The PTP vision 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. ” The five guiding principles capture the values and philosophy to be used as a guide: Honor the mariner. Take a quality approach. Seek nonregulatory solutions. Share commitment. Manage risk. These principles have five accompanying goals: Know more. Train more. Do more. Offer more. Cooperate more. Each goal has a set of objectives that the Coast Guard believes will result in improvements in marine safety. Although with one exception the PTP implementation plan does not target specific sectors, the QAT report recommends implementing the PTP strategy first in one or more of five high-risk sectors (i.e., areas that have high “human error” rates) on the grounds that these sectors “offer the greatest potential to reduce maritime fatalities, injuries, and pollution.” The five sectors are towing vessel/barge operations,

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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM tankship operations, fishing operations, passenger vessel operations, and offshore supply vessel operations. U.S. COAST GUARD'S HUMAN FACTORS R&D PROGRAM The Coast Guard's Human Factors R&D Program, which predates the PTP program, represents a human-centered approach to maritime safety but focuses largely on the Coast Guard 's internal needs, deep draft commercial vessels, and large passenger vessels. The program is intended to provide insights into the causes of accidents and point the way toward safer operations, a better understanding of problems, and improved crew performance, as well as reveal technical bases for regulation, education, common language, and guidelines for industry. The subcommittee believes that the program's specific projects are worthwhile but do not, by themselves, provide an adequate basis for the PTP program. Furthermore, the program does not specifically target high-risk sectors, such as the ones identified in the QAT report (i.e., towing vessel/barge operations, tankship operations, fishing operations, passenger vessel operations, and offshore supply vessel operations), implying that the Coast Guard 's human factors R&D efforts should be modified to be commensurate with the scope of the PTP program. IMPROVING THE TECHNICAL BASIS FOR THE PTP PROGRAM The subcommittee examined the Coast Guard's objectives in support of the PTP program and assessed them according to a number of criteria. For each PTP goal and objective, the subcommittee discussed whether there was (1) technical and/or scientific support for the objective; (2) a known methodology that could be used to achieve the objective; (3) a “development activity” that could improve the technical foundation of the PTP program;2 (4) a R&D component of the objective; and (5) a gap in the R&D component and, if so, how this could be remedied. Based on its assessments, the subcommittee identified a number of development activities and additional human factors R&D projects that could strengthen and support the goals and objectives of the PTP program and provide insights for expanding the program. All of the identified activities and projects were assessed for their potential contributions to the PTP program. The development activities that the subcommittee believes will further strengthen the technical basis of the PTP program and are essential to garner industry support for the program are the following: 2   For convenience, the subcommittee used the label “development activities” to designate technically supportive activities outside the realm of traditional basic and applied research, but within the realm of formal R&D.

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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM 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 cooperative best practices Near-Miss/Incident Reporting, Evaluation, and Dissemination All five PTP goals and many of the accompanying objectives, to varying degrees, would be supported and reinforced by a development project on near miss/incident reporting, evaluation and dissemination. In fact, this type of reporting system is a prerequisite to pursuing many of the PTP objectives because they require data that would emerge from the reporting system. PTP Information Dissemination Strategies Strategies for disseminating PTP information to Coast Guard personnel and to industry, including mariners, will be critical to the success of the PTP program. PTP strategies for information dissemination could provide (1) essential feedback, (2) access to data and information, and (3) notice of data and information to all participants (from CEOs to seamen). Accident Reporting and Evaluation A system of analysis to trace the chain of events and identify root causes of accidents in the maritime transportation system could strengthen the PTP program's goal for improved safety (i.e., fewer and less consequential accidents). A system of analysis would support, to varying degrees, all five PTP goals. Accident information systems can provide: (1) opportunities to learn from past mistakes, (2) in-depth understanding of failures in systems, (3) opportunities for disseminating lessons, (4) opportunities for conducting trend analyses, (5) indices of the relative performance levels of industry sectors and components, and (6) feedback on the effectiveness of processes and measures of risk management.

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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM Organizational Self-Assessment Instruments Organizations may not be aware of the ways they affect operations; thus, a means by which they can obtain feedback on their impact would: (1) provide feedback from organizational participants, (2) identify strengths and weaknesses in system safety, (3) provide early warnings of emerging error-inducing contributing and compounding organizational developments, and (4) provide information on the effects of policies, procedures, and regulations. Risk Analysis and Management Risk analysis and management are key activities in support of the PTP program. Risk analysis is a proactive attempt to understand the potential strengths and weaknesses of a system. Once the weaknesses are properly understood, effective strategies for managing risk can be identified and implemented. Risk management is an attempt to mitigate risk. Annual PTP Conferences The PTP “cooperate more” goal encourages the sharing of information, such as lessons learned, that could benefit the marine community. One means of implementing this goal is establishing partnerships; forming partnerships is a major thrust of the PTP program and has much potential for improving safety. Partnerships, and the exchange of information and learning engendered by them, are critical to the success of the PTP program. Annual PTP conferences could support constructive discussions of near misses; accidents; development activities; implementation strategies; emerging problems; and audits, assessments, and inspections. Data Utilization Methods for capturing and disseminating data in other industries can be adapted to the marine industry. The Coast Guard does not have a methodology or the necessary template for collecting data. Data on organizational, job, and individual factors also should be collected. Cooperative Best Practices A system for collecting and sharing information on best practices within the maritime industry should be developed. This system could also include data on best practices in other industries that appear to be adaptable to the maritime industry.

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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM 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. RECOMMENDATIONS FOR ADDITIONAL HUMAN FACTORS R&D ACTIVITIES Although the Coast Guard's Human Factors R&D Program plan was not developed to support the PTP program, to varying degrees, the ongoing projects are generally supportive. The subcommittee, however, was not charged with undertaking a detailed review of each project. The subcommittee believes that a comprehensive review of current R&D projects should be instituted by the Coast Guard to ensure that each project is compatible with the goals and objectives of the PTP program and to determine if projects can be refocused to support PTP goals more directly. Dedicated, sustained, focused efforts toward understanding the impacts of human and organizational performance can advance the principles of the PTP program and ultimately improve safety and effectiveness in the marine environment. A systems approach should be adopted that addresses individual, team, organizational, regulatory, and environmental factors, as well as their interactive effects. The multifactorial approach adopted by the PTP program is a step in the right direction. The PTP program has the potential to advance marine safety and environmental protection. The PTP program can benefit directly from the Coast Guard's current and planned human factors research. However, the PTP program also has a number of human factors R&D needs that are not part of the Coast Guard's Human Factors R&D Program. The subcommittee recommends four high-priority human factors R&D activities to support the PTP program: (1) testbed platform projects; (2) guidelines for incorporating the PTP into Coast Guard performance appraisals; (3) the identification of effective incentive and disincentive systems; and (4) the development and adoption of human factors engineering guidelines for vessel design. Each of these research activities supports several goals of the PTP program. Recommendation 1. The subcommittee, noting that what is known in one industry or sector cannot be applied in another without testing and modification, recommends that a testbed program be established to evaluate practical applications of the PTP principles. Much information learned from previous human factors and organizational research has not yet been applied in the marine industry. A testbed program could demonstrate the applicability to the marine industry of selected human factors and organizational concepts, which are the foundation of the PTP program. This testbed program should be developed for several vessel types and industry sectors, including the high-risk sectors. Successful application of PTP principles in a testbed program would increase the credibility and effectiveness of the PTP program and could encourage industry support for and participation in the PTP program.

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ADVANCING THE PRINCIPLES OF THE PREVENTION THROUGH PEOPLE PROGRAM Recommendation 2. The subcommittee recommends that the Coast Guard develop model guidelines for incorporating safety into performance appraisals that can be adapted by companies in the various sectors of the maritime industry. The Coast Guard should develop and promote an objective, criterion-based system of performance appraisal and rewards that explicitly addresses and measures safe work practices. Recommendation 3. The Coast Guard should identify incentives that can encourage implementation of proven safety culture methodologies. To this end, methods used in other industries should be reviewed, adapted, and field tested as applicable. The subcommittee also recommends that the Coast Guard undertake research to define and delineate a maritime “safety culture.” This research should address the effects of national and local cultures on the safety culture, the correlation between people's cultural backgrounds and an organization 's culture, the compatibility of individual and cultural traits and organizational cultural traits with the requirements for a maritime safety, and the effects of national culture on the interactions between people and automated systems. In conjunction with the incentive program, the subcommittee recommends that the Coast Guard identify and review reward systems that have been successful for specific maritime organizations and companies (i.e., systems that have been shown to reduce accidents, lost work hours, and claims for workman's compensation). Recommendation 4. The PTP program should develop (or at least encourage the development of) a comprehensive and universal micro- and macroergonomics code of practice to be used during the ship design, construction, operational, and maintenance stages. ALTERNATIVES TO REGULATORY ENFORCEMENT The PTP program is a bold departure from the traditional use of regulations to address safety issues. The subcommittee believes that the PTP concept is extremely valuable, particularly in its balanced approach to risk management and its emphasis on partnerships. The PTP program recognizes the need for all participants in the maritime transportation system (including government agencies, industry, classification societies, industry associations, and mariners) to work cooperatively to increase system effectiveness and safety. The Coast Guard's Human Factors R&D Program could undertake additional R&D to support the PTP program. In addition, the Coast Guard could strengthen the technical basis for the PTP program by undertaking development activities that are likely to provide insights for expanding and providing additional support for the program.

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