ERROR MANAGEMENT: Teamwork
Pulling together on the bridge. We all make errors. It is part of our human nature and how we learn and gain wisdom and experience as we progress through life. However, errors need not result in undesirable consequences if they are detected in time and immediately corrected – and teamwork can be a crucial part of that.
E rrors can result from incorrectly applying knowledge or from not following rules, but there are other types of error; the unintentional slips and lapses, such as those we may make every day. As officer of the watch on the bridge of a ship, you still have the potential to make errors, despite closely following procedures and diligently adhering to the Master’s standing orders. Such errors can lead to an incident, such as a near miss… or worse. As the lone officer of the watch, how can you create an environment favourable to the identification and correction of errors before they result in more serious incidents? It is important that you recognise when errors are more likely to occur. Their likelihood may be affected by such things as workload, wellbeing, bridge design and weather conditions.
Method in the madness
Performing important tasks in a methodical manner can help capture errors. For example, interrogating navigational instruments, such as ECDIS or ARPA, in a careful and systematic manner can help you avoid misinterpreting information.
When conning the ship, using hand signals to support your instructions will allow the helmsman to question your orders if you make an error. For example, putting your right hand out while giving the instruction “starboard twenty” will support what you are saying. Putting your left hand out would create a situation where the helmsman could question the order.
Capitalising on the full potential of the watch-keeping assistant assigned to look-out duties during your watch can also be a great resource in helping you identify errors, for example to independently confirm what you see out of the bridge window and to identify it on the radar.
Discussing error capture with your watch-keeping assistant can be a useful training exercise. This can include discussing how the workload can be shared, training the rating to recognise the behaviours of confusion, fixation or distraction, all of which will have been covered during the HELM course you will have attended. The watch-keeping rating should be trained to be confident about raising an issue, and taught how to do this in the correct way.
For your part, you must be prepared to view the raising of an issue by a watch-keeping assistant as a useful part of the process of error capture and not as a personal criticism. A timely word can spark awareness, prompt you to take stock of the situation and ask for help or call the Master if necessary.
No ‘I’ in TEAM
How often do you see included in the Master’s night orders, “If in doubt call me”? Often, it can seem easier to try to deal with a situation yourself, rather than call what may be a fatigued or even irritable boss. Rationalising the decision to call the Master with the watch-keeping assistant can be a useful part of the decision-making process. Calling the Master is one of the most important error management tools there is.
What about an error made by a pilot or a Master? How can you, as an officer of the watch, bring an error to the attention of the Master or pilot? How do you raise the issue when you observe behaviours associated with errors, such as fixation, distraction, complacency and fatigue?
Pointing out errors that affect safe navigation can be difficult, and requires extreme tact. While some pilots or Masters might welcome you highlighting errors, others might see it as criticism. Nevertheless, it is your duty as a member of the bridge team to raise awareness and bring errors to the attention of someone able to do something about them.
There may be situations in which a Master may hesitate to question the pilot, for instance, even though he or she is not entirely happy with the manoeuvre a pilot is making. The speed could appear to be too slow or too fast, or the vessel might seem to be too close to an object. As officer of the watch in such a situation, questioning the Master quietly and tactfully, or mentioning observed behaviours which increase potential for error, may be just the support the Master needs to tip the balance in favour of raising the issue with the pilot. Never underestimate the contribution you can make.
Excuse me, Captain...
Many years ago, when I was part of a team helping to prepare an exercise on a bridge simulator, an experienced practising pilot was asked to enter the bridge of a simulator just as he would normally do on board. He was then instructed to guide a VLCC, with draft of twenty-one metres, into Europoort, with a full bridge team of officers under the command of a recently promoted Master. We asked the pilot to make an intentional but subtle mistake and conduct a critical turn at slow speed without building up the required rate of turn quickly enough. This was particularly relevant as it was to test practically the application of knowledge gained during a classroom session covering the relationship between rate of turn, radius of turn and speed.
It was the behavioural psychologist, closely monitoring the exercise on CCTV, who pointed out the head scratching of a junior team member and the slight swaying of the Master as he transferred his weight from one foot to the other, which indicated that something didn’t seem right and that they looked uncomfortable. The confident way the manoeuvre was being carried out by the pilot was apparent, and it’s perhaps understandable why neither team member felt confident enough to say anything, even though the vessel would eventually have become dangerously close to grounding. If they had communicated their concerns aloud, or even if one of them had simply recognised the unease in the other’s behaviour, that could have led to the error being captured and corrected.
A quiet word with the Master – something like, “Excuse me, Captain, I have checked and it seems that the turn is not going as planned” – might have been the only thing required for the Master to bring the situation to the attention of the pilot.
Error capture by behavioural observation has long been practised in the airline industry and there is absolutely no reason why the same approach cannot be applied on the bridge of a ship. Empowering everyone on the bridge to identify critical errors in time for them to be corrected can only result in safer bridge operations.
Author: Paul Armitage MNI Captain Paul Armitage was a seagoing Master with Vela International Marine Limited for 20 years, in command of very large crude oil carriers. He is currently a Technical Adviser for Seagull Information Technologies UK Limited, providing technical input for the training products it produces for the maritime industry.