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Opinion: debunking the human error myth

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Professor Margareta Lutzhoft

Human error is a symptom; failing to consider human behaviour is the cause.

Opinion by Professor Margareta Lützhöft (originally published in Shipping Australia's Spring/Summer 2016 edition)

Over the last decades, the divide between humans and systems is widening as technology—which now intrudes on almost all aspects of our lives—frequently fails to be designed for the person who will be using it.   

Those who report not being able to get technology to work, or who feel demotivated and frustrated as a result of interaction with a tool they reply upon to do their job, are often blamed for not using it ‘in the right way’ or for making ‘mistakes’. If they are lucky, they are perhaps offered (more) training.

But efforts to get humans to use tools in the ‘right’ way are tackling a symptom and not a cause. People make vastly more ‘errors’ when the tool, system or process they use has not been designed with them in mind. By this we mean how they actually act, think and even feel, rather than how the designer wants them to behave.  

This is no-where truer than in the maritime world, where the user is frequently neglected from the design of tools, systems, vessels, training and education. Correcting this is the focus of a maritime research theme called human factors, which attempt to demonstrate that insufficient consideration of designing for human behaviour translates into poorer operations, higher training costs and an increased risk of failing at the task.

An estimated 60-80% of accidents at sea are ascribed to human error, with countless lives lost and the maritime industry forced to cover the cost of accidents. And this is before factoring in the negative impact of those quitting ships for the shore because of unpleasant working conditions, or the number of hours lost to frustration in dealing with troublesome technology.

Rather than blaming individuals, the root cause of so-called operator errors can often be traced back to the design and construction stages of a ship; primarily the operator’s exclusion from the design process.

In 1997 the Panamanian ship ‘Royal Majesty’ grounded and the National Transportation Safety Board reported at the time that ‘there have not been unifying efforts to integrate this (human factors) concept into the marine engineering and manufacturing sector’.

Almost two decades later, their findings are yet to be addressed: there have been no significant changes to either the mandatory regulations or to maritime design culture and practice. Examples of de facto inclusion of human factors in maritime design are few and far between (despite the contrary often being claimed).

Human factors researchers show via their studies, data and feedback that applying human factors knowledge can lead to better design and facilitate the understanding of practical problems and their solutions. This helps to improve countless aspects of maritime tools and processes including habitability, maintainability, workability, controllability, manoeuvrability, survivability, safety, occupational health and emergency response, security, usability, reliability, supportability, acceptability and affordability of a ship.

Improvements in any one of the above could lead to astonishing benefits in the maritime domain: the wellbeing of workers would improve, meaning they would undoubtedly do a better and more effective job. Employers also benefit from improved work performance of individuals and groups in the organization—including crew retention. With an estimated global shortfall of 13,000 ship officers—predicted by some to rise to 60,000 by 2030—preventing attrition is critical to the future of the industry.

What should we be doing differently?

Accidents could decrease significantly and attrition of seafarers would reduce if industry, education and research would conspire to put the user at the front and centre of everything they design.  

Most urgent is a need is to establish a feedback loop between users—be they officers, port operators or ship cooks—and those designing their environments and tools. This is not easy: it takes time, money and, with some users that are often at sea for months at a time, is logistically challenging.

But it can’t afford to be ignored. Problems retaining seafarers and escalating costs covering ‘human error’ mistakes will only grow as technology takes over ever more maritime work and exacerbates existing issues.

Comité International Radio-Maritime (CIRM), the principal international association for marine electronics companies, is one of the few organisations taking measurable action. By establishing a user forum, it intends to put designers and manufacturers of marine navigation and communication systems directly in touch with users during product development. Exactly this should be encouraged in every aspect of our industry.

Training in non-technical skills is urgently needed for all maritime careers. The designer’s fallacy – “everyone is like me and if I understand it then they will too” – is responsible for a significant proportion of the ‘human error’ problem. Those with (vital) technical skills must be able to empathise with an average user and view their tool from their perspective. This means understanding their job roles, the context of their use of tools as well as learning about basic design principles and general user involvement.

Finally, procedures must be designed, reviewed and updated in collaboration with users. This requires involving users in reviewing existing procedures and designing new ones. It should be observed how they carry out a task; which issues they have, and where their discomfort could be minimised.

Beginnings of a transformation

The Australian Maritime College (AMC) in Tasmania is a centre of excellence for maritime training, education and research. It is one of the few places globally that brings together researchers, students and seafarers and it has a truly holistic view of the maritime world. As such, it is the perfect place for promotion of the human factors agenda.

AMC’s human factors research is beginning to tackle some of the key challenges already mentioned: how to train people so they actually learn, how to weave an understanding of designing for users into undergraduate naval architecture courses and how to design ships and tools that help rather than hinder.

A number of research projects underway could ultimately have a significant impact on the industry by improving the way designers are taught and seafarers trained.

Integrating human centred design into degree programs

PhD student Apsara Abeysiriwardhane is working with naval architecture undergraduates to research how to users into their studies.

“Although I had worked as a naval architect for five years, at no stage as a design team did we consult users, nor did we seek out their feedback on our designs,” explained Apsara.

“Because maritime design practice today doesn’t explicitly involve end users and how they actually live and work on ships, bad design can make the lives of seafarers uncomfortable, inefficient and even dangerous.”

Having introduced human factors to students via lectures and practical workshops, Apsara had to create a methodology for measuring the results. Her research is beginning to pay off, with the results showing that most of the students made a noticeable effort to adopt human centred design considerations into their design process. Critically, they were also inspired by what they had learnt.  

“Human centred design will be a strong aspect of my design in future. Now I know that if I need to satisfy the users of my design, I must include human centred design from the beginning of the project,’ wrote one student.  

How effective is simulated training?

With simulated training increasingly relied upon for cost and efficiency reasons, researchers at AMC wanted to find out how effective it is.

A pilot study was carried out comparing simulation to on-board training, with nine undergraduate students who had no formal seafaring experience. The students were briefed together on a man-overboard scenario and then split into three groups to undertake training on how to respond: one on a training vessel, another in a full mission simulator and a third in a computer-based training lab.

Assessed post-training, the results showed that in certain practical tasks such as manoeuvring and positioning the simulator-trained students performed just as well as those on the vessel. This suggests that practical tasks can indeed be trained in full-mission simulators without affecting the quality of the results. Further research is needed to understand how other skills such as teamwork, which the simulator trained students scored poorly on, should be taught.

Tiredness on ships

Third, a fatigue study is currently being carried out in collaboration with AMSA to understand and mitigate fatigue on-board ships. The study has collected data on board an Australian ship, observing the sleep length and quality of watch keepers and identifying aspects that disturbed their sleep. Further data is being collected on another two ships.

Collecting data on how design aspects can mitigate fatigue, including the detailed design of cabin/sleep area, we intend to contribute to ship design guidelines. All of the above data will be used to develop a fatigue risk management system, to be trialled within the next 6 months.

Looking ahead

These are small but significant steps towards a more user-focused future for the maritime industry, but as a group of academics, educators and industry representatives we must do more to promote it. There are great benefits, such as staff health, wellbeing and retention. With its heritage of occupational health and safety, Australia is a great place to start.

Published on: 06 Feb 2017