SPRING 1996 SEMINAR
"Fatigue"
The following is a presentation given by Neil Hamilton at the Institute of Ocean Sciences (IOS) Patricia Bay, Vancouver Island on April 20, 1996
The Introduction was delivered by Captain David Batchelor FNI
I guess what prompted us to start on this course, which has resulted in the seminar today, was my involvement back in November of last year when myself and two pilots attended a seminar in Washington put on by NASA and the US Transportation Safety Board. This seminar involved not just the marine mode but all aspects of transportation fatigue with some 500 delegates.
Initially they focused on the general problems with fatigue and it's causes and what can be done to control it. During the second day we broke down into specific groups, Marine, Air, Rail, Road and Pipeline and it hit home with me as Jim said, you get the hallucinations the tiredness and falling asleep on the job and in my work with pilotage this has become very apparent, particularly at this time of year with the coming of the cruise ships. It was discussed, and felt, that it might be an opportune time to promote a seminar having an educational, informational session and through various recommendations I was able to contact all the speakers. On reading their CV's and I thought "my God, what have I been doing all my life, because these people are very very well qualified?" Two of them being directly involved with the marine field. Our first speaker is involved in the air specifically and the second is a brain specialist.
Firstly, I would like to introduce Mr. Neil Hamilton. He is currently a professor at the Algonquin College, teaching physics and aviation human factors. He has intertwined his interest in the process of designing and implementing effective instructional techniques with his special interest in aviation and human factors. For us less educated, and please correct me if I am wrong, human factors deals in human behaviour, fatigue and this sort of thing.
Mr. Hamilton trained as a navigator with the Royal Canadian Air Force and has been a licensed pilot since 1960. He attended Rayston Polytechnic Institute at the East Ontario Institute of Technology. He began teaching in 1967 and has designed numerous forms of instruction, workshops and courses. Recently he was involved in the development and delivery of winter bush survival training for air crew personnel for the Ministry of Natural Resources Air Services. He headed a nationwide advisory committee from the Departments of Ministry of Defence to design a training and upgrading programme for abinitio and licensed pilots with an emphasis on human factors. Mr. Hamilton, in company with Justice V. Moshansky of the Dryden Inquiry designed and implemented the inaugural aviation human factors courses in Canada. These course designs have since been adopted and implemented by many air colleges and institutions.
Mr. Hamilton was a member of the four person Air Canada team responsible for authoring and producing three books for Transport Canada, Basic Human Factors, Teaching Human Factors and Advanced Human Factors. These three books will become integral resources for the integration of human factors knowledge within the existing flight training requirements for future Canadian pilots. As one may realize, there are many parallels in the air industry with the marine industry and some are remarkable. I'd like you to welcome Neil Hamilton.
Mr. N. Hamilton
It is a pleasure to be here.
I am a technician, I take research data and construct courseware and deliver it to pilots. It's very important that we start with the young people in this complex system within all transportation modes.
Human factors is about people and about their working and living environment, it’s about their relationship with machines and equipment and the procedures around them. It's also about how they relate to people.
I'm going to start with a model called the "SHELL Model". It was developed by Dr. Edwards in 1972. The components are the Liveware (the operator); Hardware; Software; and Environment and the different issues that are involved. The shapes within the model are jagged on purpose, they have to match (like a jigsaw puzzle), if they mismatch this indicates potential errors in the system. The centre Liveware represents the operational personnel themselves. They are the hub of the system as well as the most flexible component in the system. The remaining components must be designed to match the central Liveware component. The physical and psychological well-being of the Liveware will influence how they will function with the other components of the system as well as the other components influence on the Liveware.
Liveware is constructed to function effectively only within a narrow range of environmental conditions such as temperature, pressure, noise, time of day, light, darkness. Although the Liveware component has the ability to collect vast amounts of information, the Liveware processing capabilities has severe limitations. The decision making stage of the process consist of just one single channel and this bottleneck impedes the whole processing system. While one piece of information is being processed, the others are shunted into the unreliable short-term memory to await their turn. If the Liveware is in a information overload condition, this can result in poorly managed load shedding with the possible result of discarding important information.
Liveware is subject to erroneous perception and conclusions reached about the nature and meaning of messages. Stress and fatigue can cause perception tunnelling - that is - concentrating on a single stimulus, with other stimulus being ignored.. This is a breeding ground of error. The Captain says “Take-off Power” and the new co-pilot shuts down the throttles instead of applying full power. “Cut-off date” has a different perception in a middle east prison than at the Victoria Hydro office. The Liveware has to deal with ambiguous information which causes expectation. ...There are a number of aircraft lined up waiting for take-off--two in front, two in the middle, and two in the rear. Its probably concluded that there are 6 aircraft, but there could possibly be only 4.
In the aviation transportation industry the Liveware performance is severely degraded by the three goblins of the sky: Stress Fatigue and Boredom. You sit there and wait for something to happen and you're not running at full speed. 99% of boredom and 1% sheer terror when in fact you're supposed to be up to 100% at all times.
Hardware designers must not only design comfortable seats to fit the Liveware component, but must address the complex problem of designing controls and displays to match the information processing characteristics of man. Improper location and coding of controls can provide incorrect data and lead to improper inputs by the Liveware component. The Designers of hardware must assure that the tendency known as population stereotyping is applied properly to the people operating the equipment. For example a European designing equipment for use in North America could create a problem. We in North America turn on a light switch in an upward direction - versus- downwards as in Europe. This could cause problems in an emergency. None of the pilots who died reading the three pointer altimeter (if we could consult them) would still know what happened to them. It was a notorious piece of equipment.
During the hectic Berlin Airlift there was a higher than normal accident rate among the experienced pilots participating. Pilots with multi-hours on for example, B-25’s were also acting as crew members on C-47’s and C-82’s. But there was non standard cockpit control layout between these aircraft.
| B-25’s had | Throttle | Prop | Mixture |
| C-47’s had | Prop | Throttle | Mixture |
| C-82's had | Mixture | Throttle | Prop |
Persons put into sudden emergency situation that require an action will most likely fall back automatically on their training or drills and follow that rehearsed action. The heavy workload induced fatigue and stress and in conjunction with the non standard cockpits control layouts, caused many incorrect control inputs in demanding situations resulting in unnecessary accidents.
The Liveware - Software interface encompasses the non-physical aspects of the system, manuals, checklist layout, symbology, regulations and computer software. Maps and charts that show required information under white light may lose or show incomplete information under red light. Digital Displays: if one segment fails in a 7 segment display, a figure “8” can appear as a “0” or a “6” or a “9”. In the case of regulations, “rules of the road: A vessel required not to impede the passage or the safe passage of another vessel is not relieved of this latter obligation if approaching the other vessel so as to involve risk of collision and shall, when taking action, have full regard to the action which may be required by the rules of this part. Captain A. Dickson of Shell Oil stated at the International Tanker Safety Conference, 1971 that “it’s probable fair to say that these Rules of the Road are regarded by people at sea as very clear in their application to determining responsibility after a collision, but of dubious value in relation to collision avoidance.”
The following incident illustrates poor manual design.... Upon detecting smoke from the cargo hold, the L-1011 returned to the airport, landed safely, turned off the runway and stopped. The crew searched for the cargo hold smoke warning procedure. This procedure was distributed between the emergency section, the abnormal section, and the additional sections of the manual. Three precious minutes were lost. All 301 passengers and crew died from the effects of the toxic smoke and fire. An L-1011 can be evacuated in three minutes. The manuals were poorly designed.
The Liveware - Environment interface is associated with environmental factors such as noise, heat, lighting, vibration and the disturbance of biological rhythms in long range flying resulting in irregular working and sleeping patterns. In addition this interface is associated with factors in the political, social, economic, regulatory, weather and training environments, and their impact on operational efficiency. We will touch on these later in our case study.
Liveware - Liveware interface focuses on the interaction among people and its effects on crew effectiveness. Shortcomings at this interface reduce operational efficiency and cause misunderstanding and errors. Captain/Mate - Captain/Co-pilot, Cockpit Crew/Cabin Crew. The investigation into the Dryden Crash revealed that there were three pilots on board as passengers on the aircraft. They saw the ice on the wings, but... "it's not my province he's the Captain of the ship". They could have just got up from their seats or could have yelled "Get the ice off" but they deferred to the pilot in command!
By 1975 the International Air Transport Association (IATA) concluded that the wider nature of Human Factors in aviation was still not appreciated and that this neglect may bring about a major disaster. This statement was followed 17 months later by the double 747 disaster at Tenerife in which 583 people died. In low visibility and fog, the KLM 747 had taxied to the end of runway 30 and had turned around and lined up waiting for takeoff clearance. A Pan American 747 was also taxing on runway 30 and was suppose to leave the runway at the third exit.
The KLM co-pilot was just recently checked out by KLM’s senior pilot and chief flying instructor, who happened to be serving also as captain on this flight. The KLM co-pilot radioed the tower “we are ready for takeoff”. The tower reply of “Standby for Takeoff” was obliterated by a transmission from the Pam American 747 reporting that they were still on the runway looking for the third exit. The crew of the KLM 747 were at the end of their duty cycle, and had experienced delays and minor mechanical problems but they had to fly soon to stay within their legal flight duty time limits.
The fatigued and stressed KLM captain nudged the throttles forward,- his co-pilot said “Wait a minute , we do not have ATC clearance” the captain said “Go ahead get it” The tower came back reading the ATC clearance, The Captain said “Yes, We go - check thrust” and started the roll. The co-pilot was startled, that was a ATC clearance, not a take-off clearance. The flight engineer was confused also and said “Is he not clear the Pan American” The KLM crew were unsure as to where the other 747 was, but despite this the Captain proceeded with the takeoff, unchallenged by the other confused crew members. The collision occurred 13 seconds later. . The last statement on the KLM cockpit voice recorders was the tired KLM Captain simply saying Oh, shit. 583 people died in the resulting collision and fire.
Symptoms of Fatigue
Reviewing the symptoms of fatigue we can see that the first characteristic is straight forward,. you're tired and not getting enough R&R. As well as the second symptom, if you’re out of fuel (food) or rest, your not at peak. Which brings us to the third statement, this subjective grey area of diminished human performance. The combination of stress and fatigue is very hazardous and can kill you. Stress can induce fatigue and fatigue can induce stress.
Types of Fatigue
Acute Fatigue is a normal occurrence in everyday living. It is the tiredness felt after a long day, or after long periods of physical or mental activities. Acute fatigue can be cured and prevented by adequate rest, nutrition and regular exercise. Chronic Fatigue sets in when there is not enough recovery time between episodes of Acute Fatigue. You build up a sleep debt. Your performance will continue to fall off. Recovery requires a prolonged period of rest and the root causes must be eliminated. In a well documented case, a senior U.S. Air Force pilot was being tested for a wide range of diseases including Aids, but to no avail. In the final analysis it was determined that he was suffering from severe chronic fatigue.
Effects of Fatigue
- affects decision making: The Challenger Space Shuttle accident investigation stated... “the effects of sleep loss, excessive duty shifts, disruption of circadian rhythms and resulting fatigue all were part of a misguided decision to launch that morning in spite of concern about it’s safety”
- less able to deal with other people: from a cockpit voice recorder ..“Don’t talk, do your job and I’ll fly the plane”. The captain had been involved in a crew argument before the flight and graffiti directed at the captain was found in the flight deck of the crashed L-1011. The crew had been on a long duty cycle.
- degrades attention and concentration resulting in missed cues and information: In 1974 at 0500 hrs. -a British Airways 747 was cleared from 30,000 ft. to 7500 ft. for its approach to Nairobi airport. This was incorrectly read back by the co-pilot as 5000 feet. Nairobi ATC did not detect or correct the error. The problem was that Nairobi airport is 5327 ft above sea level. The aircraft barely missed the ground by 70 ft. This is what you would call a “pucker Factor” The crew had been on duty for nine hours during what would have been their normal sleep period. Additionally, at 0500 hrs,. their physical, psychological and biochemical functions were at their lowest.
Fatigue tends to:
- focus your attention on activity and - lowers your ability to handle multi tasks: Dec. 29, 1972, an Eastern Airlines L-1011 had an indication of a gear malfunction on it’s approached Miami. The crew became totally pre-occupied with the gear and gear light indicator ...“must be the bulb”...The captain inadvertently disengaged the auto-pilot as he leaned over the yoke to fiddle with the indicator bulb. The crew ignored everything else “no one was minding the store” ,- the aircraft slowly descended into the Everglades, killing a large number of people.
- lowers your discipline, encouraging acceptance of risk. August 18, 1993 a 707 cargo plane crashed while doing an unusual demanding approach to the US navy base in Cuba. Although the crew could have used runway 28 which was the normal and easier runway. From the cockpit voice recording the Captain said "for the heck of it let's try runway 10", "lets see what it's like". The investigators concluded that the captain's fatigue affected his decision to try this unusual approach. When they reviewed the crew duty times they stated that the crew was to 'numbed' by fatigue to even tackle this procedure. You don't usually see the word ‘numbed by fatigue’ in an accident report, but that's how fatigued they were.
- difficulty to pay attention..... on the landing the captain said to his tired co-pilot "cheer up", sure enough the tired co-pilot thought the captain said " gear up" and put the gear up.
Case Study:
For the case study we will use an accident that happened in Maine on 30 May, 1979, and explore the impact of stress and fatigue on this incident. We will start at the accident site and work back over events. On May 30, 1979 approx. 20:50 hr. a Downeast Airline Twin Otter was 2 miles from the end of the runway at an airspeed of 110 M.P.H. and descending faster than either pilot realized. They were below 500 feet in fog. Seconds later the aircraft pounded into the forest - 350 feet from the shoreline of a place ironically named Otter Point. There were 15 people killed and one terribly mangled survivor.REACTIONS BY DOWNEAST PILOTS TO THE CRASH
As you can see from the overhead, the other pilots made no mention of fatigue, nor mention of sleep deprivation, nor mention of stress as a possible contributing factors to the crash. These were not causes of accidents in 1979. Pilots were made of "the right stuff". They were trained to handle fatigue and stress: isn't that why they are pilots?!
Al Diehl was a relatively new investigator with the NTSB but he gathered enough evidence to indicate the possibility of other causes of this accident. Up to this point in time, when investigators discovered human failure as the cause of an accident that was pretty well the conclusion - pilot error. "Just write it up as pilot error".
This term "pilot error" suggests that the nature of the error is unique. We don't say "surgeon error" when the operation fails, we don't say "manager\director error" when the company fails, we don't say "butcher error" when we get a bad cut of meat. The term "pilot error" or "human error" focuses our attention on what happened, not why it happened. This focus on ‘human error’ is one thing that has retarded accident prevention activities.
The second statement in the overhead is of significance also, as I have already mentioned, it was the first full human factor performance investigation and finally someone would represented the dead pilot in his absence. Canada’s turn came 10 years later with the tragic Air Ontario Crash at Dryden. The Canadian Aviation Safety Board was in turmoil and reorganizing as a result of disagreements about controversial findings into the 1986 Gander Crash in which 250 American soldiers died. Because of this turmoil, the investigation was assigned to Justice V.P. Moshansky (also a pilot). All 197 of the Commissions recommendations were implemented. The Dryden commissions investigation, from a human factors perspective is noted world wide as a document that has revolutionized aircraft accident investigation. As a note, fatigue & stress were contributing factors in the crash.
Let's get back to the Downeast accident case study. This overhead shows the Liveware-Environment in which pilots at Downeast Airlines were working in. Stedger was the owner manager of Downeast Airlines.
When you are making an instrument approach there are minimums. In this particular case Rockland Airport had a minimum of 440 feet. Pilots are allowed to come in bad weather to 440 feet and time themselves from a fixed point, if the runway is not seen within a certain period of time the pilot executes a missed approach and comes around, if he's going to try it again, or he goes to his alternate airport.
Stedger encouraged this unusual activity to save time and money. To save bussing passengers from the alternate airport back to Rockland. You can almost feel the frustration and anger that the chief pilot was experiencing... haven't we all said this at one time or another.. again more frustration, anger, fatigue, stress.
Liveware: Separation and divorce is second in rank only to the to death of a spouse in causes of life event stressors. Coupled with his visitation restrictions, we have a wounded pilot here.
Loss of self-esteem in a marriage break-up is another stress factor. Some individuals mistakenly try and recapture self-esteem in every other bed in town and to Jim's acquaintances it seemed he was constantly generating coupled relationships and the joke was he was coming to work every morning from different directions.
Hardware: In this situation we have a faulty and noisy right engine. These were turbine engines. The mechanic at Down East was an excellent mechanic on piston engines but was not experienced in the turbine aircraft and they continually had problems with them.
Cockpit Environment .. it's what the pilots had to deal with. Noise will cause stress, loud ambient noise will almost certainly fatigue you quickly. Prolonged exposure to vibration has a similar effect. It induces fatigue, stress, headaches, muscular discomfort, all of which will will detract from your duties. We can see in his statement, trying to yell or use sign language when the hands are supposed to be on the controls, is a very difficult and stressful way of communicating.
Hardware - Liveware: Although the De Havilland Otter is a reliable aircraft, serious Human Factor engineering were deficient in this design. The cockpit design layout had not been designed with a pilots human frailties or limitations in mind. There should have been tactile feedback from the flap setting handle. - A series of notches or clicks to feedback information automatically to the pilot.
The airspeed and landing techniques for landing with 20 degrees flap are considerable different from those required to land with 10 degrees flap. The 20 degree flaps setting will cause you to drop faster. The sticky or intermittent altimeter would be a major source of concern and stress in any flight environment and more so in the fog bound landscape of New England on a night Instrument Approach.
The instrument panel was a challenge to see at night or in bad weather. Some of the instruments lights were Red and some were White. The white lights destroyed the pilots night vision, but if it were turned down the instruments illuminated by the red light could hardly be seen.,. In addition to being down right dangerous, the poor instrument lighting was another stressor contributing to the chronic fatigue of the pilots. but Stengar would not provide the funds to standardize the instrument lighting.
Liveware - Liveware In the cockpit environment you've going to be in somebody's space for hours. It isn't like the bridge of a ship where you can go to the other side. You're strapped in beside him, you're looking at him, you're invading each others space so there is a necessity to get along, or to understand these dynamics at least.
Nobody had told the chief pilot that the co-pilot was having these difficulties with the aircraft. Crew Resource Management, or Bridge Resource Management, wasn't a training requirement in 1979. Obviously, the crew communication on this deck was dysfunctional to say the least.
Liveware - Liveware: Rocky the owner's son was acting as the weather observer and all round agent and was saying "bring that plane back, or else dad will be mad"... Remember the minimums as I mentioned were 440 feet at Rockland, so legally they can get in under these conditions.
Jim was weary and the noise and vibrations were endless and he knew he would have to watch Hines carefully on the approach, although without an intercom it was difficult to function as a crew.
Maybe he had a premonition and was nervous about the weather or flying the Otter with the Captain who was also chief pilot, nervous about the engine....nervous about everything. A hell of a way for a pilot to start the return trip to Riceland with 16 souls onboard. They did radio Bangor, Maine, and got the Rockland weather report, it was now down to 300 feet...below minimums... They shouldn't have even attempted the approach at this point.
You can turn on airport lighting in remote locations just by clicking your transmit button five times rapidly and the lights come on for 15 minutes and you can repeat this procedure, but they weren't going to see the runway lights anyway as it was completely socked in. Remember the flaps were at 20 degrees and they didn't realize it they were descending faster then they knew. The chain of small errors was complete the fix was in. At at this point in time they had two minutes to live.
At approx. 20:50 hr. The Twin Otter was now 2 miles from the end of the runway at an airspeed of 110 M.P.H. Neither pilot realized that the aircraft was descending faster than usual for a normal approach. They were now below 500 feet in fog......Seconds later . the aircraft pounded into the forest - 350 feet from the shoreline of a place ironically named Otter Point.
Now let's put it all together. Anyone of those faults were not critical by themselves, but somehow they all lined up that day and away they went.
Liveware: the chief pilot, was suffering from chronic fatigue and stress both in his personal life and his working environment.
Liveware - Liveware: We have this tight coupled complex system on an instrument approach and the two most important components of the system are malfunctioning. One component, the co-pilot is incompetent, and the other component is suffering chronic fatigue and cannot act as a reliable component or backup to the system
Liveware-Environment: The bad weather environment (fog), adding fatigue and stress....-a noisy environment contributing to fatigue and stress and possible error inducing mis-communications...-a company environment that encourages risk taking, if the blame can be put on the dead pilot why not promote risk taking for profit. As an added note, Downeast had a previous accident on 19 Aug. 1971 in which three people died and 5 others seriously injured for life. The accident was no exception to the investigators. They determined that a perfectly good aircraft with operating engines and adequate fuel had been flown into a hill (in a foggy approach) by a pilot who screwed up “it was pilot error”. No one looked deeper in 1971. Pilot error, case closed. Two other incidents occurred in 1976 and 1977, both non injuries. The aircraft in the 1977 incident clipped the trees on its low approach in fog. Now remember the Minimum’s for Rockland airport is 440 ft. Trees don't grow that high in Maine.
And finally we have the Regulatory Environment that is essentially at that time ineffective in preventing the illegal activities of Downeast airlines. In fact at that time, the FAA had just started to document a problem almost as serious as aircrew fatigue. ... -Inspector Fatigue-, inspector burnout, disillusionment, disgust. Retirements were rising in direct proportion to the pressures that deregulation was placing on the inspectors shoulders, -yet manpower was being reduced at the same time. . So we have all the environment systems dysfunctional.
Software: Training was minimal or non-existent and SOP’s (standards operating procedures) were illegal
Hardware: We've already gone through that one. We've got the faulty engines, non standard and non consistent cockpit lighting of instruments, faulty flap handle design, faulty flap position indicator, non existent cockpit intercom, vibration from right engine, noisy working environment, unusual cockpit control layout. A lot of things to deal with in those two minutes in which you have to perform at 100%.
Every landing the pilot makes is different and every one is essentially his first or his last. In this particular accident there were too many issues stacked up against the pilot to deal with the most critical portion of flight, an instrument landing at night in fog.
Why did it take so long to associate human performance with accidents? There were many reasons why. one being that it was not polite to recognize the existence of crew performance problems in light of the elevated public relations image of a Captain. Captains of Ship’s and Aircraft did not have such ordinary human behaviour deficiencies. That's why they are Captains, they had “The Right Stuff.” Even the Captains believed it. this has turned out to be “The Wrong Stuff.”
Before I conclude I would like to refer to the overall Human Factor issues in the Marine world, and I quote “There is probably no enterprise that could profit more from human factor considerations than the merchant shipping industry. The accident figures are incredible: on average, about 370 merchant vessels are lost at sea each year - one a day! Regulations concerning staffing, qualifications (other than officers), training, crew communication, and operations are almost non-existent. At a joint safety meeting between aviation and marine experts in London in 1970, the two domains seemed a century apart, and those from the marine world readily admitted it” (Royal Aeronautical Society, 1990) Robert Helmreich, Barbara Kanki & Earl Wiener’s book CRM , 1993
Why do these two domains seem a century apart? The answer partly lies in the fact that the air transport system was regulated from the beginning by each nation because the first planes flew primarily within the nation. E.g. Postal Air service, Government survey services. Pilots and owners grew up with this regulatory system and made it work. It was comparatively easy then to extend the practice to international contacts. The Marine world has not had that experience. Nations have little experience with national regulatory systems in the marine world; most have few ports, and these are visited by foreigners as well as nationals. National regulations were minor and slow to come. International regulations are even less significant.
The potential for CRM and other human factors areas such as our topic today “Fatigue” to contribute to the safety in the maritime industry is great, but whether it will ever be realized is difficult to say. There is a humongous inertia to overcome. The Nautical Institute noted that despite the efforts of this Organization, “there has been little sign of world -wide improvement to regulate safety”, it summarized another study this way,- as the Rochdale report pointed out A “Ship” beneficially owned in one Country, directly owned by a company resident in another Country, registered under a flag of a third Country, managed by a company in a forth Country, but on long term charter to interest in a fifth Country an even sub-chartered to interest in another Country. This complexity reflects the efforts of owners and shippers to avoid the efforts of Countries to impose safety constraints. The economics of this system conspire to induce error. Who is responsible? It’s a tough call!
There are other reasons why the two domains are far apart: -politicians travel on Airlines, - they don’t travel on freighters, -easily identifiable victims and perpetrators in aircraft accidents- VS.- Marine victims who are sometimes unidentifiable and /or are low status (foreign crew) ..-the aviation world has strong unions: the pilots , mechanics, cabin Crew.- VS - poorly organized or unorganized seamen., -victims of air disaster are first party victims whereas Marine disaster such as pollution and toxic spills produce third party victims who are anonymously random. -federal presence and international controls promoting aviation safety VS International marine associations concerned with safety are advisory in nature, not pro-active. -a confidential voluntary aviation incident reporting system implemented VS “Traditions of the Sea” promotes risk acceptance, -elasticity of demand in the airlines system allows passengers to change to varies air carriers or planes for safety reasons,
The marine World faces other major issues in it’s operating system, -Captains can be on duty for forty -eight continuous hours, -Mates on a 14 hour days in coastal waters is not uncommon, - Crew communication problems, - native languages are not shared by officers and crew, -Ships sail with faulty equipment, -Captains are fined for missed schedules regardless of weather, -Crews rotate every voyage in many cases, resulting in little incentive to maintain equipment or learn how to use it.
Now these are very serious issues but let reflect, it’s not that long ago that aviation was a little messed up too. -50% of allied aircrew lost during W.W.II were lost in training accidents. -Germany lost 25% of it total aircraft production in the last year of the war in ferrying accidents. -31 of the first 40 pilots were killed trying to meet the imposed schedules of the US Air Mail Service designed by people who didn't fly. . (I think I’d rather be fined for being late)
It’s not that long ago that the aviation world started to take human performance seriously. And this is a very significant point, it was championed by individuals rather than management. Individuals that took a leadership role upon themselves to promote the importance of human factor performance. Individuals like Dr. Edwards, Earl Wiener NASA/AMES, Prof. Charles Perrow, Al Dielh NTSB, Frank Hawkins KLM, Moray Hill TSB, Justice Moshansky, Robert Helmreich U of Tex., John Lauber FAA, and the list goes on. All these fellows stuck their necks out and made it work.
In the early 80’s Airline management didn’t want this stuff. Some saw it as meddling, training with clinical psychology, others feared that the Captain’s authority would be eroded by this kind of Dale Carnegie charm school approach to developing interpersonal skills.
Human factors performance education was welcomed almost unanimously by the pilot community “the system operators” and grew by the synergy it created. Leadership by individuals, not management was responsible for bringing human factors into the forefront as a safety inducing factor. The Marine world doesn’t have to go through that process of re-inventing the wheel, the path has been cleared, the examples of Human Factor training and Knowledge and its effects on positive safety is well documented.. As the old saying goes,“if you think safety training is expensive, try having an accident”
and I conclude and it might sound brazen but I want to make the point ...in light of the human factor research, documentation, and resources now available, there should be no excuse for anyone of us in this room to be sitting in a board of inquiry at the pointed end of the stick or for any one of us to ever have to defend ourselves in a civil suite because one of our employees slammed into a tree after falling asleep at the wheel, on his way home after 13 days of 12 hour shifts because we didn’t have a replacement for him. Human Factors is a way of life 24 hours a day.
Thank You
References:
Blind Trust, John Nance; Normal Accidents, Charles Perrow; Human Factors In Flight, Frank H. Hawkins Cockpit Resource Management, Robert Helmreich, Barbara Kanki & Earl Wiener; Justice Moshansky, Dryden Commission