Chapter 6

Human error– One man error – Decision making process

The cause of human error. 

Error is something wrong. The reasons of error may cause by many factors as     

l               Knowledge base is something wrong while using his ST memory.

l               Skill base is something wrong while using his LT context memory.

l               Culture base is nothing wrong by his group LT memory.

l               Emotional base is something wrong while his feeling forced him.

l               Intuition base is something wrong while using his working habit.

l               Attention base is something wrong while using his procedural memory.

There is no error in Culture eye.

These six elements above were exactly what our brain work for us. When something wrong in these elements we bear the consequence as a mistake which have to be fixed by some compensation efforts or resources. Sometimes we feel regretful for the compensations we have to pay for the mistake. Sometimes we take payment of compensation as the things must be if it has culture influence. For example in oriental countries parents raise their child till he can get a job and in Italia mother feed his son till he gets married, these sacrifices of parent is deemed as things of nature but in a western eye this is a indulge. As long as everybody around us is doing the same thing we won’t feel any extra works done are mistake, this is culture. For culture ( is Group LT memory) element in our brain’s deem nothing is mistake or wrong. And, everything have to be done will be done, like the Harmas carry on jihad at any cost.

We are willing to pay the error by the strength of our emotion.

Sometimes we know it is wrong in our mind but still want to do it by heart, this is emotional error called violation. Violation is a wrong thing to do but we feel it is OK, like violate the speed limit while our wife is laboring (just pay the penalty) or take short cut to save time although it is forbidden. Violation will cause some consequence from time to time; it is the risk we take for our convenience. If the intention forced us to violation is a bad one (malicious), this is a sabotage act. The consequence of sabotage action may be huge or small depends on the violator’s target. For example some crew deliberate sunk the vessel for insurance premium. Some may just wet the floor to get one extra days rest due to painting won’t be possible on wetted surface. If violation had no penalty someone might encourage trying it again. When the emotion gets stronger we are keen to violate a greater risk. As there is no right or wrong in emotion, we violate the rules depends on our mood which is our long term emotion. While we feel happy we will violate more frequent according to our emotion. While we feel sad we will not want to try anything even violation. Eventually, we violate as our guts tell us (which is our personality or personal trait). The reason to commit violation sometimes is to get even with our superiors while we don’t like them. Violation can give us a sense of comfort if we are not in a way to challenge the leadership of our superior while company paid the cost. These extra costs are the reason why we need good leader to inspire the team.

Basic error need a little more effort to overcome.

Basic error may be easily avoided by a little more attention in the thing we are doing, but the consequence may be very huge.  For example one vessel has to alter course to starboard to exit the break water entrance after pilot disembark. However Captain forgets to alter course and vessel just pass the break water entrance. Vessel ended in grounding inside the harbor. This lapse of mind is only last about 10 seconds but consequence is huge. Early on March 24, 1989, a little over three hours after leaving port, the Exxon Valdez strikes Bligh Reef, spilling approximately 10.9 million gallons of oilinto Prince William Sound in Alaska due to forget to alter course in time. Major errors are like part of our working habits have the nature of recurrence if had not corrected in time. Sometimes it is hard to change due to too many years practice had shown nothing is wrong about it. Only the skeptic or outside parties can identify the causes of a major error, this is the reason why all quality system has to be audited by third party, not by ourself. Basic or major does not relate to the compensation size, but an expression of the efforts that is needed for correct it.  

Intuition based error are something we decide to do in our subconscious, the problem is our conscious have no clue at all. The decision comes so natural that we don’t even know we are doing something wrong. This is the concept we had automatically that anything without conscious examine are basically mistake prone. The truth is on the contrary as the study show below:  

"Error-related negativity" (ERN) is a concept that has captivated the scientific world. It refers to a characteristic wave of voltage beneath the skullcap, which can be measured whenever the brain detects that an error has been made. Especially surprising is the fact the ERN signal already begins to flicker even before a person is aware of his error.” This finding shows our subconscious have the ability to detect the error before our conscious knows and  "It's truly astonishing, but the brain performs these difficult calculations online, that is, constantly, while dealing with many other things at the same time," says Richard Ridderinkhof, a neuroscientist at the University of Amsterdam.  

The reason we know is the limitation of magical 7. We have the feeling of subtle unease while our subconscious is telling us something is wrong. In March 1977, two jumbo jets collided on the runway at the airport in Tenerife, one of the Canary Islands. A Boeing 747 operated by Dutch airline KLM was standing on the tarmac, ready for takeoff, while a Pan Am jumbo jet blocked the runway. Dense fog made visual contact impossible. The tower had assigned a specific runway path to the KLM jet, but the impatient captain misinterpreted the Air Traffic Control instructions to mean that he was cleared for takeoff. As accident investigators listening to the voice recorder later learned, Willem Schreuder, the flight engineer on the Dutch jumbo, asked the captain: "Is he not clear (of the runway) then, that Pan American?" A sense of unease had apparently flickered through his consciousness. But the captain brushed aside the engineer's timidly expressed suspicion and began the takeoff. When he saw the other Boeing appear in the fog, it was too late to correct his fatal error, and 583 people paid the price. The lesson we have learnt from these studies may be like that give it a second thought while we are challenged by our colleagues or by our own feeling before our gut tell us what to do next.

One human error. 

There are six kinds of error bases, only the culture base error is no cue if everybody were doing the same thing in the same way. The culture change cannot accomplish by one man in one generation. This field will need more discussions later to try to set up one universal accepted culture to combat the ever changing world we know. Emotional based error need great leadership to overcome and provide even better motivation (not incentive as business man always say) to each individual to comply with company’s policy. Leadership in nowadays is not one way street only. The violation could also happen in our superior which needs our leadership to guide them back to normal track. The way to influence other to accomplish our want and vision is leadership. If the leadership is working on both way up and down, this will become part of new age culture as we will see it later.

What is one man error now limited to four kinds:    

l    Knowledge base is something wrong while using his ST memory, called joke.

l    Skill base is something wrong while using his LT context memory, called incompetency.

l    Attention base is something wrong while using his procedural memory, called slip.

l    Memory based is something wrong while we forgetting, called lapse of mind

Knowledge base error is a joke.

Very often we regard knowledge based error as a joke. If we overheard some story of wrong ST memory application usually we found it is an amusement. The thing we doling everyday are not part of their life before. There is nothing funny about it but to understand we have been there before and it’s long time ago we already forget this is part of our automatic mechanisms now. For example, there is a fire and explosion on board. Everybody on board are running in a rush to prepare the combat. The sound of explosion astonished the OOW mind. In the bridge Master need to organize the emergency fire fighting squad and engine supporting team and corresponding with them and …… Master calling from the other side of the bridge now is 59 meter wide maybe “ OOW, report to outside authority of the incident and warn other vessel passing by of the possible risk”. OOW took the VHF in Channel 16 and cried out “ Mayday Mayday Mayday…… this is M.V………”. The Master shouted from other side of bridge window again “ What are you doing now? OOW.” What’s wrong? Maybe this is also strange to non seafarer too. Is that not critical yet? Yes, it is critical but vessel did not need immediate help yet. The knowledge base error is not part of our working habit or our daily practice yet. Once we got it, it becomes our second nature doing without over thinking any more. We laugh at others in doing wrong without a faintest idea that we could do it wrong by ourself in another day. These kinds of errors are happened in young or inexperienced OOW most. If a senior OOW had one they will become a joke in the company. To avoid knowledge kind of error will need a supervisor to overlook his job to avoid major loss.   

Attention base error is a slip.

People do make an error in a plain job due to attention failure, this called slip. Slip of mind or slip of hand due to our selective memory. This is not our lazy nature but the nature compromise for our tiredness due to the magical 7 conscious limitation. It is the electrical discharge of over electrical connections (grounded it to blank) in our brain neurons cell but to a limited procedural memory of our jobs at hand only. This inattention may be recovery immediately while we are about to move. This feeling comes when we lost or slow down the movement of our body to accomplish the things we are about to do. Like we stop our hand in the air while our intention are to turn off the gas stove and we remember we go to the kitchen is for fetching a cup only not turn off the gas. Or we turn off the gas for boiling water not for the soup we are told to. This is the case happened in a capable man who suppose to finish the job effortless but find out something is wrong later immediately. Another cause of slip is reluctant to do something, like my daughter often drop her folk while she is not hungry yet. The cause of the slip maybe simple, the consequence may be not especially while operating the machinery interaction with shipboard crew. One slip could be ended up with human life or major injury. To avoid slip is to avoid tiredness of the employer or increase his interest in his work whether it is physical or mental. Tiredness is a relative term to anyone and very likely to be determined by his own feeling. To make the feeling better even in a very consuming job, we need the skill of motivation which will discuss later. 

Skill base error is incompetence.            

Over the years at the sea, every one had his own skills to handle various job requirements facing him day after day. Some could do it quite easy and some may do it quite nervous. As long as there are no major incidents and general procedures are followed without failed, shore based or shipboard management won’t give extra comments to the job we had done. The skill of a good manager or leader seems come in a nature way cultivated by the times we stand before the mast. However, this is not the case. The experience is not the cue for everything. We all have the experiences but no one knows if it is enough for all the cases we will face. Like the Master of cruise ship Costa Concordia which crashed into a reef off the Italian coast in 2012, killing 32 people. Witnesses said Master jumped into a lifeboat to flee the ship, even though hundreds of passengers were still on board. In his trial, the captain said he fell into a lifeboat when the ship listed sharply. Capt. Lee Joon-seok of the Sewol, the South Korean ferry that sunk April 2014, has come under heavy criticism for abandoning the ship while hundreds of passengers remained on board. These are two critical cases of skill base error while our LT memory is not enough to handle the crisis at hand, called incompetency. There are no cue (or any kind of training) can solve this kind of situation as the variants are so many (hundreds or thousands of people life involved) and the time frame/available means may have its limitations. What we can do to mitigate this kind of catastrophe is guiding by our intuition only. In Boston marathon explosion incident, we can see American police show their training for emergency goes without saying. When the runner fell off due to the explosion, first police guiding on his left side, second one guiding right side and the third one with no security concern automatic looked after falling man. Judging by the standing position, we can see the job assignment is guiding automatically by their training before.   

In normal life, the incompetency may not involve so serious consequence only our training can decide we are competent or not? The way to avoid the skill based error is to do more case studies by self training beyond the comfort zone. As long as we had more related information or study on the difficult case we are more capable to come out the solution when we need it most. 

Memory base error is a lapse.

The memory based errors are related to our working memory failure at all due to aging or high blood pressure. When the lapse moment passes, our reactions return from our procedural memory first. These brief cut-offs in working memory may last only a few seconds or a few minutes, and could be very frustrating, as we may feel momentarily helpless until our memories recovered slowly. The error we made due to working memory failure may be the direct consequence of the lapse of mind (not knowing what to do) or the rush actions we took while recovery from the lapse shortly after. In the shipping industrial, our working memory content many sophisticate elements need to be aware of by our working habits. We can barely handle it with our team member or equipments or gut only. For example, if we transit the English Channel we could meet traffic in each kind of vessels in every each degree of 360 course cultivated on compass card and the feeling of doing something to solve the case all the time in rush hours by the numbers of 10, 15 or 20 targets at same time. In a turning basin of 450 meters we turn a 350 meters vessel 180 degrees. In 60 meters wide fairway we sailed the vessel of 32 meters width. In a 33.5 meters wide PANAMA Canal we squeeze in 32 meters width vessel. We constantly maneuver the vessel with blind area all around our vessel only guide in our mental picture of overall distance clearance. The water below our ship provides the best lubrication for almost every impossible maneuvering in other kind of transportation vehicles. Of course ship men take it as granted to undertake the job we are entrusted. Nothing will go wrong as long as our working memory and working habits can guide us through all these. If the lapse of mind kicks in we need more time to fully recover than other industrial. This is the problem with lapse of mind in shipping. 

For example, one vessel outbound of Hakata port master found he had missed the turn in the break water entrance. In the rush hour while he recovery from lapse master decide to make the turn in next break water entrance. This decision lead the vessel aground on the shallow water channel as the second break water entrance is for fishing boat use only. The water depth is not enough for ocean going vessel to navigate. Another vessel outbound Suez Canal disembarked Suez pilots, Master order the ship to alter course to starboard while vessel is still inside the buoyed channel. Vessel went aground in an impossible position to every vessel passing by to see. Master made the rudder order is following the vessel ahead of him which already sailed out buoyed channel and made the turn for open sea. The reason of grounded vessel master is the lapse of mind kick in which block the flow of working memory of the procedures sailing inside a buoyed channel. Master picked up the clue by other vessel’s action and unable to evaluate whole picture of the situation in time.           

The master on board is in charge the navigation in the most dedicated situations which are no room for errors. Any interval of lapsed mind will cause huge property lost and this is the most challenging part for an experienced Master. He who needs someone capable to provide the timely advice the perfect candidate should be the Chief Mate to stand by on the bridge while berthing and unberthing or senior OOW instead of the junior OOW in some shipping line.

No one is exempt from error.

Young OOW have no working habit to support their daily work. They have to do their job by the knowledge he remembered from the university. He is prone to the knowledge base errors which need a supervisor beside him to provide timely check of his work. For an experienced OOW, he had correct working habits and fitful body to do the job. But the enthusiasm of the job is lost, his attention is drifting to some place else. He is prone to the attention base error which needs extra motivation to make him focus again. For top management on board, he is cautious and reliable in every details of his job. But his sleeping quality is deteriorated due to the aging in these days he is prone to memory based error which need an experienced OOW to help in time. To mistake is human nature. No one is invisible before the mast. We need our companions to work along the journey at the sea.     

As our conscious capacity is limited by magical 7, we depend on our working habit to direct our attention and the possibility that error will have some consequence to bear. If no major consequence occurred immediately the error may be found out by someone or sometimes later. If the error causes immediately consequence we will need to correct it in the first available instant. The different age group will have the tendency with different type of error 

All our memories competing in our subconscious and the strongest brain voltage in choice options (or Error-related negativity" (ERN) feedback) enable us to enhance by each success in work. Soon or later, the correct working sequence will form in some place of our brain. Now, it becomes our working habit. We are capable of doing something, but how?              

Decision Making Process

System one: done by intuition positive.

Whenever there is a situation whether our conscious can recognize it or not is depend on our familiarity of the scene. Maybe this is just a picture we had seen it before where all elements inside are not strange to us. From human brain structure, we can easily understand left brain (low speed ) in charge of context LT memory which organized by words, letters and theories, right brain (high speed) we can remember the pictures we sought without even one words to describe it. The ability to imprint the picture in our brain is a very primitive one. One oversea Taiwanese movie student found one picture of Taiwan East Coast sea shore in a documentary film. He recognizes it immediately by the blue of the sky and the shape of the cloud. Every one can know that the color of the sky and the shape of the cloud can vary in every minute or everyday. The feeling is like that and he look carefully into the subscripts in the end of the film. The letters show the coast scenes are taken from another films made in Philippine coast, not Taiwan. This student doesn’t buy it and go to the library to find out the original film and prove his observation. Another story is the brother lost for 30 years find each other by the soup he tastes in a restaurant. Believe it or not, human sense of taste can easily identify the home town cooking after 60 years. This familiarity is aroused by the emotion not ration which beyond all the words can describe in our ability.

We recognize the world by our emotion not ration; it is a kind of intuition. Our decision making ability is in a great sense depend on our familiarity of the world around us. The more familiar the more swift our decision will be made, like the movie student decide to find out the location of the scene just by few pictures he saw.  Our intuition is first system we applied in decision making. Psychologists called this system of intuition “system 1”. For example, when we sought the water overflowed from a kettle in the sink we close the faucet immediately or turn the wheel when we found the car already off the center of the road.    

These little things in our daily life seem need no more attention to consider any other option. For some decisions unusual in our life are also decided in this way. Like we going to buy a second hand car in a dealer’s shop and most of the time come out with different millage/price/modal in our original plan because we receive TOO MANY HINT AND SUGGSTIONS from dealer.    

System two : done by intuition negative.

Just after the decision been made in a familiar situation (or no decision making efforts in our conscious), we are ready to move and begin hesitate of what we are doing for no reason clear in mind. This strange feeling will make us confused. It is something in our subconscious holding us back to do extra check once more. We could call it System 2 which is the activity to do the sequential check of our work by our LT procedural memory. In our procedural memory, everything just happens too fast in intricate steps and rehearsal in our mental pictures without any appropriate means. The strange feeling took hold of our movement which makes us slow down on the movement. Sometimes we stay at the scene to wait for little longer to compensate the strange feeling due to uncertainty of what we are doing. The point is we had made the decision and did it in any way. But the strange feeling just stay with us either to slow down our movement or hesitate while finished. Why we have to do it anyway if this strange feeling filled in our mind? It is because we trust our system 1 for our life time without any problem. Why in this time we have to question our intuition decision? 

Here comes the point of our personal trait in decision making. Some were with more gut and some were to retreat. Some were to receive the hints and suggestions from other parties and some were stubborn to change his decision. 

System three : done by logical inference.

If the outcome of our decisions is no good, only then our logical mind begin to work out the reasons. This is system three done by logical inference. Usually this is not a simple or personal decision any more. Appropriated actions will be study with a group of stakeholder to decide what is involved (variants), what is the plan, in what sequence, what option we have, what is the risk……… there is no quick solution. Even the option or plan have to execute by the person in charge and one man along, the decision is the conclusion of the group. When thongs getting more complex we will need a whole set of written instructions step by step, this is Standard Operation Procedures (SOP). 

Working Habits : Automatic Decision Maker.

Most of the time, our decision is made by our working habits. What will you do if you stand behind the service counter and one customer is complaining your serviced coffee is too cold? If company recognize this kind of complain is the responsibility of company you can resolve this by company resource and put it into company account, like the Starbuck (sold coffee 10 times expensive than Coffee Americano before in any American town) do in their service booklet to each counter employer. The answer they gave in this kind of complains is “your Starbuck apron is Starbuck itself” which means any complain should stop before your apron. These complain are toward Starbuck, not you. So don’t get personal, just give the customer another hot coffee by company expense.  If this small dinning shop is yours, you will struggle in your mind how to do with this cold coffee. This is working habits help in our decision making. Here needs a clear company policy to support our actions to avoid possible consequence.       

Our working habit is our personal SOP (Standard Operation Procedures) established long time ago. As the proverbs say

“A bird in the

the hand is worth

   two in the bush.”

Some finds it reasonable and some find it odd. This is also the price we paid for the habits (growing with our age) we had. People can automatically rip out the weed (two the) in their logical thought if their attention is not on it. Over the time, he will lose his situational awareness for nothing bad ever happened. Everything seems OK in our daily practice. We automatically form our LT memory from ST memory of daily operation after two months. Anything else of daily operation seems irrelevant to our requirement either in knowledge base or in skill base. If we ask the simple question to an experienced OOW “ What is the definition of a collision? “ . Rare OOW can give it a proper answer although COLREG is the bible each OOW obeyed from the day one of his navigational watch. Why bother? For their whole career there is no collision ever happened? No proper procedures are prepared for close quarter collision situations is for same reason. Three years experience in Captain Capacity on board made the working habits more robust than anytime else, for he is young and the shock experiences of collision have not experience yet. Only after the moment of collision, the thought pop out from logical inference “Why am I in this situation that is no way out?”. If no collision happened during his maneuverings, OOW may deem these close quarter situations as normal risk in sea career. This is the complacency set in our working habits.        

One case of wrong application of decision making:

AT 1515  UTC: Own Ship sailing outbound Shanghai Traffic Separation Scheme (TSS) where the general sailing direction is 090 degree true. Vessel now steering at 135 degree true to avoid two vessels in close port bow (sailed due North) with another two vessels at starboard side (sailed due East) and further two vessels on dead ahead (sailed due North). It is a pocket trap. 

From the radar picture we can see both outbound vessels altered course to give way to North bound vessel. Own ship is faster than vessel in our starboard bow. This is the time vessel used “hard port” rudder order to activate the avoidance action to the vessel in his starboard bow at true bearing about 175 degrees.

At 1519 UTC: Own Ship took the turn and lost control of her turning. After successfully avoid  the vessel in starboard side (bearing due South) own ship collide with the vessel on port bow ( which had passed dead ahead at 2315 hours) in her continued port turning.

At 1520 UTC : collision happened with the vessel already passed our bow at 1515 UTC. 2^nd near miss collision about to happen with the vessel Own Ship already overtaken. And possible targets to collision are merged during the lost control turn to port side.

The reasons to this collision are easy to define as:

1. 1.    Lost situation awareness of dense traffic into the pocket trap.
2. 2.    Over speed of general vessel sailing caused unnecessary overtaken situation.
3. 3.    Use the “Hard Port”rudder desperately to avoid vessel in same direction.
4. 4.    Collision happened 1520 UTC with one vessel already clear at 1515 UTC.
5. 5.    Possible collision with vessel around due to lost control of turning rate.

The utmost reason of this difficult maneuvering is over speed while other vessels proceed with caution in 9 Knots and own ship is in 14-15 Knots. Complacency is the main reason.

End of chapter 6