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Chapter 7 Human Errors and River Navigation
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### 第七章 各級人員的人為疏失 (Chapter 7 Human Errors Across All Ranks)
鑑於海事產業獨特且惡劣的作業環境，海上事故往往被歸因於不可避免的必然。諸如惡劣天氣（暴風雨、巨浪、強風）、航行危險（淺水區、航行盲區、吃水限制），以及船舶本身的物理局限性（龐大的體積、遲緩的操縱性、超重貨物帶來的慣性動能）等挑戰，統稱為不可抗力（force majeure）——即考驗船員與設備的不可避免之自然力量。面對海上如此多的變數，理論上是無法達到「零事故」紀錄的。
然而，這些挑戰並不代表人類束手無策。正如一位液化天然氣（LNG）船公司的經理對其繼任者所建議的，約有 90% 的海事事故源於人為因素：其中約 60% 來自直接疏失（誤判或程序失誤），30% 來自間接的人為要素問題（培訓不足或組織文化問題）。對於 LNG 船這類高風險船舶而言——如桑吉號（Sanchi）碰撞等悲劇所警示——即使是微小的疏失也可能演變成災難性的後果。雖然其他船型或許能承受偶發的小事故，但根植於人為疏失的事件對所有海事領域均構成普遍的威脅。
#### 疏失的文化建構 (The Cultural Construction of Error)
疏失的概念並非生來固有的，而是由社會與文化所建構。圖 7-01 展示了與人為疏失相關的六個認知要素——即注意力、記憶力和決策等大腦功能的基本層面。當其中任何一項出現偏差（例如因注意力不集中或風險評估失誤），就可能發生錯誤或違規行為，且往往需要耗費大量資源才能糾正。
文化規範進一步塑造了人們對疏失的看待與容忍程度。在某些社會中，對成年子女提供長期支持被視為理所當然的義務；而在其他社會中，這可能被視為過度溺愛。在極端的文化或意識形態背景下，外人視為錯誤的行為（例如被冠上道德崇高名義的高風險行為）可能在特定群體內部被常態化，從而導致巨大的犧牲。在海事環境中，船員因工作場所文化而形成的根深蒂固的例行公事或習慣，可能會掩蓋風險，使偏離規範的行為看起來毫無問題。文化扮演著群體「集體記憶」的角色，使原本可能被標記為危險的行為變得合理化。
#### 船上海事文化的缺口 (Gaps in Onboard Maritime Culture)
當前的船上海事文化揭示了基礎安全實務中的重大缺口，營造出一個危險的環境。基本技能（例如嚴謹的目視瞭望程序與熟練的雷達航行）已在整個行業中逐漸退化。儘管持有合格證書，許多值班航行員（OOW）和船長的準備工作仍未達標準，缺乏完整的情境意識。由於麻痺大意（complacency）以及「其他人也是這樣操作」的心態，船員和公司往往無視這些風險——即使已有大量的出版物、指南和模擬器培訓課程可供利用。
令人擔憂的是，即使人員獲得了適當的技能與經驗，人類易犯錯的本質依然存在。疲勞、過度自信或根深蒂固的習慣等因素都會削弱警覺性，導致關鍵時刻發生疏失。這反映了更廣泛的「風險常態化」文化：當不良做法成為日常例行公事時，它們就不再被視為偏離規範。如果沒有積極地去培養責任感、正念與持續改進，可預防的事故循環將會持續下去。
#### 緩減建議 (Recommendations for Mitigation)
為解決這些人為因素，海事組織應優先開展符合 IMO 標準的「人為要素（Human Element）」培訓，包括疲勞管理（依據 STCW 公約）以及結合目視、雷達和自動化工具（如 AIS 和 ARPA）的複合技能。鼓勵建立不互相指責的「公正文化（Just Culture）」以促進錯誤通報，定期進行駕駛台團隊模擬演練，並開展文化審計以挑戰麻痺大意的現象。透過整合這些做法，業界可以降低 90% 的人為疏失統計數據，朝向更安全的作業邁進。
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### 7.1 人為疏失：決策過程中的個人疏失 (Individual Errors in the Decision-Making)
人為疏失是人性中不可避免的一部分，但理解其類型、根本原因和緩減策略，對於包括海事作業在內的各個行業至關重要，以預防事故、提升安全性並優化效能。當行動或決策偏離預期結果時，就會發生這些疏失，這通常源於認知、情感或系統性的脆弱性。在駕駛台單個人的決策背景下，疏失可分為六種類型，每種類型都與不同的認知過程相關。這些如圖 7-01 所示，並且經常在航行等高風險環境中相互作用。
1. **知識相關疏失 (Knowledge-Related Errors)：** 源於短期記憶（STM）的缺口或不準確，阻礙了對自身知識庫的存取（例如在壓力下遺忘關鍵程序，如在緊迫局面中忽視了避碰規則 COLREG）。
2. **情感相關疏失 (Emotion-Related Errors)：** 當高漲的情緒（如壓力、恐懼或過度自信）壓倒理性判斷並干擾認知功能時發生（例如緊急情況下引發恐慌的決策，或平靜航程中因麻痺大意而跳過安全檢查）。
3. **注意力相關疏失 (Attention-Related Errors)：** 由注意力不集中引起，損害了執行任務所需的程序性記憶（例如在監控多個雷達目標時因分心、疲勞或注意力分散而遺漏航行警告）。
4. **技能相關疏失 (Skill-Related Errors)：** 源於應用與已學技能相關的長期記憶（LTM）時存在缺陷，通常是由於練習不足、培訓過時或未能適應新程序所致。例如：
* 因不熟悉分道航行制（TSS）中更新的規程而誤判船舶的操縱。
* 錯誤應用依據過時標準教授的避碰技巧，導致無效的轉向。
5. **直覺相關疏失 (Intuition-Related Errors)：** 源於過度依賴透過習慣養成的自動化直覺思維（例如因對例行公事的盲目自信、時間緊迫或衝動的「突發奇想」決策，如在繁忙水域未經全面評估即改變航向，而跳過檢查表步驟）。
6. **文化相關疏失 (Culture-Related Errors)：** 根植於文化或組織架構內的集體長期記憶中，其中被常態化的做法在群體內部被視為「正確」，但在更廣泛的背景下可能構成疏失（例如同儕間對安全規程持麻痺大意態度，如在熟悉航線上容忍放鬆瞭望警覺）。
#### 圖 7-01 記憶與人為要素圖表 (Memory and Human Element Chart)
人類的記憶系統由三個核心部分組成：感官記憶（感官輸入的短暫初始儲存）、短期記憶（暫時保持與操作，常稱為工作記憶）和長期記憶（知識與經驗的永久儲存）。認知過程可以是可言語化的（意識到的且可描述的）或非言語的（自動的與無意識的）。許多行動往往是在無意識中執行的，依賴程序性記憶（技能的肌肉記憶），而非需要意識解釋的陳述性記憶（事實或情境知識）。這解釋了為什麼重複性的任務隨著時間推移會變得自動化。
當在這種無意識模式下正確執行時，這些行動會形成有益的習慣——想想一位經驗豐富的輪機員反射性地進行例行檢查，從而提高效率與安全性。相反，當在無意識層面執行不當，則可能導致無意注意疏失（inattentional errors，例如因根深蒂固的麻痺大意而跳過關鍵安全步驟，可能在高風險的海事作業中引發疏忽）。*(註：在實際駕駛台作業中，「無意注意疏失」的概念可以更廣泛，包括壓力下的優先順序混亂或漏掉交叉覆核。以您觀察到的具體、重複出現的駕駛台情境來舉例說明可能會有所幫助。)*
在此基礎上，我們的認知努力在三個不同的層面上運作，每個層面都會影響任務的執行方式，以及在船舶駕駛台等動態環境中可能出現疏失的地方：
* **無意識（程序性記憶）：** 像走路或進食等任務依賴長期程序性記憶——在沒有意識思考的情況下自動執行的習慣性動作（例如根據多年經驗本能地調整船舶的油門或舵，而無需回想每個步驟）。*(注意：請確保您的舉例與駕駛台任務直接相關，以保持讀者對海事相關性的關注。)*
* **潛意識（半自動）：** 像打結或監控雷達螢幕等活動需要極少的意識注意力，在完全意識之下運作（例如在多工處理的同時保持船舶航向，允許在未經充分斟酌的情況下進行快速調整）。*(建議：可以指出「半自動」在壓力下可能會變得模糊；船員可能會過度依賴自動化，或者在需要關鍵注意力時未能充分利用自動化。)*
* **有意識（長期陳述性記憶）：** 像緊急操縱或應對火災等深謀遠慮的任務需要高度集中的注意力，利用長期陳述性記憶來確保首次嘗試即正確執行步驟（例如在突發風險中遵循 COLREG 避碰規程）。*(這是一個很好的錨點；您可以添加一個您在培訓中發現有效的具體演練，以使概念更具體。)*
人類的有意識大腦通常只能在短期記憶中同時處理 7±2 個項目（米勒法則 Miller’s Law；有些人考慮到干擾因素則採用 5±2）。超出此容量的任務（例如在風、流和附近有多艘船舶的繁忙水域進行靠泊）需要結構化的程序，將複雜性拆解為循序漸進的步驟。當程序無法應對累積的挑戰時（例如連鎖系統故障），必須投入額外的資源——如增加船員、專用工具或自動化設備——以減輕認知負荷並防止因負荷過載引發的疏失。
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### 7.2 記憶與人航要素圖表解析 (Memory and Human Element Chart)
本節透過記憶過程的視角探討主要的人為疏失類型，並建立在 7.1 的認知框架之上。該圖表（如圖 7-01 所示）根據記憶失效（短期記憶 STM、長期記憶 LTM、程序性記憶和陳述性記憶）如何與情感、注意力及技能因素相互作用，對疏失進行分類。每個類型都結合海事案例與緩減策略進行剖析，以強調其對安全的影響。
#### 知識型疏失：常被輕描淡寫為「好笑」的錯誤 (Knowledge-Based Errors)
知識型疏失經常被輕描淡寫地當成幽默的笑話，但這忽視了它們根植於短期記憶（STM）的缺口或向長期記憶（LTM）轉移不完整的事實。我們可能會對某人笨拙地執行新學程序的 STORIES 一笑了之，然而我們現在輕鬆掌握的每一項技能都曾是陌生的。這種幽默往往源於「後見之明偏誤（hindsight bias）」，即我們在內化了正確流程後，回過頭來看會覺得當初的錯誤顯而易見。
##### 案例：船上緊急情況下的昂貴代價
船長正在協調應變小組：緊急滅火隊、機艙支援組和外部聯絡組。船長指示值班航行員（OOW）：「向主管機關報告事故，並警告附近船舶注意風險。」在恐慌中，OOW 抓起 VHF 頻道 16 並廣播：「Mayday, Mayday, Mayday! 本船為 M.V. ___，船上發生火災與爆炸！」船長急忙糾正：「你在幹什麼？我們又沒有要沉船——改用『Sécurité, Sécurité, Sécurité』！」
這混淆凸顯了一個關鍵的區別：
* **「Mayday」** 專門用於即刻性、危及生命的緊急情況（如沉沒或嚴重人員傷亡）。
* **「Sécurité」** 用於安全警告（如已控制住但仍構成航行風險的火災）。
OOW 因壓力與培訓不足而引發的錯誤，展示了短期記憶中根深蒂固（但海員極少使用）的詞彙如何導致錯誤。透過重複演練，程序會變成習慣，從而減少恐慌並實現自動、正確的反應。
#### 情感驅動的違规及其後果 (On Emotional Driven Violations)
人類常因情感衝動而將違規行為合理化，儘管在認知上意識到了風險卻仍繼續進行——這是一種違规（violation）的形式。這涉及明知是害行為卻將其合理化為可接受（例如在家庭緊急情況下超速趕往醫院，或為了趕交期而繞過安全規程）。違規行為優先考慮短期情感需求而非長期風險，其結果從輕微處罰到釀成大禍不等。諸如狂喜（增加魯莽行為）或悲傷（降低動力）等情感狀態會放大這種傾向，往往反映了根深蒂固的性格特徵或潛意識本能。
##### 破壞行為：違規的極端表現 (Sabotage: The Extreme End)
當違規行為出自惡意時，就會升級為破壞行為（sabotage），其嚴重程度取決於目的：
* **高風險破壞：** 故意弄沉船舶以詐領保險金。
* **低風險破壞：** 弄濕甲板以延誤油漆工程從而獲得休息。
如果沒有問責機制，隨著情緒加劇，違規行為將變得常態化，從而引發更大的風險。
**透過適應性領導力遏制情感驅動的疏失：**
* **動機激勵：** 將個人價值觀與組織目標相結合（例如培養對安全紀錄的自豪感），以激發自律合規。
* **雙向影響：** 提倡雙向領導力，讓下屬能夠對同儕和上級問責（例如對不安全的指令提出質疑）。
* **文化融合：** 將相互問責嵌人為核心特徵，從而實現對共同安全願景的集體堅守。
#### 注意力相關疏失：「無心之過/失誤」(Attention-Related Errors: "Slip")
失誤（Slip）是指儘管個人先前具備相應能力，但在執行例行任務時因注意力暫時集中不集中而發生的錯誤。這些並非源於懶惰，而是源於大腦的認知局限，例如短期記憶 7±2 個項目的容量（依據米勒法則）。當神經訊號在程序性記憶路徑中「短路」時就會發生失誤，從而打亂自動化動作。
它們通常在執行過程中顯現，例如動作中途停頓（例如伸手去關火，卻意識到自己原本是想去拿水）。海事案例包括在多工處理時關錯了氣閥，或在長時間值班後放錯了航行控制設備。疲勞或注意力分散（例如船員在長途值班期間失去焦點）都會引發失誤，而在高風險環境中，這些失誤可能會升級為災難——例如傳達錯誤的舵令，可能直接導致碰撞或坐底。
**透過以下方式減少失誤：**
* 透過充分休息和任務輪換來防止身體疲勞，避免精神過載。
* 嚴格遵守休息時間以保持專注。
* 透過有意義的認可來培養內在動機，即使是在重複性的崗位上。
* 針對關鍵任務實施檢查表、警報系統或雙人覆核制（Buddy system）。
#### 技能型疏失與能力不足 (Skill-Based Errors and Incompetence)
失誤（Slip）是指儘管個人先前具備相應能力，但在執行例行任務時因注意力暫時集中不集中而發生的錯誤。失誤並非源於懶惰，而是源於大腦的認知局限，包括短期記憶 7±2 個項目的容量限制（米勒法則）。當程序性記憶路徑中的訊號發生短暫短路時，就會發生失误，打亂自動化動作。
在執行中，失誤可能表現為動作中途的停頓（例如伸手去關火，卻意識到自己原本是想去拿水）。在船上，海事案例包括在多工處理時關錯了氣閥，或在長時間值班後放錯了航行控制設備。疲勞或注意力分散（如船員在漫長的值班中失去焦點）可能會引發失誤，而在高風險環境中，它們可能會升級為災難——例如傳達錯誤的舵令，進而可能導致碰撞或坐底。
#### 案例研究：當技能缺口引發災難 (Case Studies: When Skill Gaps Lead to Catastrophe)
這些真實世界的案例說明了技能型疏失——往往因規程在長期記憶（LTM）中的鞏固存在缺口以及情感驅動的決策而加劇——如何最終演變成災難。在高風險的海事環境中，當培訓未能填補適應性技能的缺口時，即使是經驗豐富的領導者也可能會犯錯。雖然沒有任何培訓計畫能完全複製真實世界的混亂——那裡數百人的生命懸於一線且時間極其緊迫——但結構化的演練可以培養有效應對所需的直覺。
##### 歌詩達協和號災難 (Costa Concordia Disaster, 2012)
在義大利海岸附近郵輪「歌詩達協和號」坐底並傾覆期間，船長法蘭西斯科·斯凱蒂諾（Francesco Schettino）過早棄船，事後聲稱自己在船身突然傾斜時「滑落」進了救生艇。他未能優先組織乘客疏散——這是核心的領導技能——導致了 32 人死亡。調查揭示了航行錯誤、危機管理不善以及情感驅動的失誤，凸顯了在壓力下緊急規程的長期記憶（LTM）未經鞏固如何削弱專業技術能力。
##### 世越號客輪沉沒事故 (Sewol Ferry Sinking, 2014)
在韓國「世越號」客輪沉沒的悲劇中，船長李準錫拋棄了船舶，將數百名乘客（主要是高中生）困在甲板下方。在超載和結構缺陷的情況下發生的這一棄船行為，導致了 304 人死亡，並凸顯了危機應對中的嚴重缺陷。船長的行為歸因於培訓不足、情緒失控以及未能將規程內化至長期記憶（LTM）中，從而讓恐慌壓倒了理性決策。
##### 對比：2013 年波士頓馬拉松爆炸案中的有效應對 (2013 Boston Marathon Bombing)
上述兩個海事案例說明了長期記憶（LTM）鞏固不足和情感驅動的決策如何在高風險情況下侵蝕良好的技術技能。相反，對 2013 年波士頓馬拉松爆炸案的應對展示了透過嚴格培訓建立起來的適應性直覺的好處。第一應變人員——儘管面對混亂、大量傷亡和時間壓力——進行了有效的協調、分診傷患，並以最小的額外傷害鞏固了現場安全。這個非海事案例表明，結構化演練如何能夠深化程序性記憶，使人們即使在模擬無法完全複製現實的情況下，也能採取冷靜、直覺的行動。
這些事件表明，如果沒有刻意練習和心理韌性培訓，技能缺口將持續存在。為減緩此類疏失，海事組織應實施符合 IMO STCW 規範的演練，模擬不斷升級的混亂情境、融入情商（EQ）組成部分，並包含事後檢討（debriefs）。透過重複和適應性情境來培養長期記憶，船員可以更好地應對不可預測的情況，從而降低災難風險。
---
### 第七章 各級人員的人為疏失 (Chapter 7 Human Errors Across All Ranks)
鑑於海事產業獨特且惡劣的作業環境，海上事故往往被歸因於不可避免的必然。諸如惡劣天氣（暴風雨、巨浪、強風）、航行危險（淺水區、航行盲區、吃水限制），以及船舶本身的物理局限性（龐大的體積、遲緩的操縱性、超重貨物帶來的慣性動能）等挑戰，統稱為不可抗力（force majeure）——即考驗船員與設備的不可避免之自然力量。面對海上如此多的變數，理論上是無法達到「零事故」紀錄的。
然而，這些挑戰並不代表人類束手無策。正如一位液化天然氣（LNG）船公司的經理對其繼任者所建議的，約有 90% 的海事事故源於人為因素：其中約 60% 來自直接疏失（誤判或程序失誤），30% 來自間接的人為要素問題（培訓不足或組織文化問題）。對於 LNG 船這類高風險船舶而言——如桑吉號（Sanchi）碰撞等悲劇所警示——即使是微小的疏失也可能演變成災難性的後果。雖然其他船型或許能承受偶發的小事故，但根植於人為疏失的事件對所有海事領域均構成普遍的威脅。
#### 疏失的文化建構 (The Cultural Construction of Error)
疏失的概念並非生來固有的，而是由社會與文化所建構。圖 7-01 展示了與人為疏失相關的六個認知要素——即注意力、記憶力和決策等大腦功能的基本層面。當其中任何一項出現偏差（例如因注意力不集中或風險評估失誤），就可能發生錯誤或違規行為，且往往需要耗費大量資源才能糾正。
文化規範進一步塑造了人們對疏失的看待與容忍程度。在某些社會中，對成年子女提供長期支持被視為理所當然的義務；而在其他社會中，這可能被視為過度溺愛。在極端的文化或意識形態背景下，外人視為錯誤的行為（例如被冠上道德崇高名義的高風險行為）可能在特定群體內部被常態化，從而導致巨大的犧牲。在海事環境中，船員因工作場所文化而形成的根深蒂固的例行公事或習慣，可能會掩蓋風險，使偏離規範的行為看起來毫無問題。文化扮演著群體「集體記憶」的角色，使原本可能被標記為危險的行為變得合理化。
#### 船上海事文化的缺口 (Gaps in Onboard Maritime Culture)
當前的船上海事文化揭示了基礎安全實務中的重大缺口，營造出一個危險的環境。基本技能（例如嚴謹的目視瞭望程序與熟練的雷達航行）已在整個行業中逐漸退化。儘管持有合格證書，許多值班航行員（OOW）和船長的準備工作仍未達標準，缺乏完整的情境意識。由於麻痺大意（complacency）以及「其他人也是這樣操作」的心態，船員和公司往往無視這些風險——即使已有大量的出版物、指南和模擬器培訓課程可供利用。
令人擔憂的是，即使人員獲得了適當的技能與經驗，人類易犯錯的本質依然存在。疲勞、過度自信或根深蒂固的習慣等因素都會削弱警覺性，導致關鍵時刻發生疏失。這反映了更廣泛的「風險常態化」文化：當不良做法成為日常例行公事時，它們就不再被視為偏離規範。如果沒有積極地去培養責任感、正念與持續改進，可預防的事故循環將會持續下去。
#### 緩減建議 (Recommendations for Mitigation)
為解決這些人為因素，海事組織應優先開展符合 IMO 標準的「人為要素（Human Element）」培訓，包括疲勞管理（依據 STCW 公約）以及結合目視、雷達和自動化工具（如 AIS 和 ARPA）的複合技能。鼓勵建立不互相指責的「公正文化（Just Culture）」以促進錯誤通報，定期進行駕駛台團隊模擬演練，並開展文化審計以挑戰麻痺大意的現象。透過整合這些做法，業界可以降低 90% 的人為疏失統計數據，朝向更安全的作業邁進。
---
### 7.1 人為疏失：決策過程中的個人疏失 (Individual Errors in the Decision-Making)
人為疏失是人性中不可避免的一部分，但理解其類型、根本原因和緩減策略，對於包括海事作業在內的各個行業至關重要，以預防事故、提升安全性並優化效能。當行動或決策偏離預期結果時，就會發生這些疏失，這通常源於認知、情感或系統性的脆弱性。在駕駛台單個人的決策背景下，疏失可分為六種類型，每種類型都與不同的認知過程相關。這些如圖 7-01 所示，並且經常在航行等高風險環境中相互作用。
1. **知識相關疏失 (Knowledge-Related Errors)：** 源於短期記憶（STM）的缺口或不準確，阻礙了對自身知識庫的存取（例如在壓力下遺忘關鍵程序，如在緊迫局面中忽視了避碰規則 COLREG）。
2. **情感相關疏失 (Emotion-Related Errors)：** 當高漲的情緒（如壓力、恐懼或過度自信）壓倒理性判斷並干擾認知功能時發生（例如緊急情況下引發恐慌的決策，或平靜航程中因麻痺大意而跳過安全檢查）。
3. **注意力相關疏失 (Attention-Related Errors)：** 由注意力不集中引起，損害了執行任務所需的程序性記憶（例如在監控多個雷達目標時因分心、疲勞或注意力分散而遺漏航行警告）。
4. **技能相關疏失 (Skill-Related Errors)：** 源於應用與已學技能相關的長期記憶（LTM）時存在缺陷，通常是由於練習不足、培訓過時或未能適應新程序所致。例如：
* 因不熟悉分道航行制（TSS）中更新的規程而誤判船舶的操縱。
* 錯誤應用依據過時標準教授的避碰技巧，導致無效的轉向。
5. **直覺相關疏失 (Intuition-Related Errors)：** 源於過度依賴透過習慣養成的自動化直覺思維（例如因對例行公事的盲目自信、時間緊迫或衝動的「突發奇想」決策，如在繁忙水域未經全面評估即改變航向，而跳過檢查表步驟）。
6. **文化相關疏失 (Culture-Related Errors)：** 根植於文化或組織架構內的集體長期記憶中，其中被常態化的做法在群體內部被視為「正確」，但在更廣泛的背景下可能構成疏失（例如同儕間對安全規程持麻痺大意態度，如在熟悉航線上容忍放鬆瞭望警覺）。
#### 圖 7-01 記憶與人為要素圖表 (Memory and Human Element Chart)
人類的記憶系統由三個核心部分組成：感官記憶（感官輸入的短暫初始儲存）、短期記憶（暫時保持與操作，常稱為工作記憶）和長期記憶（知識與經驗的永久儲存）。認知過程可以是可言語化的（意識到的且可描述的）或非言語的（自動的與無意識的）。許多行動往往是在無意識中執行的，依賴程序性記憶（技能的肌肉記憶），而非需要意識解釋的陳述性記憶（事實或情境知識）。這解釋了為什麼重複性的任務隨著時間推移會變得自動化。
當在這種無意識模式下正確執行時，這些行動會形成有益的習慣——想想一位經驗豐富的輪機員反射性地進行例行檢查，從而提高效率與安全性。相反，當在無意識層面執行不當，則可能導致無意注意疏失（inattentional errors，例如因根深蒂固的麻痺大意而跳過關鍵安全步驟，可能在高風險的海事作業中引發疏忽）。*(註：在實際駕駛台作業中，「無意注意疏失」的概念可以更廣泛，包括壓力下的優先順序混亂或漏掉交叉覆核。以您觀察到的具體、重複出現的駕駛台情境來舉例說明可能會有所幫助。)*
在此基礎上，我們的認知努力在三個不同的層面上運作，每個層面都會影響任務的執行方式，以及在船舶駕駛台等動態環境中可能出現疏失的地方：
* **無意識（程序性記憶）：** 像走路或進食等任務依賴長期程序性記憶——在沒有意識思考的情況下自動執行的習慣性動作（例如根據多年經驗本能地調整船舶的油門或舵，而無需回想每個步驟）。*(注意：請確保您的舉例與駕駛台任務直接相關，以保持讀者對海事相關性的關注。)*
* **潛意識（半自動）：** 像打結或監控雷達螢幕等活動需要極少的意識注意力，在完全意識之下運作（例如在多工處理的同時保持船舶航向，允許在未經充分斟酌的情況下進行快速調整）。*(建議：可以指出「半自動」在壓力下可能會變得模糊；船員可能會過度依賴自動化，或者在需要關鍵注意力時未能充分利用自動化。)*
* **有意識（長期陳述性記憶）：** 像緊急操縱或應對火災等深謀遠慮的任務需要高度集中的注意力，利用長期陳述性記憶來確保首次嘗試即正確執行步驟（例如在突發風險中遵循 COLREG 避碰規程）。*(這是一個很好的錨點；您可以添加一個您在培訓中發現有效的具體演練，以使概念更具體。)*
人類的有意識大腦通常只能在短期記憶中同時處理 7±2 個項目（米勒法則 Miller’s Law；有些人考慮到干擾因素則採用 5±2）。超出此容量的任務（例如在風、流和附近有多艘船舶的繁忙水域進行靠泊）需要結構化的程序，將複雜性拆解為循序漸進的步驟。當程序無法應對累積的挑戰時（例如連鎖系統故障），必須投入額外的資源——如增加船員、專用工具或自動化設備——以減輕認知負荷並防止因負荷過載引發的疏失。
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### 7.2 記憶與人航要素圖表解析 (Memory and Human Element Chart)
本節透過記憶過程的視角探討主要的人為疏失類型，並建立在 7.1 的認知框架之上。該圖表（如圖 7-01 所示）根據記憶失效（短期記憶 STM、長期記憶 LTM、程序性記憶和陳述性記憶）如何與情感、注意力及技能因素相互作用，對疏失進行分類。每個類型都結合海事案例與緩減策略進行剖析，以強調其對安全的影響。
#### 知識型疏失：常被輕描淡寫為「好笑」的錯誤 (Knowledge-Based Errors)
知識型疏失經常被輕描淡寫地當成幽默的笑話，但這忽視了它們根植於短期記憶（STM）的缺口或向長期記憶（LTM）轉移不完整的事實。我們可能會對某人笨拙地執行新學程序的 STORIES 一笑了之，然而我們現在輕鬆掌握的每一項技能都曾是陌生的。這種幽默往往源於「後見之明偏誤（hindsight bias）」，即我們在內化了正確流程後，回過頭來看會覺得當初的錯誤顯而易見。
##### 案例：船上緊急情況下的昂貴代價
船長正在協調應變小組：緊急滅火隊、機艙支援組和外部聯絡組。船長指示值班航行員（OOW）：「向主管機關報告事故，並警告附近船舶注意風險。」在恐慌中，OOW 抓起 VHF 頻道 16 並廣播：「Mayday, Mayday, Mayday! 本船為 M.V. ___，船上發生火災與爆炸！」船長急忙糾正：「你在幹什麼？我們又沒有要沉船——改用『Sécurité, Sécurité, Sécurité』！」
這混淆凸顯了一個關鍵的區別：
* **「Mayday」** 專門用於即刻性、危及生命的緊急情況（如沉沒或嚴重人員傷亡）。
* **「Sécurité」** 用於安全警告（如已控制住但仍構成航行風險的火災）。
OOW 因壓力與培訓不足而引發的錯誤，展示了短期記憶中根深蒂固（但海員極少使用）的詞彙如何導致錯誤。透過重複演練，程序會變成習慣，從而減少恐慌並實現自動、正確的反應。
#### 情感驅動的違规及其後果 (On Emotional Driven Violations)
人類常因情感衝動而將違規行為合理化，儘管在認知上意識到了風險卻仍繼續進行——這是一種違规（violation）的形式。這涉及明知是害行為卻將其合理化為可接受（例如在家庭緊急情況下超速趕往醫院，或為了趕交期而繞過安全規程）。違規行為優先考慮短期情感需求而非長期風險，其結果從輕微處罰到釀成大禍不等。諸如狂喜（增加魯莽行為）或悲傷（降低動力）等情感狀態會放大這種傾向，往往反映了根深蒂固的性格特徵或潛意識本能。
##### 破壞行為：違規的極端表現 (Sabotage: The Extreme End)
當違規行為出自惡意時，就會升級為破壞行為（sabotage），其嚴重程度取決於目的：
* **高風險破壞：** 故意弄沉船舶以詐領保險金。
* **低風險破壞：** 弄濕甲板以延誤油漆工程從而獲得休息。
如果沒有問責機制，隨著情緒加劇，違規行為將變得常態化，從而引發更大的風險。
**透過適應性領導力遏制情感驅動的疏失：**
* **動機激勵：** 將個人價值觀與組織目標相結合（例如培養對安全紀錄的自豪感），以激發自律合規。
* **雙向影響：** 提倡雙向領導力，讓下屬能夠對同儕和上級問責（例如對不安全的指令提出質疑）。
* **文化融合：** 將相互問責嵌人為核心特徵，從而實現對共同安全願景的集體堅守。
#### 注意力相關疏失：「無心之過/失誤」(Attention-Related Errors: "Slip")
失誤（Slip）是指儘管個人先前具備相應能力，但在執行例行任務時因注意力暫時集中不集中而發生的錯誤。這些並非源於懶惰，而是源於大腦的認知局限，例如短期記憶 7±2 個項目的容量（依據米勒法則）。當神經訊號在程序性記憶路徑中「短路」時就會發生失誤，從而打亂自動化動作。
它們通常在執行過程中顯現，例如動作中途停頓（例如伸手去關火，卻意識到自己原本是想去拿水）。海事案例包括在多工處理時關錯了氣閥，或在長時間值班後放錯了航行控制設備。疲勞或注意力分散（例如船員在長途值班期間失去焦點）都會引發失誤，而在高風險環境中，這些失誤可能會升級為災難——例如傳達錯誤的舵令，可能直接導致碰撞或坐底。
**透過以下方式減少失誤：**
* 透過充分休息和任務輪換來防止身體疲勞，避免精神過載。
* 嚴格遵守休息時間以保持專注。
* 透過有意義的認可來培養內在動機，即使是在重複性的崗位上。
* 針對關鍵任務實施檢查表、警報系統或雙人覆核制（Buddy system）。
#### 技能型疏失與能力不足 (Skill-Based Errors and Incompetence)
失誤（Slip）是指儘管個人先前具備相應能力，但在執行例行任務時因注意力暫時集中不集中而發生的錯誤。失誤並非源於懶惰，而是源於大腦的認知局限，包括短期記憶 7±2 個項目的容量限制（米勒法則）。當程序性記憶路徑中的訊號發生短暫短路時，就會發生失误，打亂自動化動作。
在執行中，失誤可能表現為動作中途的停頓（例如伸手去關火，卻意識到自己原本是想去拿水）。在船上，海事案例包括在多工處理時關錯了氣閥，或在長時間值班後放錯了航行控制設備。疲勞或注意力分散（如船員在漫長的值班中失去焦點）可能會引發失誤，而在高風險環境中，它們可能會升級為災難——例如傳達錯誤的舵令，進而可能導致碰撞或坐底。
#### 案例研究：當技能缺口引發災難 (Case Studies: When Skill Gaps Lead to Catastrophe)
這些真實世界的案例說明了技能型疏失——往往因規程在長期記憶（LTM）中的鞏固存在缺口以及情感驅動的決策而加劇——如何最終演變成災難。在高風險的海事環境中，當培訓未能填補適應性技能的缺口時，即使是經驗豐富的領導者也可能會犯錯。雖然沒有任何培訓計畫能完全複製真實世界的混亂——那裡數百人的生命懸於一線且時間極其緊迫——但結構化的演練可以培養有效應對所需的直覺。
##### 歌詩達協和號災難 (Costa Concordia Disaster, 2012)
在義大利海岸附近郵輪「歌詩達協和號」坐底並傾覆期間，船長法蘭西斯科·斯凱蒂諾（Francesco Schettino）過早棄船，事後聲稱自己在船身突然傾斜時「滑落」進了救生艇。他未能優先組織乘客疏散——這是核心的領導技能——導致了 32 人死亡。調查揭示了航行錯誤、危機管理不善以及情感驅動的失誤，凸顯了在壓力下緊急規程的長期記憶（LTM）未經鞏固如何削弱專業技術能力。
##### 世越號客輪沉沒事故 (Sewol Ferry Sinking, 2014)
在韓國「世越號」客輪沉沒的悲劇中，船長李準錫拋棄了船舶，將數百名乘客（主要是高中生）困在甲板下方。在超載和結構缺陷的情況下發生的這一棄船行為，導致了 304 人死亡，並凸顯了危機應對中的嚴重缺陷。船長的行為歸因於培訓不足、情緒失控以及未能將規程內化至長期記憶（LTM）中，從而讓恐慌壓倒了理性決策。
##### 對比：2013 年波士頓馬拉松爆炸案中的有效應對 (2013 Boston Marathon Bombing)
上述兩個海事案例說明了長期記憶（LTM）鞏固不足和情感驅動的決策如何在高風險情況下侵蝕良好的技術技能。相反，對 2013 年波士頓馬拉松爆炸案的應對展示了透過嚴格培訓建立起來的適應性直覺的好處。第一應變人員——儘管面對混亂、大量傷亡和時間壓力——進行了有效的協調、分診傷患，並以最小的額外傷害鞏固了現場安全。這個非海事案例表明，結構化演練如何能夠深化程序性記憶，使人們即使在模擬無法完全複製現實的情況下，也能採取冷靜、直覺的行動。
這些事件表明，如果沒有刻意練習和心理韌性培訓，技能缺口將持續存在。為減緩此類疏失，海事組織應實施符合 IMO STCW 規範的演練，模擬不斷升級的混亂情境、融入情商（EQ）組成部分，並包含事後檢討（debriefs）。透過重複和適應性情境來培養長期記憶，船員可以更好地應對不可預測的情況，從而降低災難風險。
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Chapter 7 Human Errors Across All Ranks
Marine accidents are often framed as inevitable, given the uniquely harsh operational environment
of the maritime industry. Challenges such as extreme weather (storms, high waves, strong winds),
navigational hazards (shallow waters, blind navigation zones, draft restrictions), and the physical
limitations of vessels (massive size, sluggish maneuverability, momentum from ultra-heavy cargo) are
collectively described as force majeure—unavoidable natural forces that test both crew and equipment.
With so many variables at sea, a zero-accident record is, in theory, unattainable.
Yet these challenges do not render humans powerless. As one LNG-tanker company manager
advised his successor, approximately 90% of maritime accidents stem from human factors: about 60%
from direct errors (misjudgments or procedural lapses) and 30% from indirect human-element issues
(inadequate training or organizational culture). For high-risk vessels like LNG carriers—highlighted by
tragedies such as the Sanchi collision—even minor incidents can escalate into catastrophic
consequences. While other ship types may tolerate occasional mishaps, incidents rooted in human
error pose a universal threat across all maritime sectors.
The Cultural Construction of Error
Notions of error are not intrinsic; they are socially and culturally constructed. Figure 7-01 illustrates
six cognitive elements tied to human error—fundamental aspects of brain function such as attention,
memory, and decision-making. When any of these falter (for example, due to inattentiveness or flawed
risk assessment), errors or violations can occur, often requiring significant resources to rectify.
Cultural norms further shape how errors are perceived and tolerated. In some societies, extended
parental support for adult children is viewed as a natural obligation, while in others it may be seen as
overindulgence. In extreme cultural or ideological contexts, actions outsiders deem erroneous (for
example, high-risk behaviors framed as morally imperative) may be normalized within a group, leading
to substantial sacrifices. In maritime settings, seafarers’ ingrained routines or habits—shaped by
workplace culture—can obscure risks, making deviations appear unproblematic. Culture functions as a
group’s collective memory, legitimizing behaviors that might otherwise be flagged as hazardous.
Gaps in Onboard Maritime Culture
Current onboard maritime culture reveals critical gaps in foundational safety practices, creating a
perilous environment. Essential skills, such as disciplined visual lookout procedures and proficient
radar navigation, have eroded across the industry. Many Officers of the Watch (OOWs) and captains
operate with substandard preparedness, lacking full situational awareness despite holding
certifications. These risks often go unrecognized by crews and companies, justified by
complacencyand the mindset that “everyone else operates this way”—even with abundant publications,
guidelines, and simulator-based training available.
Alarmingly, human fallibility persists even when personnel acquire proper skills and experience.
Factors like fatigue, overconfidence, or ingrained habits can undermine vigilance, leading to errors in
critical moments. This reflects a broader cultural normalization of risk: when poor practices become
routine, they cease to be seen as deviations. Without proactive efforts to foster accountability,
mindfulness, and continuous improvement, the cycle of preventable accidents will continue.
Recommendations for Mitigation
To address these human factors, maritime organizations should prioritize IMO-aligned training on
the Human Element, including fatigue management (per the STCWConvention) and hybrid skills
blending visual, radar, and automated tools (e.g., AISand ARPA). Encourage a “just culture” that
promotes error reporting without blame, regular bridge-team simulations, and cultural audits to
challenge complacency. By integrating these practices, the industry can reduce the 90% human-error
statistic and move closer to safer operations.
7.1 Human Error: Individual Errors in the Decision-Making
Human error is an inevitable aspectof human nature, but understanding its types, root causes, and
mitigation strategies is essential across industries—including maritime operations—to prevent
accidents, enhance safety, and optimize performance. These errors arise when actions or decisions
deviate from intended outcomes, often due to cognitive, emotional, or systemic vulnerabilities. In the
context of a single individual’s decision-making on the bridge, errors can be categorized into six types,
each linked to distinct cognitive processes. These are illustrated in Figure 7-01 and often interplay in
high-stakes environments like navigation.
1. Knowledge-Related Errors: These arise from gaps or inaccuracies in short-term memory
(STM), hindering access to one’s knowledge base (e.g., forgetting a critical procedure under
pressure, such as overlooking a COLREG rule during a close-quarters situation).
2. Emotion-Related Errors: These occur when heightened emotions (e.g., stress, fear, or
overconfidence) overwhelmrational judgment, disrupting cognitive function (e.g., panic
induced decisions during emergencies or complacencyleading to skipped safety checks on a
calm voyage).
3. Attention-Related Errors: These are caused by lapsesin focus, impairing the use of
procedural memory needed for task execution (e.g., missing a navigation warning due to
distraction, fatigue, or divided attention while monitoring multiple radar targets).
4. Skill-Related Errors: These stem from deficiencies in applying long-term memory (LTM)
associated with learned skills, often due to inadequate practice, outdated training, or failure
to adapt to new procedures. For example:
Misjudging a vessel’s maneuver due to unfamiliarity with an updated protocol in a
traffic separation scheme (TSS).
Misapplying a collision-avoidance technique taught under outdated standards,
leading to an ineffective course alteration.
5. Intuition-Related Errors: These result from overreliance on automatic, intuitive thinking
ingrained through habit (e.g., skipping checklist steps due to misplaced confidence in routine,
rushed timelines, or impulsive “jump-out” decisions, such as altering course without full
assessment in dense traffic).
6. Culture-Related Errors: These are rooted in the collective long-term memory within a cultural
or organizational framework, where normalized practices are perceived as “correct” within
the group but may constitute errors in broader contexts (e.g., complacencytoward safety
protocols deemed acceptable by peers, such as tolerating reduced lookout vigilance on
familiar routes).
Figure 7 – 01 memory and human element chart
Human memory systems consist of three key components: sensory memory (the brief initial
storage of sensory input), short-term memory (temporary holding and manipulation, often called
working memory), and long-term memory (permanent storage of knowledge and experiences).
Cognitive processes can be verbalizable (conscious and describable) or non-verbal (automatic and
unconscious). Actions are often performed unconsciously, relying on procedural memory (muscle
memory for skills) rather than conscious explanation, which engages declarative memory (factual or
contextual knowledge). This explains why repeated tasks tend to become automated over time.
When executed correctly in this unconscious mode, these actions form beneficial habits—think of
a seasoned engineer performing routine engine checks reflexively, enhancing efficiency and safety.
Conversely, when performed incorrectly at an unconscious level, they can lead to inattentional errors
(for example, skipping a critical safety step due to ingrained complacency, potentially causing
oversights in high-stakes maritime operations). (Note: In real bridge operations, “inattentional error” can
be broader, including mis-prioritization or missed cross-checks under pressure. It might be helpful to
illustrate with a concrete, recurring bridge scenario you’ve observed.)
Building on this, our cognitive efforts operate at three distinct levels, each influencing how tasks
are performed and where errors may arise in dynamic environments like a ship’s bridge:
Unconscious (Procedural Memory)
Tasks such as walking or eating rely on long-term procedural memory—habitual actions executed
automatically without conscious thought (e.g., adjusting a ship’s throttle or rudder instinctively based on
years of experience, without recalling every step). (Caution: ensure your examples tie directly to bridge
tasks to maintain the reader’s focus on maritime relevance.)
Subconscious (Semi-Automatic)
Activities like tying knots or monitoring radar screens require minimal conscious attention,
operating just below full awareness (e.g., maintaining a vessel’s course while multitasking, allowing
quick adjustments without full deliberation). (Consider noting that “semi-automatic” can blur under
stress; crews may either over-rely on automation or underutilize it when critical attention is needed.)
Conscious (Long-Term Declarative Memory)
Deliberate tasks such as emergency maneuvers or fire responses demand focused attention,
drawing on long-term declarative memory to execute steps correctly on the first attempt (e.g., following
a collision-avoidance protocol under COLREGsduring a sudden risk). (This is a strong anchor; you
might add a specific drill you’ve found effective in training to ground the concept.)
The conscious mind can typically handle 7±2 items in short-term memory simultaneously (Miller’s
Law; some apply 5±2 to account for distractions). Tasks that exceed this capacity (for example, docking
in heavy traffic with wind, current, and multiple nearby vessels) require structured procedures that
break complexity into sequential steps. When procedures fail to address cumulative challenges (e.g.,
cascading system failures), additional resources—such as extra crew, specialized tools, or automation
—must be deployed to reduce cognitive load and prevent overload-induced errors.
7.2 memory and human element chart
This section explores key human error types through the lens of memory processes, building on
the cognitive frameworks in 7.1. The chart (as illustrated in Figure 7-01) categorizes errors based on
how memory failures—short-term memory (STM), long-term memory (LTM), procedural memory, and
declarative memory—interact with emotional, attentional, and skill-based factors. Each type is
examined with maritime examples and mitigation strategies to highlight their impact on safety.
Knowledge - based Errors: Often Dismissed as "Amusing"
Knowledge-based errors are frequently trivialized as humorous anecdotes, but this overlooks their
roots in gaps in STM or incomplete transfer to LTM. We may laugh at stories of someone fumbling a
newly learned procedure, yet every skill we now perform effortlessly was once unfamiliar. The humor
often stems from hindsight bias, where we retroactively view the error as obvious after internalizing the
correct process.
####### Example: A Costly Mistake During a Shipboard Emergency
The Master coordinates response teams: an emergency firefighting squad, an engine
support group, and external communications. The Master orders the OOW, “Report the
incident to authorities and warn nearby vessels of risks.” In a panic, the OOWgrabs the VHF
on Channel 16 and broadcasts: “Mayday, Mayday, Mayday! This is M.V.
—fire
and explosion onboard!” The Master corrects urgently: “What are you doing? We’re not sinking
—use ‘Sécurité, Sécurité, Sécurité’!”
This confusion highlights a critical distinction:
Mayday” is reserved for immediate, life-threatening emergencies (e.g., sinking or critical
casualties).
“Sécurité” is for safety warnings (e.g., a contained fire posing navigational risks).
The OOW’s error, triggered by stress and incomplete training, shows how ingrained knowledge in
STM (rarely used mariner terms) can lead to mistakes. Through repeated drills, procedures become
habitual, reducing panic and enabling automatic, correct responses.
On Emotional Driven Violations and Their
Consequences
Humans often rationalize rule-breaking due to emotional impulses, proceeding despite cognitive
awareness of the risks—a form of violation. These involve knowingly engaging in harmful behavior
while justifying it as acceptable (e.g., speeding to a hospital during a family emergency or bypassing
safety protocols to meet deadlines). Violations prioritize short-term emotional needs over long-term
risks, with outcomes ranging from minor penalties to catastrophes. Emotional states like euphoria
(increasing recklessness) or sadness (reducing motivation) amplify this propensity, often reflecting
ingrained personality traits or subconscious instincts.
Sabotage: The Extreme End of Violations
When violations arise from malicious intent, they escalate to sabotage, with severity depending on
goals:
High-stakes sabotage: Deliberately sinking a vessel for insurance fraud.
Low-stakes sabotage: Wetting a deck to delay painting and gain rest.
Without accountability, violations normalize, encouraging greater risks as emotions intensify.
Curb emotional-driven errors through adaptive leadership:
Motivation: Inspire compliance by aligning personal values with organizational goals (e.g.,
fostering pride in safety records).
Upward/Downward Influence: Promote bidirectional leadership, where subordinates hold
peers and superiors accountable (e.g., questioning unsafe orders).
Cultural Integration: Embed mutual accountability as a core trait, enabling collective
adherence to shared safety visions.
Attention related Errors : “Slip”
A slip is an error occurring due to momentary lapsesin attention during routine tasks, despite the
individual's prior competence. These do not result from laziness but from the brain's cognitive limits,
such as the 7±2 item capacity of short-term memory (per Miller's Law). Slipsarise when neuronal
signaling "short-circuits" in procedural memory pathways, disrupting automatic actions.
They often manifest during execution, such as pausing mid-movement (e.g., reaching to turn off
the stove but realizing you intended to get water). Maritime examples include shutting the wrong gas
valve while multitasking or misplacing a navigation control after extended watchkeeping. Fatigue or
disengagement (e.g., a child dropping utensils due to lack of interest) can trigger slips, and in high-risk
settings, they can lead to disasters like miscommunicating a helmorder, causing a collision or
grounding.
Reduce slipsby: :
Preventing physical fatigue through adequate rest and task rotation to avoid mental overload.
Respecting rest periods to maintain focus.
Fostering intrinsic motivation via meaningful recognition, even in repetitive roles.
Implementing checklists, alarms, or buddy systems for critical tasks.
Skill - Based Errors and Incompetence
A slip is an error born from momentary lapsesin attention during routine tasks, despite the
individual’s prior competence. Slipsdo not stem from laziness but from the brain’s cognitive limits,
including the 7±2 item capacity of short-term memory (Miller’s Law). Slipsoccur when signals in
procedural memory pathways briefly short-circuit, disrupting automatic actions.
In execution, slipsmay appear as a pause mid-movement (for example, reaching to turn off the
stove but realizing you intended to fetch water). On a ship, maritime examples include turning off the
wrong gas valve while multitasking or misplacing a navigation control after extended watchkeeping.
Fatigue or disengagement (such as a crew member losing focus during a long watch) can trigger slips,
and in high-risk settings they can escalate to disasters—miscommunicated helmorders, for instance,
potentially leading to collision or grounding.
Case Studies: When Skil Gaps Lead to Catastrophe
These real-world examples illustrate how skill-based errors—often compounded by gaps in long
term memory (LTM) consolidation of protocols and emotion-driven decision-making—can culminate in
disaster. In high-stakes maritime environments, even seasoned leaders may falter when training does
not bridge gaps in adaptive skills. While no program can perfectly replicate real-world chaos—where
hundreds of lives are at risk and time is relentlessly scarce—structured drills can cultivate the intuition
needed for effective responses.
Costa Concordia Disaster (2012)
During the grounding and capsizing of the cruise ship Costa Concordia off Italy, Captain Francesco
Schettino abandoned the vessel prematurely, later claiming he “fell” into a lifeboat amid the ship’s
sudden list. His failure to prioritize passenger evacuation—a core leadership skill—contributed to 32
deaths. Investigations revealed navigational errors, poor crisis management, and emotion-driven
lapses, underscoring how unconsolidated LTM for emergency protocols can undermine technical
proficiency under pressure.
Sewol Ferry Sinking (2014)
In the tragic sinking of the South Korean ferry Sewol, Captain Lee Joon-seok deserted the ship,
leaving hundreds of passengers (mostly high school students) trapped below deck. This abandonment,
amid overloading and structural failures, resulted in 304 deaths and highlighted significant
shortcomings in crisis response. The captain’s actions were attributed to insufficient training, emotional
overwhelm, and a failure to internalize protocols in LTM, allowing panic to override rational decision
making.
Contrast: Effective Response in the 2013 Boston Marathon Bombing
Both maritime cases illustrate how inadequate LTM consolidation and emotion-driven decisions
can erode well-developed technical skills in high-stakes situations. In contrast, the response to the
2013 Boston Marathon bombing demonstrated the benefits of adaptive intuition built through rigorous
training. First responders—despite chaos, mass casualties, and time pressure—coordinated effectively,
triaged victims, and secured the area with minimal additional harm. This non-maritime example shows
how structured drills can engrain procedural memory, enabling calm, intuitive actions even when
simulations cannot fully replicate reality.
These incidents show that skill gaps endure without deliberate practice and emotional resilience
training. To mitigate such errors, maritime organizations should implement IMO STCW-compliant drills
that simulate escalating chaos, incorporate emotional intelligence components, and include post-event
debriefs. By fostering LTM through repetition and adaptive scenarios, crews can better handle the
unpredictable, reducing the risk of catastrophe.
Marine accidents are often framed as inevitable, given the uniquely harsh operational environment
of the maritime industry. Challenges such as extreme weather (storms, high waves, strong winds),
navigational hazards (shallow waters, blind navigation zones, draft restrictions), and the physical
limitations of vessels (massive size, sluggish maneuverability, momentum from ultra-heavy cargo) are
collectively described as force majeure—unavoidable natural forces that test both crew and equipment.
With so many variables at sea, a zero-accident record is, in theory, unattainable.
Yet these challenges do not render humans powerless. As one LNG-tanker company manager
advised his successor, approximately 90% of maritime accidents stem from human factors: about 60%
from direct errors (misjudgments or procedural lapses) and 30% from indirect human-element issues
(inadequate training or organizational culture). For high-risk vessels like LNG carriers—highlighted by
tragedies such as the Sanchi collision—even minor incidents can escalate into catastrophic
consequences. While other ship types may tolerate occasional mishaps, incidents rooted in human
error pose a universal threat across all maritime sectors.
The Cultural Construction of Error
Notions of error are not intrinsic; they are socially and culturally constructed. Figure 7-01 illustrates
six cognitive elements tied to human error—fundamental aspects of brain function such as attention,
memory, and decision-making. When any of these falter (for example, due to inattentiveness or flawed
risk assessment), errors or violations can occur, often requiring significant resources to rectify.
Cultural norms further shape how errors are perceived and tolerated. In some societies, extended
parental support for adult children is viewed as a natural obligation, while in others it may be seen as
overindulgence. In extreme cultural or ideological contexts, actions outsiders deem erroneous (for
example, high-risk behaviors framed as morally imperative) may be normalized within a group, leading
to substantial sacrifices. In maritime settings, seafarers’ ingrained routines or habits—shaped by
workplace culture—can obscure risks, making deviations appear unproblematic. Culture functions as a
group’s collective memory, legitimizing behaviors that might otherwise be flagged as hazardous.
Gaps in Onboard Maritime Culture
Current onboard maritime culture reveals critical gaps in foundational safety practices, creating a
perilous environment. Essential skills, such as disciplined visual lookout procedures and proficient
radar navigation, have eroded across the industry. Many Officers of the Watch (OOWs) and captains
operate with substandard preparedness, lacking full situational awareness despite holding
certifications. These risks often go unrecognized by crews and companies, justified by
complacencyand the mindset that “everyone else operates this way”—even with abundant publications,
guidelines, and simulator-based training available.
Alarmingly, human fallibility persists even when personnel acquire proper skills and experience.
Factors like fatigue, overconfidence, or ingrained habits can undermine vigilance, leading to errors in
critical moments. This reflects a broader cultural normalization of risk: when poor practices become
routine, they cease to be seen as deviations. Without proactive efforts to foster accountability,
mindfulness, and continuous improvement, the cycle of preventable accidents will continue.
Recommendations for Mitigation
To address these human factors, maritime organizations should prioritize IMO-aligned training on
the Human Element, including fatigue management (per the STCWConvention) and hybrid skills
blending visual, radar, and automated tools (e.g., AISand ARPA). Encourage a “just culture” that
promotes error reporting without blame, regular bridge-team simulations, and cultural audits to
challenge complacency. By integrating these practices, the industry can reduce the 90% human-error
statistic and move closer to safer operations.
7.1 Human Error: Individual Errors in the Decision-Making
Human error is an inevitable aspectof human nature, but understanding its types, root causes, and
mitigation strategies is essential across industries—including maritime operations—to prevent
accidents, enhance safety, and optimize performance. These errors arise when actions or decisions
deviate from intended outcomes, often due to cognitive, emotional, or systemic vulnerabilities. In the
context of a single individual’s decision-making on the bridge, errors can be categorized into six types,
each linked to distinct cognitive processes. These are illustrated in Figure 7-01 and often interplay in
high-stakes environments like navigation.
1. Knowledge-Related Errors: These arise from gaps or inaccuracies in short-term memory
(STM), hindering access to one’s knowledge base (e.g., forgetting a critical procedure under
pressure, such as overlooking a COLREG rule during a close-quarters situation).
2. Emotion-Related Errors: These occur when heightened emotions (e.g., stress, fear, or
overconfidence) overwhelmrational judgment, disrupting cognitive function (e.g., panic
induced decisions during emergencies or complacencyleading to skipped safety checks on a
calm voyage).
3. Attention-Related Errors: These are caused by lapsesin focus, impairing the use of
procedural memory needed for task execution (e.g., missing a navigation warning due to
distraction, fatigue, or divided attention while monitoring multiple radar targets).
4. Skill-Related Errors: These stem from deficiencies in applying long-term memory (LTM)
associated with learned skills, often due to inadequate practice, outdated training, or failure
to adapt to new procedures. For example:
Misjudging a vessel’s maneuver due to unfamiliarity with an updated protocol in a
traffic separation scheme (TSS).
Misapplying a collision-avoidance technique taught under outdated standards,
leading to an ineffective course alteration.
5. Intuition-Related Errors: These result from overreliance on automatic, intuitive thinking
ingrained through habit (e.g., skipping checklist steps due to misplaced confidence in routine,
rushed timelines, or impulsive “jump-out” decisions, such as altering course without full
assessment in dense traffic).
6. Culture-Related Errors: These are rooted in the collective long-term memory within a cultural
or organizational framework, where normalized practices are perceived as “correct” within
the group but may constitute errors in broader contexts (e.g., complacencytoward safety
protocols deemed acceptable by peers, such as tolerating reduced lookout vigilance on
familiar routes).
Figure 7 – 01 memory and human element chart
Human memory systems consist of three key components: sensory memory (the brief initial
storage of sensory input), short-term memory (temporary holding and manipulation, often called
working memory), and long-term memory (permanent storage of knowledge and experiences).
Cognitive processes can be verbalizable (conscious and describable) or non-verbal (automatic and
unconscious). Actions are often performed unconsciously, relying on procedural memory (muscle
memory for skills) rather than conscious explanation, which engages declarative memory (factual or
contextual knowledge). This explains why repeated tasks tend to become automated over time.
When executed correctly in this unconscious mode, these actions form beneficial habits—think of
a seasoned engineer performing routine engine checks reflexively, enhancing efficiency and safety.
Conversely, when performed incorrectly at an unconscious level, they can lead to inattentional errors
(for example, skipping a critical safety step due to ingrained complacency, potentially causing
oversights in high-stakes maritime operations). (Note: In real bridge operations, “inattentional error” can
be broader, including mis-prioritization or missed cross-checks under pressure. It might be helpful to
illustrate with a concrete, recurring bridge scenario you’ve observed.)
Building on this, our cognitive efforts operate at three distinct levels, each influencing how tasks
are performed and where errors may arise in dynamic environments like a ship’s bridge:
Unconscious (Procedural Memory)
Tasks such as walking or eating rely on long-term procedural memory—habitual actions executed
automatically without conscious thought (e.g., adjusting a ship’s throttle or rudder instinctively based on
years of experience, without recalling every step). (Caution: ensure your examples tie directly to bridge
tasks to maintain the reader’s focus on maritime relevance.)
Subconscious (Semi-Automatic)
Activities like tying knots or monitoring radar screens require minimal conscious attention,
operating just below full awareness (e.g., maintaining a vessel’s course while multitasking, allowing
quick adjustments without full deliberation). (Consider noting that “semi-automatic” can blur under
stress; crews may either over-rely on automation or underutilize it when critical attention is needed.)
Conscious (Long-Term Declarative Memory)
Deliberate tasks such as emergency maneuvers or fire responses demand focused attention,
drawing on long-term declarative memory to execute steps correctly on the first attempt (e.g., following
a collision-avoidance protocol under COLREGsduring a sudden risk). (This is a strong anchor; you
might add a specific drill you’ve found effective in training to ground the concept.)
The conscious mind can typically handle 7±2 items in short-term memory simultaneously (Miller’s
Law; some apply 5±2 to account for distractions). Tasks that exceed this capacity (for example, docking
in heavy traffic with wind, current, and multiple nearby vessels) require structured procedures that
break complexity into sequential steps. When procedures fail to address cumulative challenges (e.g.,
cascading system failures), additional resources—such as extra crew, specialized tools, or automation
—must be deployed to reduce cognitive load and prevent overload-induced errors.
7.2 memory and human element chart
This section explores key human error types through the lens of memory processes, building on
the cognitive frameworks in 7.1. The chart (as illustrated in Figure 7-01) categorizes errors based on
how memory failures—short-term memory (STM), long-term memory (LTM), procedural memory, and
declarative memory—interact with emotional, attentional, and skill-based factors. Each type is
examined with maritime examples and mitigation strategies to highlight their impact on safety.
Knowledge - based Errors: Often Dismissed as "Amusing"
Knowledge-based errors are frequently trivialized as humorous anecdotes, but this overlooks their
roots in gaps in STM or incomplete transfer to LTM. We may laugh at stories of someone fumbling a
newly learned procedure, yet every skill we now perform effortlessly was once unfamiliar. The humor
often stems from hindsight bias, where we retroactively view the error as obvious after internalizing the
correct process.
####### Example: A Costly Mistake During a Shipboard Emergency
The Master coordinates response teams: an emergency firefighting squad, an engine
support group, and external communications. The Master orders the OOW, “Report the
incident to authorities and warn nearby vessels of risks.” In a panic, the OOWgrabs the VHF
on Channel 16 and broadcasts: “Mayday, Mayday, Mayday! This is M.V.
—fire
and explosion onboard!” The Master corrects urgently: “What are you doing? We’re not sinking
—use ‘Sécurité, Sécurité, Sécurité’!”
This confusion highlights a critical distinction:
Mayday” is reserved for immediate, life-threatening emergencies (e.g., sinking or critical
casualties).
“Sécurité” is for safety warnings (e.g., a contained fire posing navigational risks).
The OOW’s error, triggered by stress and incomplete training, shows how ingrained knowledge in
STM (rarely used mariner terms) can lead to mistakes. Through repeated drills, procedures become
habitual, reducing panic and enabling automatic, correct responses.
On Emotional Driven Violations and Their
Consequences
Humans often rationalize rule-breaking due to emotional impulses, proceeding despite cognitive
awareness of the risks—a form of violation. These involve knowingly engaging in harmful behavior
while justifying it as acceptable (e.g., speeding to a hospital during a family emergency or bypassing
safety protocols to meet deadlines). Violations prioritize short-term emotional needs over long-term
risks, with outcomes ranging from minor penalties to catastrophes. Emotional states like euphoria
(increasing recklessness) or sadness (reducing motivation) amplify this propensity, often reflecting
ingrained personality traits or subconscious instincts.
Sabotage: The Extreme End of Violations
When violations arise from malicious intent, they escalate to sabotage, with severity depending on
goals:
High-stakes sabotage: Deliberately sinking a vessel for insurance fraud.
Low-stakes sabotage: Wetting a deck to delay painting and gain rest.
Without accountability, violations normalize, encouraging greater risks as emotions intensify.
Curb emotional-driven errors through adaptive leadership:
Motivation: Inspire compliance by aligning personal values with organizational goals (e.g.,
fostering pride in safety records).
Upward/Downward Influence: Promote bidirectional leadership, where subordinates hold
peers and superiors accountable (e.g., questioning unsafe orders).
Cultural Integration: Embed mutual accountability as a core trait, enabling collective
adherence to shared safety visions.
Attention related Errors : “Slip”
A slip is an error occurring due to momentary lapsesin attention during routine tasks, despite the
individual's prior competence. These do not result from laziness but from the brain's cognitive limits,
such as the 7±2 item capacity of short-term memory (per Miller's Law). Slipsarise when neuronal
signaling "short-circuits" in procedural memory pathways, disrupting automatic actions.
They often manifest during execution, such as pausing mid-movement (e.g., reaching to turn off
the stove but realizing you intended to get water). Maritime examples include shutting the wrong gas
valve while multitasking or misplacing a navigation control after extended watchkeeping. Fatigue or
disengagement (e.g., a child dropping utensils due to lack of interest) can trigger slips, and in high-risk
settings, they can lead to disasters like miscommunicating a helmorder, causing a collision or
grounding.
Reduce slipsby: :
Preventing physical fatigue through adequate rest and task rotation to avoid mental overload.
Respecting rest periods to maintain focus.
Fostering intrinsic motivation via meaningful recognition, even in repetitive roles.
Implementing checklists, alarms, or buddy systems for critical tasks.
Skill - Based Errors and Incompetence
A slip is an error born from momentary lapsesin attention during routine tasks, despite the
individual’s prior competence. Slipsdo not stem from laziness but from the brain’s cognitive limits,
including the 7±2 item capacity of short-term memory (Miller’s Law). Slipsoccur when signals in
procedural memory pathways briefly short-circuit, disrupting automatic actions.
In execution, slipsmay appear as a pause mid-movement (for example, reaching to turn off the
stove but realizing you intended to fetch water). On a ship, maritime examples include turning off the
wrong gas valve while multitasking or misplacing a navigation control after extended watchkeeping.
Fatigue or disengagement (such as a crew member losing focus during a long watch) can trigger slips,
and in high-risk settings they can escalate to disasters—miscommunicated helmorders, for instance,
potentially leading to collision or grounding.
Case Studies: When Skil Gaps Lead to Catastrophe
These real-world examples illustrate how skill-based errors—often compounded by gaps in long
term memory (LTM) consolidation of protocols and emotion-driven decision-making—can culminate in
disaster. In high-stakes maritime environments, even seasoned leaders may falter when training does
not bridge gaps in adaptive skills. While no program can perfectly replicate real-world chaos—where
hundreds of lives are at risk and time is relentlessly scarce—structured drills can cultivate the intuition
needed for effective responses.
Costa Concordia Disaster (2012)
During the grounding and capsizing of the cruise ship Costa Concordia off Italy, Captain Francesco
Schettino abandoned the vessel prematurely, later claiming he “fell” into a lifeboat amid the ship’s
sudden list. His failure to prioritize passenger evacuation—a core leadership skill—contributed to 32
deaths. Investigations revealed navigational errors, poor crisis management, and emotion-driven
lapses, underscoring how unconsolidated LTM for emergency protocols can undermine technical
proficiency under pressure.
Sewol Ferry Sinking (2014)
In the tragic sinking of the South Korean ferry Sewol, Captain Lee Joon-seok deserted the ship,
leaving hundreds of passengers (mostly high school students) trapped below deck. This abandonment,
amid overloading and structural failures, resulted in 304 deaths and highlighted significant
shortcomings in crisis response. The captain’s actions were attributed to insufficient training, emotional
overwhelm, and a failure to internalize protocols in LTM, allowing panic to override rational decision
making.
Contrast: Effective Response in the 2013 Boston Marathon Bombing
Both maritime cases illustrate how inadequate LTM consolidation and emotion-driven decisions
can erode well-developed technical skills in high-stakes situations. In contrast, the response to the
2013 Boston Marathon bombing demonstrated the benefits of adaptive intuition built through rigorous
training. First responders—despite chaos, mass casualties, and time pressure—coordinated effectively,
triaged victims, and secured the area with minimal additional harm. This non-maritime example shows
how structured drills can engrain procedural memory, enabling calm, intuitive actions even when
simulations cannot fully replicate reality.
These incidents show that skill gaps endure without deliberate practice and emotional resilience
training. To mitigate such errors, maritime organizations should implement IMO STCW-compliant drills
that simulate escalating chaos, incorporate emotional intelligence components, and include post-event
debriefs. By fostering LTM through repetition and adaptive scenarios, crews can better handle the
unpredictable, reducing the risk of catastrophe.
