Get your sleep boys and girls

File under “can happen to anyone” I guess.

http://www.ntsb.gov/investigations/AccidentReports/Reports/MAB1609.pdf

Written standing orders in place but this “OOD” didn’t feel, what, “empowered” to speak up that he was impaired or not fit to stand the watch? (What would have been the consequences of doing the right thing in this case anyway? Worse than what happened?)

This kind of process interests me because there is a ‘moment of truth’ in the sequence of events when one should just know better. Whether fatigue, complacency, rushing, frustration, making poor assumptions or some other faulty thought / decision making process is at work, at the end of the day a competent person must take action. Why didn’t this guy know better? Because he didn’t have enough written procedures?

Revising / tweaking the written procedures (in this case standing orders) should always be considered but I’m starting to feel like that is becoming the go to solution. And instead of providing true, consise and valuable guidance these documents are becoming encyclopedic, disjointed and I fear little referred to and ultimately of declining usefulness. Except for after the fact, CYA or however you would like to phrase it.

This was not a merchant vessel / crew but one would expect the leadership/management skills onboard to be be top notch no? So if a crew member has the technical and administrative skills and knowledge why is that not enough? Where / when / how does good judgement and decision making skills come in to it?

One has to exercise one’s judgment, discretion, whatever to get better at it but that means making mistakes on the way to good judgement. Do we do enough to establish the climate for this development?

These are some of the things I think about when I read reports like this. How do I react to small mistakes? Big ones? Do I have the resources to get everyone enough rest? How do I react to someone “stopping the job”? What does the office do or say about it after the fact.

I came out of ERM and LMS courses with a good bibliography of references to add to my library and some good ideas but no silver bullets with regard to changing “culture”. Of course not, there are none. One thing I notice is that the talent pool responds better to graduated development of technical skills than to judgement skills. I have a feeling that this judgement thing starts long before a guy / gal steps on to a ship. It’s not tested for and it’s not taught per se. I do think increased technical skills builds confidence and that seems to have a beneficial effect on judgement.

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[QUOTE=KPChief;187438]

I came out of ERM and LMS courses with a good bibliography of references to add to my library and some good ideas but no silver bullets with regard to changing “culture”. Of course not, there are none. One thing I notice is that the talent pool responds better to graduated development of technical skills than to judgement skills. I have a feeling that this judgement thing starts long before a guy / gal steps on to a ship. It’s not tested for and it’s not taught per se. I do think increased technical skills builds confidence and that seems to have a beneficial effect on judgement.[/QUOTE]

I’ve seen the popular term “dysfunctional family” so many times it almost didn’t mean anything. But “function” is a good word. The basic function of a family is to provide food, clothing and shelter. A family that functions on higher level is going to provide higher order services, rides to soccer practice and the warm and fuzzies, support, guidance etc.

A ship’s crew must provide basic functions as well. Watch standing, M&R, serving meals, housekeeping, inventories, emergency response etc, The question is how can the crew provide higher level functions or avoid having the lower level functions fail?

Knowledge, values procedures etc have to be passed from senior members to more junior members. But it has to be done with some mixture of confidence and humility, seriousness and humor. It’s a lot of trial and error, the manuals (books) can help.

Read something interesting the other day, should be less focus on decision making and more on “sense-making”. If people can correctly make sense of what’s going on making the actual decision about what to do is almost a no-brainer.

An example of higher-level functioning is having a robust procedure in place to deal with normal problems that come with a little twist, like Joaquin.

[QUOTE=Kennebec Captain;187447]
Read something interesting the other day, should be less focus on decision making and more on “sense-making”. If people can correctly make sense of what’s going on making the actual decision about what to do is almost a no-brainer.
[/QUOTE]

Yes, “Sense-making” would seem to be what I am talking about as an outgrowth of technical competency that is the “beneficial effect” on (in my case) good engineering judgement / decision making. (As an aside - I almost used the words “common sense” in my post but talk about an overused term. It means nothing to me anymore since I have been exposed to people professed to have common sense but who seem predisposed to fear of technical knowledge, too eager to avoid “the real labor of thinking” and taking short cuts in the name of common sense.)

I also appreciate your description of the manner in which the what? knowledge?, elements of professionalism / seamanship? are passed on:

with some mixture of confidence and humility, seriousness and humor

However, as far as a “focus on decision making” this is something I have not observed in any of the canned training mentioned or even the dozen charm-school type courses I have participated in as a condition of employment. Always something to be learned for sure but if I had to define a focus from these experiences of mine it would be that they are concerned with or “focused on” lack of communication or awareness of the fact that a good idea can come from anywhere (i.e. don’t discount based on hierarchic structure or cultural biases). These are truisms so banal for any thoughtful senior staff that is no wonder many people seem to consider these course a waste of time.

Don’t get me wrong, I witness miscommunication all too frequently but I’m not too sure lack of communication is the culprit of as many incidents as it gets blamed for.

What I am looking for (using the NTSB incident referenced above as an example) is how does a guy - who acknowledges he is impaired - NOT use good judgment and make a decision to call somebody up to the bridge to help him? Did he have “experience” that suggested there would be negative or extreme negative consequences to making the “right” decision? I could give plenty of examples from the engine room too this is not a pick on the deck thing or even the USCG (although there is a certain irony in that aspect, given their studies of manning and watch standing and the human element in general they like to offer advice on).

As I said I agree with the traits you describe above for setting the stage for development of the skills needed to achieve this optimum functionality. However, I would suggest corporate tolerance of “mistakes” and the use of “risk management” to preposterously suggest anyone can do this with enough risk assessments filled out, enough procedures written and published, etc, etc. has a negative effect on setting the stage giving junior staff the space to develop.

I think you yourself have spoken on these pages before about a concern that the Master’s authority in any number of areas was being changed in ways that might be “tying the hands” of the master and indeed the entire shipboard management team. I guess I am wondering if (and which ones of the) aspects of the whole SMS approach and the hatchet knot of systems, sub-systems and reporting could also have a downside.

A fine line to be drawn by the shoreside developers/implementers of SMS’s which brings me to the topic of qualifications required for ship management. Talk about a judgement garden in need of weeding. Different story for a different day.

Communication is a broad topic. If I want the mate to call me when he requires assistance it may not be sufficient to simply explicitly say so in the night/standing orders. I might want it to be understood that I appreciate their skills but sometimes things are not what they seem and I just want to quick check the bridge that everything is ok. Or I might want to stay and ease the workload.

Those are not simple ideas to communicate, especially if we are poorly acquainted. I’m going to spend a few minutes with new mates trying to communicate my principles, concerns and ideas informally, maybe a sea story or two. What is not right but tolerable and what’s not acceptable.

The C/E, 1 A/E, C/M and I sometimes discuss issues openly with jr officer present. We are not above making jokes at each others expense but that there is an underlying respect for each others expertise and experence. Our shipboard “culture” is communnicated in this way. Also in the way we interact with the unlicensed.

That could all be put under the umbrella of “communication”. There is the actual technical information being transferred but also our attitudes, and general approach.

Fatigue is a major cause of accidents, both personal and in a wider sense: http://fairplay.ihs.com/safety-regulation/article/4281391/project-martha-sheds-new-light-on-fatigue-at-sea
This has been discussed somewhere on the forum before, but I liked the title on this thread better.