Human Performance and Resource Management

A journey of application and implementation for the David

MacBrayne Group

How did we get here and why?

The Group operates lifeline Ro-Ro Ferry Services to Island Communities off the

West and North Coasts of Scotland

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CalMac Ferries Ltd

operate 26 routes to and between the Western Isles of Scotland

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NorthLink Ferries Ltd

operate 4 routes to and between the Northern Isles of Orkney and Shetland

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Types of Vessels operated

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The David MacBrayne Group Meets the following standards

• Fully ISM Certificated

• Each Vessel is surveyed annually for its Passenger certificate

• Each Vessel is manned to meet, and often exceeds, the requirements of Safe Manning Documents, Muster Lists and the Hours of Work regulations

• Every Officer and Seafarer is certificated according to regulatory requirements and often exceed this standard

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In other words….

We comply fully with required standards in both vesseloperation and the training of our staff

SO WHY do we continue to suffer incidents when thevarious systems and competencies appear to be in placeto prevent them?

There had to be another factor involved, but we did notknow exactly what it was

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The wake–up call came in December 2004 when we had an incident which had the potential for serious injury

• The M.V. Isle of Mull Incident at Oban

• Crew fully trained

• Crew fully familiar with their vessel and the route

• No Hours of Work issues or time constraints

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Our investigation found that1. The Bridge Team were distracted during the

approach to the port

2. Poor Bridge practice, rushed changeover of controls

3. Failure to follow procedures and checklists

4. Poor communication with the Engine Room

5. Engineers were not aware of all of theconsequences of removing and replacing a pitchcontrol card

6. No positive reporting system in place

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Analysis found that Procedures and checklists were in place to follow (ISM)

A defect report had been raised regarding the pitch controlcard and was being acted upon

It was apparent that, although there were technical issuesinvolved, there was another problem hiding in thebackground….

The Human Element

Problems were related to people as well as being technical

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What could be done?

• Our Technical Director was aware of a Human Performancecourse (CRM) as delivered by Wrightway Training

• Myself and a Technical Manager were invited by Wrightway toevaluate the course for suitability

• The course was both theory and simulator based

• Two Office Managers also attend as delegates to showconnection with shore management

• We found that the CRM course addressed all of the issues aswe saw them, i.e.

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• Communication

• Situation Awareness

• Decision Making

• Team Skills

• Leadership

• Management

• Professional Conduct

• Stress and Fatigue

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Two sometimes 3 courses per year since 2005training 10 Senior Officers and two ShoreManagers on each course

Course well reported upon by delegates withoutexception. Everybody thought it was excellent

As of now we have completed 15 courses trainingc. 170 delegates with more planned

End of Story?

NO

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Incidents continued despite more and more officersbeing trained at significant investment cost

We found that the training was not being implemented out in the fleet for a variety of ‘reasons’ e.g.

‘Not my ship, I’m only here relieving’

‘We’ll wait for everybody to be trained’

‘I was going to but they moved the Chief Engineer’

‘I was going to on that ship but they moved me’

etc.

We had not really offered much in support fromashore

We just expected change to happen

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Wrightway Training always advocated that to beeffective this training must be validated on board(i.e. ‘Phase 2’)

We were not doing this

After another incident happened in 2010 it wasdecided to implement ‘Phase 2’ - we had to do moreto change the culture

But how?

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We started by consulting course delegates as to how management could help. This is now part of the course and has been very fruitful

A number of actions came from this process, some of which are still on-going, but some significant ones were:

• Presentation to Executive Directors• All Junior Officers, Crew and Shore Staff to attend a one

day course• All Senior Commercial Managers to attend 5 day course• Exec.Director to take responsibility for implementation• Company Standard Checklists• …….plus many more

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DAVID MACBRAYNE PRESENTATION TO EXECUTIVE DIRECTORS

4th October 2010

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Human Performance

Reasons for

supporting Human

Performance and

Resource

Management

Training

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Organisational Culture

„One team – one goal‟

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Why?

• MV „Isle of Mull‟ Incident December 2004

• MV „Isle of Mull‟ Incident 2009

• MV „Isle of Arran‟ Incident 2009

• MV „Isle of Arran‟ Incident 2010 (preliminary investigation)

• MV „Isle of Lewis‟ Mooring Incident October 2005

• MV „Hrossey‟ Bulk Lorry Incident 2009

• Numerous other minor incidents

• To enhance safe operations & customer service

• Professionalism

• To maintain the reputation of the David MacBrayne Group

These incidents are a matter for serious concern

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“It‟s about the

relationship between

people and complex technology”

“It‟s also about the relationship

between people”

Human Performance

‘The operations manual for the human being’21

Preventing Errors

Managing errors and learning from them

– to reduce• accidents / incidents

• losses

• re-work

• cost

• repeat events

– Improving standards and behaviours

All of which will realise huge business benefits

and more importantly, improve the safety

and reliability of the vessels and maintain the reputation of the group

Fundamentally Human Performance & Resource

Management is about:

Human Performance

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Subjects covered

Communication

Situation Awareness

Decision Making

Stress and Fatigue

Team Skills

Leadership

Management

Professional Conduct

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Notable events

MV Queen of the North March 22nd 2006Herald of Free Enterprise March 6th 1987

2004

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Strategy

Ship & Port Safetyparamount to everything we do

Raise Company Awareness of

Human Performance

to achieve

Operational

Excellence

Human Performance Phase 2Train internal auditors and coaching managers

Independent audits

Human Performance Phase 1

Ongoing training of Senior Ship‟s Officers

Human Performance Phase 3

Roll out to other staff groups

Focus will be Port & Support staff

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Strategy

Programme of Training and Awareness

Roll out in stages to ALL port and support service staff

Senior staff will be involved in Coaching and Mentoring

Board member support considered absolutely vital

The successful roll out of this programme will lead to the tangible benefits previously referred to being realised

and embedded across the whole Group. In other words…

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Organisational Culture

„The way we do things round here‟

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Communicate to create a common understanding

Take personal responsibility

Anticipate error likely situations

Use error prevention techniques

The collective behaviours of staff and managers determine the level of Safety and

Operational performance achieved within the group

4 key expectations for all staff

Summary

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It was clear that we needed a plan to

co-ordinate, properly control and

measure implementation, and

introduce an improvement loop

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CRM Phase 1: Five day course for Senior Ship’s Officers delivered by Wrightway

One day refresher course for nominated Line and Safety Dept Managers

One day coaching course for Line Managers

One day auditing course for Safety & Training Managers

Auditors carry out CRM Audits according to agreed audit plan. Results fed back to Coaching Managers and Wrightway.

Note: Periodic independent check audits to be carried out by CRM Consultant

Phases 1 and 2

One day course for all other Company personnel

Nominated Managers carry out coaching on Small Vessels & with Shore Staff

Company Auditors carry out HP & RM audits as per agreed audit plan with feedback

Phase 3

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• We formed a Human Performance Strategy Team comprised of:

• Group Safety Manager

• Group Training Manager

• Line Management representatives

• Wrightway Training Ltd

• M.J.Wilkinson

• Safety Dept Auditors

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WE HAVE HAD TO RECOGNISE

The process will take time, probably years

Resources will be needed, both human and financial

There will be barriers to overcome

Continued Board Support is essential

Good communication is needed between ship and shore

For it to be effective a ‘no blame’ culture is essential –incident, accident & near miss reporting procedures are being revised to be more effective and emphasise ‘no blame’ (‘Just’ Culture)

The training courses, coaching and auditing by themselves would not be enough……

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Additional Support Material

From Industry From Training Providers

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Additional Support Material

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we also wantedsomething handyand ‘marinised’ for the purpose – our own handbook forall our staff, which we could issue straight away

Human Performance & Resource Management Handbook

• Supported by Senior Management

• Uses the lessons learned from the Wrightway and M.J.Wilkinson courses

• User friendly• Pocket sized• Good quality• Sent to every employee in

the Group• Forms the notes for the

one day courses

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STCW 2010 Establishes Leadership and Management Training

Provides for CRM and Human Performance

training

MCA planning stand alone 5 day course for SeniorDeck and Engine Officers

Introductory training for all Junior Officers and Crew.

Several Companies as well as ourselves have already been investing significantly in this training over a period of time

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In Conclusion• This implementation plan is in its infancy and will be

developed over time as improvements are identified

• We have a long way to go but believe we now have a

basis on which to go forward

• The ‘Human Element’ is now an accepted core part of

our Group Safety Strategy and SMS

• We have to be patient, ensure a just, ‘no blame’

safety culture becomes embedded throughout the

Organisation and understand that not everybody will

buy into this from the start

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Early evidence – a “green shoot” “I recently attended a CRM course at South Shields. One of thepoints raised for further action by the group was the ineffectivenessof our Near Miss reporting.Each Near Miss should of course be regarded as a learningopportunity, and as a guide a company should expect to have a 12:1ratio of Near Miss reports to one minor accident. Over the last 5years on board this vessel this ratio was 1:4. I would envisage similarresults throughout the fleet. Obviously if there are more accidentsthan Near Misses there is something fundamentally wrong.On my return to this vessel I decided, along with other bridge teammembers, to investigate bridge operations to see if there wererecurring incidents that may have merited a Near Miss report whichhad they been completed may now have been raising alarm bells.

Continued………

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…Two areas became apparent and both had potential to cause damage to the vessel. They were ergonomic issues for which solutions can and will be found namely

1. The Bowthruster transfer switch being situated beside the B/T Off switch. There have been several occasions whereby the B/T was switched off instead of being transferred to the bridge wing.

2. "In Command" lights at all consoles can be very hard to see in sunlight and also have a long flash which is far from ideal. There have been instances where the control was not successfully transferred.

Solutions for the above are possible and will be investigated.”

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How important is this? “The greater understanding of the Human Element

is a major contributor to improvements, althoughShipping has come late to this. Understandingbehaviour, and why people do things is a necessaryprocess in eliminating accidents and mistakes.”

“The closer the senior officers of a ship are to theOffice the better, with good communications weldingship and shore teams together.”

….Jan Kopernicki, retiring Vice President, Shell Corporation.(ex Michael Grey, Lloyds List 28.3.11)

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