How to Learn From Human Error and Behaviour.

 The Superyacht Industry - Working and living together

Before it's too late.

Learning from human error / failure seems like a simple thing, yet when you research the subject it's easy to quickly get turned off with academic papers and language you may need a dictionary for.

But what if we cut through the crap and get down to learning how our actions and behaviour "labeled human error / human failure" can offer vital places to learn from!

Let's face it, nobody gets up in the morning thinking they are going to behave in a way that will get them into an accident. No captain or crew make plans to create error, cause miscommunication or create confusion aboard.

So why with all the training, regulations and best intentions do we continue to see situations where accidents happen, and fatalities occur!

Perhaps one danger sign is in thinking these types of situations won't happen to us, simply because we think we know better!

Or perhaps too many think there is only one way to lead or manage, and only one way people behave, and that's their way! Thinking that there is little they can do to change!

In an industry that for the most part one would think was a safe industry to work in, why do we seem to constantly see 2 or more fatalities a year, and goodness knows how many near miss incidents, many of which go unreported?

Let's face it, no captain, manager, or crew wants to face a parent of crew member with news their loved one was in a serious accident. Yet we continue to see behaviour on yachts by so called "professional" crew that is not only dangerous (and in many cases against policy and standing orders), but strengthen something called the "Drift to low Performance".

This is where a system not only resists policy and stays in a normal bad state, it keeps getting worse. A drift to low performance feeds upon itself. As everyone gets used to mediocrity it becomes easy for standards to slip still further — which lowers expectations and allows even worse performance. Not following standard operating procedures becomes accepted as normal.

For many crew the hardest part of living and working together is creating, building and developing relationships, and communication. While there may be a bit of eye rolling here I believe most good leaders, managers and crew know this to be true.

While this may not seem like it has much to do with learning from human error, its actually a huge place of leverage. Or put another way a place where intervention can change the long-term behaviour of the whole system quite dramatically. Taking the yachting industry from not very professional, to a profession others look up to for its professionalism.

When you look at a crew member (whatever their role), as a part of the system that runs a yacht. We also need to remember there is no such thing as an independent part of a system. So whatever the role of the crew they are as integral to the safe and efficient running of the yacht.

It is here you can then start to look at each individual crew as they also arrive with their own mental models, personality, behavioural preferences, backgrounds, beliefs and attitudes.

Add to this (because a poor level of crew longevity), many crew will arrive aboard one day and expected to take on the full responsibilities of their role that day, or at best the next day.

Little understanding of the word or process of "Onboarding" is know to a vast majority of the industry and crew are just expected to "get on with it" on arrival.

Few yachts spend time prior to engaging new crew to ensure a new recruit is aligned to the yacht and captains' vision, yacht values, history or strategic messages of the captain, yacht and owner, or such things as standing orders etc.

While most of the larger management companies have long new crew familiarization check lists. In reality the time given for a new crew member to learn all this, on top of the added pressure of getting to know other crew they are to work and live and as stated earlier, start work today perhaps with owner and guests aboard, is just not practical!

Most of us have spent very little or any time really developing self-awareness, so we are in the most cases not the greatest at seeing or knowing our own blind spots.

But as we see a lot of people agree self-awareness is important to understand why people behave the way they do.

It's just not reality to think we can all be treated in the same way and expect the same result in the same situation!

Those with a good development of self awareness know this already. They tend to know many of their blind spots and hopefully have adjusted accordingly. People with high levels of self awareness also have more flexibility in their leadership style and how to approach others.

Let's quickly look at a scenario where there is a group of people that work together with a manager that has poor development of self-awareness. He of course has little idea about how his team is very different to himself.

While the video is built around one of the tools I use (Everything DiSC), in a more office based environment, it doesn't take much imagination to see how this could be a meeting with heads of department or team leaders, or perhaps the only meeting a new crew has with their captain before starting work, or the owner arriving, or even the first time a helicopter is to be boarded!

Notice how listening is turned off for some, with obvious confusion and disbelief created in others.

This is about human behaviour and our patterns of behaviour. Not knowing yours is just an incident or accident waiting to happen.

A casualty investigation report from the ISLE OF MAN SHIP REGISTRY found here on the loss of a deckhand (deck rating), in 2016 on a large superyacht offers examples of miscommunication at many levels, and brings important questions to ask for all about the following:

• Understanding of what communication actually is, one way, two way etc?
• What is the understanding of leadership aboard yachts today?
• Verbal and non verbal, communication.
• Relationships and hierarchy between crew, off and on watch.
• Onboarding and lack of it.

 If one looks at Appendix 1. and 2. and the comments in the conclusion on page11. there are points related to communication that contradict what is in the Appendix.

While it feels like good safety culture is being attempted to be installed as new crew arrive aboard, time is an issue as some crew are just not self-aware enough to say NO, or that they do not understand fully all they need.

Some questions to a new crew's direct reports might be:

• Do you adjust your communication to the individual?
• How do you confirm competence in such things as communicating with others on board?
• How do you know the risk level of new crew, and how will this affect the understanding of personal health and safety, risk assessment and competence.

I bring these up as I know from first hand experience how easy it is to assume someone saying "I get it" can feel like they understood, even agreed with all they were just told or just read.

But in some cases the result can be the opposite. They did not understand, but said "I get it" because they didn't want to risk getting into trouble, or saying NO on their first day, or their first week!

Or they have a personality that has a high level of comfort with risk and happy to just get stuck in!

What was reported in the I.O.M casualty investigation highlights some of the above and offer many places all can use to look at their own onboarding policies and communication.

A look at what leadership means to crew and the yacht should also bring up great talking points for all crew.

The following is taken from an academy site that delivers HELM to yacht crew:

Students will be able to control the operation of the ship and care for persons on board at the management level through the use leadership and managerial skills to ensure that:

• The crew are allocated duties and informed of expected standards of work and behaviour in a manner appropriate to the individuals concerned;
• Training objectives and activities are based on assessment of current competence and capabilities and operational requirements;
• Operations are planned and resources are allocated as needed in correct priority to perform the necessary tasks;
• Communication is clearly and unambiguously given and received;
• Effective leadership behaviours are demonstrated;
• Operations are demonstrated to be effective and in accordance with applicable rules.

The above seems like it makes sense and relevant. But looking at the report one might feel some of these were not clearly understood.

Again if you think back to the video and change some of ideas to include some of the points above you might start to see where a crew can get switched off, or not relate to way the information is being given by a supervisor.

Whether in a classroom or onboard in meetings, or at onboarding, it all comes back to principally the same thing.

We do not all learn, take in information, or behave in the same way, even if the situation is the same.

Being efficient and working safetly on yachts is about relationships and communication!

Relationships and communication are not easy, and judging by today's more open society and talk about mental health, abuse, discrimination, and just about anything else, we STILL have a way to go, and plenty to learn.

This last part for me is integral to safety being raised in the industry. A willingness to learn and an openness to being vulnerable. If captains and officers do not feel comfortable in asking for help and obviously feeling a little vulnerable in their position and job, there is little hope other members of crew will either.

So let's take these points and think how we as an industry can change some of the ways we go about thinking and behaving.

From #captain to #yachtcrew to #yachtmanager, and all involved in the superyacht industry, taking the time to read accident and casualty reports issued by flag states, talking about them with your crew and fellow captains, sharing thoughts about them, and learning from them, should be standard operating procedure (SOP).

Apart from the fact these reports take flag states a lot of time and energy to create and publish, they offer everyone many places to learn more about human error, behaviour safety, relationships and basic human behaviour.

Each report will have different learning points and situations to talk about, and all of them linking one or more crew resource management (CRM) skills to the situations.

If you have not read this report from the ISLE OF MAN SHIP REGISTRY on the loss of a deckhand (deck rating) in 2016, from a large superyacht PLEASE READ!

Or the recently released REPORT Accident Investigation Board Norway Issued February 2019 found here on the helicopter crash. PLEASE READ!

Or the KIBO final report found here Again PLEASE READ!

While in each report you will find evidence of crew going above and beyond the very highest levels of professionalism, it is with sadness that each report also offer many examples of miscommunication at all levels, and brings important questions and issues on many subjects, some being:

• Onboarding, time given to new crew to learn procedures before taking full responsibilities?
• Leadership, what do crew think it means aboard yachts today?
• Leadership and understanding of levels of leadership aboard and by leadership?
• Communication, one way two way, non verbal and understanding?
• Relationships and hierarchy between crew off watch, and on watch?
• Relationships of all crew with owner and guests. Who really is the leader?
• The drift to low performance from regulations not being required

Sadly in the crew swimming case a system break down and failure ended with a crew fatality.

In the crew cleaning topside accident there are multiple talking points on communication and leadership. Sadly for the latter this report has left many unanswered questions, and led to the death of the crew member involved some time later.

In the Helicopter report while there was no loss of life, it is something that could easily have gone the other way. The extract below brings to point onboarding and general issues as to safety behaviour and regulations, or lack of:

• The first mate was new on the yacht the day before the accident, and stated he had received a superficial brief on helicopter operations by the former first mate without any reference to the yacht’s Helicopter Operations Manual. 

Conclusion in the Helicopter crash report:

• The accident was caused by the breach of multiple safety barriers.

Miscommunication is not unusual, and there is never a single cause to it. You can search through many accident reports and find situations where this happens.

Crew have to live and work together and come with different mental models about just about everything. Many 20+ year olds can consider texting, a way of "talking", while a 40+ year old captain or officer may just not "GET" the youth of today!

Mental models, like visions need sharing.

Leadership is not taught in school, and we also know each person will have a slightly different way of approaching the same situation, even when in a leadership role.

Google 'Leadership' and you get: About 3,540,000,000 results (0.47 seconds) 

For some captains and officers, HELM may be the first time they really studied leadership and then done little more to improve their skill level.

Others may feel they are born leaders, and others may feel they have learnt everything they need to know about leadership on the job, or simply don't need to learn anything new.

These are just recipes for disaster and reasons why the aviation industry took to CRM years ago to save hundreds, possibly thousands of lives!

Whether you love or hate HELM is not really the point here. I'm more interested in asking the following about your own personality and behaviour?

• HOW does your level of self awareness affect the results of your style of leadership and communication ( think about the video)?

My own style in DiSC language happens to be a (Di ), and say I work with a person that has an (S) style, the below clip from a report we use offers some insight into how we can both look at the same situation quite differently.

The beauty of DiSC is it offers reliable information about a person (whether you know this or not), and also about the people you work with. The long term use of a tool like this is invaluable as there is information to continually refer back to as you gain better self awareness.

Even for such things as taking risks we see some people (like myself) can be more daring, while others tend to be more careful. Of course the more careful individual may want to take things slowly while the more daring may want to charge ahead. In DiSc language this shows on a continuum.

When you start to add this knowledge to a crew that is newly put together, or even a whole crew getting aboard a new yacht, or even a crew member taking an onshore course, you might ask yourself:

• Who would be more bold to jump into something, rather than assess risks?
• Who would rather say NO, but not be expressive or confident enough to say NO?
• Who would rather learn from a manual and who would rather learn by doing and watching?

I hope you can start to see some leverage points in knowing more about all crew, individually and as a team, at any point.

• When did you last think about an individual crew like this?
• How do you think all this can effect crew culture aboard, or the level of behavioural safety?
• How do you think each individual of your crew looks at authority, rules, and regulations?
• Have you ever sat down and really considered how different each crew member is and accessed their own styles of communication and level of self awareness?

No one wants to have an accident, no one wants to be in command of a yacht that has a fatality aboard, but it happens. Even with good intentions some things inexplicably happen. 

The secret to raising the percentage that it will not happen on your yacht is to be proactive and never stop learning. Never stop asking questions and remember that we all see and act in different ways, even when looking at the same situation.

STILL NOT CONVINCED

You might as an experiment watch a busy pedestrian crossing in a city and see how people behave so differently when crossing the road. Some will wait for the light, some will just find a gap in traffic and some will wait for the masses and the green man to light up.

These are all different behaviours, because they are all different people, with different mental models of the environment, even when looking at the same situation. Like crew on a yacht each person has their own styles. Their own level of risk they are willing take!

Watch a captain and crew dock a yacht and see the them do it differently than perhaps you would. Read the report and maybe leave a comment as to what you and your crew might have learnt.

For myself every report I read (I read a lot), constantly reminds me how important it is to continually develop self awareness and better listening skills. 

Each of us has strengths that make us unique and valuable, in general most of us like to be acknowledged for our strengths, as well as feel effective in our environment. However, any strength, when used excessively or inappropriately, can create problems.

If you can not see yourself in the reports noted in this post, please read them again. We can all feel we would never get into situations we would not wish on our greatest enemy, yet it can happen. If we are to have the best possible chances of avoiding being in situations like these, then we must constantly keep learning and training our own brain.

WHAT ARE YOUR THOUGHTS ON LEADERSHIP AND THE SUPERYACHT INDUSTRY?

Simon Harvey - director at N2Peopleskills Ltd, personal development coach working with superyacht captains, crew and professionals.