UK MCA The Deadly Dozen 2016 12
UK MCA The Deadly Dozen 2016 12
UK MCA The Deadly Dozen 2016 12
This notice should be read with the Human Element Guidance series of MGNs, "The Human
Element - a guide to human behaviour in the shipping industry" and other maritime human
element publications.
Summary
There is a wide range of contributory factors that result in maritime accidents, incidents and
errors.
A consistently occurring factor throughout almost all accidents, incidents and errors is the
human element.
This Note raises awareness of twelve of the most common people related factors the
Deadly Dozen - which can affect maritime safety, along with suggested mitigating actions
available to companies, masters and seafarers.
Based on the article the Dirty Dozen, Gordon Dupont, source: www.skybrary.aero, and
adapted for the maritime industry.
1. Introduction
1.1 There is a wide range of contributory factors that result in maritime accidents, incidents and
errors. Most result from a combination of several, even many, different contributory factors
ranging from purely technical failures to environmental, systemic, procedural, competence
and behavioural factors.
1
2. The Human Element
2.1 A consistently occurring factor throughout almost all accidents, incidents and errors is the
human element peoples ability and capability to deal effectively and safely with the
complexity, difficulty, pressures and workload of their daily tasks, not only in emergency
situations but also during routine operations.
2.2 The majority of these accidents, incidents and errors are potentially avoidable if peoples
understanding, actions and behaviour were different. This not only applies to seafarers
(where the accidents usually occur) but also to people at all levels and positions within the
overall wider maritime system, including ship owners, operators and managers and other
shipping and maritime industry leaders whose actions can have a major influence on
outcomes far removed in place and time.
3.1 This Note provides a summary of twelve of the most common people related factors along
with tips and learning points which, if managed effectively have the potential to avoid and
avert accidents, and make a dramatic improvement to maritime safety.
3.2 They are the twelve most common conditions that can influence or act as pre-cursers to
human error, leading to accidents or incidents. It is not a comprehensive list of accident and
incident pre-cursers, indeed, there are several hundred possible pre-cursers. However,
experience shows that the Deadly Dozen provides a useful and pragmatic introduction to
understanding aspects of human error in organisations and workplaces and ship owners,
ship operators and managers, masters, officers and crews are encouraged to become
familiar with its principles and practices.
4. Annex
a) the Deadly Dozen twelve factors in diagram form with a summary of the key points
b) the Deadly Dozen a diagram showing analysis of the breakdown of the twelve
factors by near miss reports submitted to CHIRP Maritime
c) more detailed information on each factor
description and summary of the factor
key Dos and Donts
what companies, masters and seafarers can do to help
issues to be aware of
sources of further information
key behaviours that will help
-2-
More Information
For further information on the Deadly Dozen, and maritime Human Element generally, please
contact;
-3-
Situational Awareness Fatigue
Do You REALLY Know
The Deadly Dozen Just Tired
Whats Happening? OR Dangerously Fatigued?
The Big Picture AND fine detail DONT accept it - Its a killer!
Constantly update your awareness Fit for Duty Leads to accidents and ill health
Actively seek input from others Are you REALLY fit to work? Ever present danger at sea
Never assume anothers intentions Avoid alcohol and drugs they are major killers Learn about cause, effect and prevention
WHIM ask: What Have I Missed? Illness can impair judgement and thinking Recognise it, report it, manage it effectively!
Injuries can be distracting
Alerting Distractions
Do You REALLY Speak Up Multi-Tasking
When You Should? OR Dangerously Distracted?
Vital skill use it effectively encourage it
Be positive and constructive propose solutions It happens very easily
Some may find it difficult to do Personal as well as job distractions
Its not a threat its good teamwork Use checklists and Red Zone techniques
Be assertive it can save lives! If distracted go back 2 steps
Be assertive insist on calling back when convenient
Communication
Pressure
Do You REALLY
Just Busy
Understand Everyone?
Message understood? DONT assume - CHECK OR Dangerously Overloaded?
Use closed loop communications Good pressure can improve performance
Words are only 30% of communication Too much leads to stress always bad
Remember effect of tone and body language Dont let pressure lead to taking short cuts
Different cultures may interpret things differently Ensure adequate resources people, time, tools
Watch out for accidentally causing offence
Capability
Complacency Is Your Team REALLY Capable?
Is Everything REALLY OK? Check training and qualifications and experience
Never assume all is OK Regularly assess capability
Follow procedures they work! Provide on-board training, mentoring, coaching
Use checklists Ensure any capability gap is addressed
Seek input from others
Early action avoids later difficulties
Check your situation - CONSTANTLY
Distractions - 1.8%
Multi-Tasking OR Dangerously Distracted?
Alerting 15.3%
Do You REALLY Speak Up When You Should? Pressure 1.9%
Just Busy OR Dangerously Overloaded?
Capability 4.9%
Is Your Team REALLY Capable?
Communication 13.4%
Do You REALLY Understand Everyone?
Teamwork 6.8%
How Well Do You REALLY Work Together?
-5-
1. SITUATIONAL AWARENESS - do you know whats REALLY happening?
Situational awareness understanding what is really happening and assess its impact on
your voyage now and in the future.
Poor situational awareness has been a contributory factor in many maritime incidents. Loss of
effective situational awareness is often due to:-
lack of up to date information
situation changing too quickly to be understood
new and novel problems that are not understood
insufficient capability and experience of those involved
distraction e.g. paperwork, interruptions
complacency
fatigue
Do Dont
always look out for problems assume everything is OK
make sure procedures, risk assessments put someone in a situation beyond their
and checklists etc. are up to date capability
plan effectively carry on regardless
know what to do before you start a task ignore a problem
ask for input from your team members assume someone elses intentions
advise and help your team
communicate effectively
value input from others
if you notice a problem speak up - NOW
-6-
2. ALERTING - do you REALLY speak up when you should?
Alerting - bringing concerns about actions, situations or behaviour to the attention of others in
a timely, positive and effective way.
Raising awareness assertively Alerting being positive and effective when raising issues of
concern significantly improves safety and operational performance. In the complex world of
maritime operations many things can go wrong. Speaking up in a timely manner can help
avoid many accidents. This is particularly critical during emergency or high stress situations.
Do Dont
if you see a problem, alert the appropriate be afraid to speak up it can save lives
team member ignore a problem it will only get worse
be assertive let someone ignore you if your first alert
if you are alerted to an issue, is ignored, repeat it
acknowledge it and act upon it -
effectively
Be Aware !!
alerting and assertiveness is not easy for everyone
some people do not feel comfortable behaving assertively in the presence of more senior
people
some senior people do not feel comfortable with junior people behaving assertively
some senior people actively expect and encourage assertiveness from junior people, and
may incorrectly assume everything is OK if no-one speaks up
-7-
3. COMMUNICATION - do you REALLY understand each other?
Communication transmitting and receiving full and correct information ensuring sender
AND receiver share the same understanding.
For communication to be effective everyone involved must share the same understanding of
the message, and know that everyone else shares that same understanding. Use closed loop
communication where the message sender and message receiver repeat the message to each
other to confirm understanding.
Do Dont
use closed loop communication assume a message is properly understood
use simple words and phrases where CHECK
possible use slang or colloquialisms
repeat the most important parts of a assume something you found rude or
message offensive was intended it could be
if in any doubt, ask for confirmation perfectly acceptable in another culture
take care with pronunciation assume something that is acceptable in
work with your colleagues to understand your culture will automatically be
each others cultures, taboos etc. acceptable in another
if someone looks puzzled or offended,
discuss the issues with them and explain
what you meant and ask why it puzzled
or offended them
-8-
4. COMPLACENCY - is everything REALLY OK?
It is dangerous but an easy trap to fall into. Just because everything appears OK, doesnt
mean that it is. There are many possible reasons and we are all susceptible to them.
Common reasons are:-
the same work has been repeated satisfactorily many times in the past without incident
the operator has insufficient experience or knowledge to recognise when a situation
has changed
poor briefing before taking up duty
forgetting something
inadequate monitoring/checking of the situation
poor teamwork, alerting, communications
fatigue
Do Dont
update your situational awareness assume everything is OK
regularly ignore procedures
get regular input from your team expect something to be OK just because it
give/receive an effective briefing at always has been in the past
handover
expect to find problems actively look out
for them
use checklists effectively
get help if you dont understand a
situation
Be Aware !!
complacency is an easy trap especially if nothing has gone wrong for a long time
if it can go wrong it will sometime. Always be alert to what can go wrong.
-9-
5. CULTURE do you REALLY have a good safety culture?
Culture the blend of understanding, beliefs and attitudes of people and organisations that
result in behaviour and actions.
The term culture is often misunderstood. In simple terms, it means the way we do things
here. The way things are done stems from a combination of understanding, beliefs, attitudes
and behaviour. These come from a number of sources, for instance:-
Personal culture everybody has their own personal beliefs and attitudes
National culture cultural norms in different parts of the world
Company culture the beliefs, attitudes and behaviours that are prevalent in the
company, and that may be different to other companies
Professional culture beliefs, attitudes and behaviours that may be common to
professional mariners and acquired during training
In terms of safety culture, the important aspects are those beliefs, attitudes and behaviours
that improve or potentially compromise the safe operation of ships and the safety of everyone
on board.
Do Dont
constantly look out for safety problems assume everything is OK
report all safety issues ignore or hide near misses
think safety at all times ignore other peoples unsafe behaviour
encourage safe behaviour in others believe safety is someone elses problem
put off safety issues to a later date
- 10 -
6. LOCAL PRACTICES - efficiency OR dangerous short cuts?
Local practices behaviour and actions applied locally that differ from the official
documented practices. Also known as procedural violations.
Correct behaviour and actions are fundamental to safety. Procedures and practices have
been designed to ensure that work is carried out correctly, safely, legally and to the expected
standard. However, actual local practices can vary from the expected procedures and
behaviour. If it is not addressed effectively, this behaviour can become established as the new
norm with a lower safety and quality threshold.
There are many reasons why actual practices and behaviour vary from the expected standard,
including:-
official procedures and practices are not clear, or difficult to follow or do not work
specified equipment is not available
training is not effective, people may think they are doing it correctly
supervision and monitoring is not effective
the safety culture is not effective or there is a carefree attitude
insufficient people, tools or time to carry out the procedures as expected
shortcuts are more convenient or satisfying
people dont fully understand the risk of their actions
Do Dont
follow correct procedures take short cuts
report difficulties and problems with ignore problems and difficulties
procedures take risks by using unsuitable work
question the effectiveness of procedures practices or tools
accept others breaking rules
Be Aware !!
shortcuts are usually done with the best intentions to get the job done but not always!
it is IMPOSSIBLE to write procedures to cover ALL eventualities. Seafarers will be
faced with novel and unpredictable situations. Make sure only suitably qualified
and experienced personnel are used. Use effective teamwork, including shore
based experts for support, if necessary
- 11 -
7. TEAMWORK - do you work REALLY well together?
It underpins both safety and operational effectiveness. A team that has a common purpose,
shared mental model and communicates effectively and supports each other is much more
likely to perform well and operate safely. You can be in:-
a permanent team e.g. ships crew, management team
a temporary team e.g. bridge team and harbour pilot, ships crew and dock workers
more than one team at the same time
A team may also involve more than those in your immediate place of work, and include:-
ships crew
shore management
charterers
maintainers and suppliers
port authorities
insurance industry
All contribute to the successful running of the vessel, and the wider maritime industry. Each
has an impact on the others and need to work together.
Do Dont
alert team members to potential problems assume everyone will act or behave in the
help team members same way
discuss issues with team members assume everyone has the same skill and
work with colleagues to overcome knowledge
language or other communication ignore problems
difficulties
be inclusive - encourage everyone to
participate in all shipboard activities
- 12 -
8. CAPABILITY - is your crew REALLY capable?
Capability the blend of knowledge, skills and attitude to enable effective, safe performance.
Do they have tools and resources to perform competently?
It is critical to maritime safety. Competence is about more than holding an appropriate training
certificate, it is about a blend of skills-
technical and professional skills and knowledge:-
o navigation
o engineering
o seamanship
o cargo handling
o ship handling
non-technical skills:-
o communication
o leadership and management
o teamwork
o workload management
o situational awareness
o behaviours, attitude and professionalism
o dealing with problems
High performing people are able to combine technical and non-technical skills successfully. A
failure in either technical or non-technical performance can have a negative impact on ships
performance, potentially leading to accidents.
Do Dont
ask for guidance if you are unsure put people in roles beyond their
help each other competence and experience
check evidence of competence and claim you can do more than you really can
qualifications assume peoples level of competence
Be Aware !!
watch out for forged and falsified certificates
be alert to alarming or concerning behaviour
- 13 -
9. PRESSURE - busy OR dangerously overloaded?
Pressure real and perceived demands on people. Do you REALLY have the resources you
need.
It can be motivating and inspire good performance and a sense of achievement. However, too
much pressure can be demotivating, lead to stress and health problems, degraded
performance and threaten safety.
Excess pressure usually involves too much work, but also includes meeting tight deadlines,
schedules, port turn round times etc. This can be aggravated by changes to schedules,
unexpected delays, additional port calls, changes to routes, crew changes, problems with
weather and port inspections, all of which can lead to disturbed rest periods and long working
hours which increase stress.
Do Dont
always be alert to workload pressures assume that people are coping with their
speak up if you are overloaded workload effectively
ensure you have the necessary take unnecessary short cuts to catch up
resources to complete a task properly on work
before beginning struggle on regardless
ask for help if required
- 14 -
10. DISTRACTIONS - multi-tasking OR dangerously distracted?
These are commonplace. They can usually be managed effectively but it is easy to become
drawn in to a distraction and overlook much more critical events with serious implications for
safety. They are a significant cause of forgetting things and losing situational awareness.
They can be lethal!
Do Dont
declare a red zone whilst under pilotage allow unnecessary interruptions
or other times of difficult navigation be afraid to be assertive in dealing with a
only allow essential communications in distraction
the red zone distract someone performing a safety
use checklists effectively to monitor critical task
progress allow minor issues to distract you from the
if distracted during a task, go back 2 main task
steps in the procedure before restarting
if you notice someone being distracted,
alert them
keep focussed on the main task
deal with non-essential distractions later
be assertive
Be Aware !!
it is easy to become distracted even when you know about distractions!
- 15 -
11. FATIGUE - just tired OR dangerously fatigued?
Fatigue A reduction in physical and/or mental capability as the result of physical, mental or
emotional exertion which may impair nearly all physical abilities including: strength; speed;
reaction time; co-ordination; decision making; or balance
IMO MSC/Circ.813
Fatigue kills. It degrades performance at all levels which can lead to accidents and in the
longer term have a bad effect on health.
Fatigue clearly has an adverse effect on people and their performance. It is a significant factor
in many maritime accidents. The main causes of fatigue are:-
natural biological (circadian) rhythms it is natural to want to sleep at night and early
afternoon
the length of time we are awake
the length of time we spend working
the difficulty of the work (mental and physical)
stress
the amount of rest we get between work periods
the amount of adequate quality, undisturbed sleep absolutely essential for recovery
Do Dont
look out for the effects of fatigue accept fatigue as a way of life its
speak up about fatigue dangerous
Be Aware !!
Fatigue can creep up on you. Ironically, being fatigued makes it more difficulty to
recognise fatigue.
More Information
Further guidance can be found in MGN 505 (M) and IMO MSC/Circ.1014 Guidelines on
Fatigue Mitigation and Management.
- 16 -
12. FIT FOR DUTY are you REALLY fit to carry out your duties safely?
Fit for Duty the combination of physical and mental state of people which enables them to
carry out their duties competently and safely.
It is critical to maritime safety. Mental and/or physical impairment can have a seriously
adverse effect on performance and the ability of an individual or team to operate safely. The
main causes of degraded fitness for duty are:-
misuse of alcohol and/or drugs
physical injury
illness
stress, worry, personal problems
mental impairment
Do Dont
seek medical attention if you feel unwell or consume alcohol before or during work
are injured periods
report sick if you are not well enough to report for duty if under the influence of
work safely alcohol
seek help if you have personal problems take illegal drugs
affecting your fitness for duty try to hide the effect of degraded fitness
help your colleagues who are for duty
experiencing problems
Be Aware !!
Degraded fitness for duty, especially misuse of alcohol and drugs, is a major cause of
accidents, particularly Person Overboard
- 17 -