Bridge Resource Management Trai - Rexford Penn
Bridge Resource Management Trai - Rexford Penn
Bridge Resource Management Trai - Rexford Penn
• The Rexford Penn Group, LLC
CONTENTS
Chapter
Soon after, the maritime industry instituted similar training but called it
“Bridge Resource Management” (BRM). This BRM course is designed to
give the merchant marine officer the latest information to improve crew
management skills, increase safety, and meet future IMO regulations. In
addition it prepares a crewmember for simulator based training.
Please answer the following questions to determine for yourself your level
of knowledge regarding the subject of Bridge (Team) Resource
Management.
Question 1: Is Bridge Resource Management for Officers only?
Question 2: Can Bridge Resource Management techniques be measured?
Question 3: Does Bridge Resource Management teach you how to steer the
ship?
Question 4 Do crews have to cooperate with each other to run a safe ship?
Question 5: If this Bridge Resource Management training teaches
something that is different from company SOP’s, does the SOP take
precedence?
Answers: No.1: No; No. 2: Yes; No.3: No; No.4: Yes; No.5: Yes
If you answered four or five of these questions correctly, you already have a
good start on the techniques of resource management. If you answered
fewer correctly, then this course is designed to prepare you for a better work
relationship with other crew members.
The third element is the awareness of time. Keeping track of how much
time has passed while on watch, and knowing the exact time of day are key
factors in maintaining a constant and safe watch on the ship. Maintaining an
awareness of time helps to identify future problems that may affect the ship.
In navigation, keeping track of time is the primary device used to verify the
course and speed of the ship.
Situational Awareness on the bridge or in the engine room requires that
individual crewmembers participate continuously and to be fully involved
in order to be successful. The Captain and Chief Engineer have their own
levels of situational awareness, and their Assistants and Mates have their
own. Good communications will increase total situational awareness and
improve the synergy by adding ideas and knowledge to the Situational
Awareness of each. Improvement in awareness can be achieved when the
crew communicates well with each other. The combined effect of increased
communication is to improve individual situational awareness and facilitate
crew synergy (a collective effect by which the total result is greater than
individual contribution).
Non-Technical skills (Non-tech) are those skills which do not require a
specific technical capability from the individual, (such as steering the ship,
using the navigation equipment, radar operation, etc.). These Non-tech
skills refer instead to a crewmember’s attitude and behaviour. Often referred
to as ‘soft’ skills, which can include decision making, leadership, and
management, there is a new classification system of observed behaviours of
a crewmembers Non-tech skills, and it covers a range from very good to
very poor. This system is used to determine a subjective level of these skills
and uses a marking or grading system which follows below. This
classification system is known as a Behavioural Markers grading system.
Behavioural Markers classification and observation must be clearly
understood by the Captain and his Officers. Each individual ship’s officer
should have a general idea of how to measure and grade these skills because
appropriate non-technical skills and behaviour have been identified as a key
aid in preventing a loss of Situational Awareness.
Behavioural Marker classifications are graded from Very Poor to Very
Good.
Components of the Error Chain
The following are clues that help identify links in the error chain involving
operational and human events.
Reasons for human errors;
29. Misunderstanding
30. Fatigue
31. Physical limitations
32. Personal ability
33. Personal confidence
34. Personality clash
35. Skill (or lack of skill)
36. Nerves (too many or too few)
37. Lack of personal preparation
Matching an error to the cause of an accident or incident is not easy. With
experience the crewmember acquires more of the ‘tools’ necessary to
discover which of the possible underlying causes have resulted in an error.
Tools used to identify the causes of an error include:
37. Listening, watching and questioning activity
38. Looking for a non-technical reason behind a technical error
39. Learning the handling characteristics of the vessel
Almost every accident can be attributed to a chain of events (the Error
Chain), where the breaking of this chain would have prevented the accident
from happening.
Exxon Valdez Grounding
In the case of the tanker ‘Exxon Valdez’ which ran aground on shoals
in Alaska, there were many chances to break the error chain, any one of
which may have prevented the accident. The March 24, 1989 oil spill in
which the tanker, bound for Long Beach, California hit Prince William
Sound’s Bligh Reef and spilled an estimated minimum 10.8 million US
gallons (40.9 million liters) of crude oil has been recorded as one of the
largest spills in United States history and one of the greatest ecological
disasters. As the ship pulled into the channel late at night the Captain left
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the bridge, leaving the 3 Mate in charge of the navigation watch, in
darkness and through treacherous shoals. The ship came to grief shortly
afterwards.
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At any point communication could have been improved and might have
prevented the disaster by interrupting the Error Chain. By using questions to
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enhance the communication, the 3 Mate might have related his concerns
to the Captain before he left the bridge, and made it clear that he did not
have the skill to operate the vessel in restricted waters, at night, and alone.
It takes a focused mind to recognize when there is a need to break the chain
of errors, and it takes accurate communication to make it happen.
Braer
The Liberian registered tanker Braer was transiting between the Orkney and
Shetland Islands while on a voyage from Norway to Canada with a cargo of
23,000,000 gallons of light crude oil. The Master, Chief Engineer and First
Assistant Engineer were all Greek and the remainder of the officers and
crew were Filipino. Eleven miles south of the Shetland Islands the engine
failed. During the passage some steel pipes on deck had come adrift and
damaged air vents to the fuel tanks which allowed sea water contamination
of the fuel. The master was notified of the pipes being adrift quickly, nut
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when the engine failed the 3 assistant engineer did not recognize the
reason for the problem and began to make routine adjustments. When the
nd
2 assistant engineer came on watch, they both attempted to relight the
boiler where they found seawater contamination of the fuel. It took more
than 4 hours before the engineering department notified the Master of the
contamination. The main engine and generator failed approximately five
hours after the contamination occurred. The Master used satellite
communications to request permission for a tug to assist. He notified the
British Coastguard of the problem but did not ask for assistance. Rescuers
tried to save the ship as it drifted without power for a week while salvors
were unable to get lines on the crippled ship due to continuing high winds.
It finally broke up and sank.
47. The Braer was lost because several large steel pipes which had
been stored on deck came adrift. Was this a technical failure, or a
non-technical failure?
48. Even though the Chief Mate and the Chief Engineer notified
the Captain that the pipes had come adrift the Captain decided to
continue the voyage. What could the Chief Mate have done to break
the error chain?
49. Were any of the reasons for human errors a factor in this
accident?
50. Was it reasonable to assume that steel pipes coming adrift in
high seas could be a hazard to the safety of the vessel?
51. How could the Chief Mate or Engineer have convinced the
Captain that the ship was no longer seaworthy with those loose pipes
adrift on the deck?
Answers to Questions:
1. The pipes coming adrift were a non-technical failure because the
Captain noted that the stowing of the pipes would not be sufficient
for winter operations, yet sailed anyway.
2. By using the techniques of listening, watching and questioning,
the Mates might have had a better understanding of the potential
danger of the loose pipes. They could have examined the deck cargo
before sailing and estimated the handling characteristics of a vessel
with loose cargo on deck.
3. There were at least five human error factors involved in this loss.
4. Yes. By looking carefully in advance to see what damage might be
caused if the pipes came loose, the crew might have recognised that
the fuel tanks were vulnerable to contamination if they broke off in a
high sea state.
5. By applying the clues to identifying links in the error chain,
communications would have been improved. Whether or not the
pipes presented a hazard was an unresolved discrepancy which the
Mates should have insisted was resolved before sailing.
At 8:30 a.m. on Wednesday 7 November 2007, the Bar Pilot in charge
of navigating the container ship Cosco Busan radioed the Coast Guard
vessel traffic service on Yerba Buena Island with an urgent message.
“I touched the Delta tower,” he told the traffic service, which monitors
ship movements in and out of the bay. The Pilot reported that the 902-foot-
long container ship had hit the wooden fender surrounding one of the
towers that hold up the San Francisco Bay Bridge.
The ‘incident’ occurred while the ship was making eleven knots and
caused a gash in the side of the ship 160 feet long and 4 feet deep which
ruptured the fuel tanks allowing approximately 58,000 gallons of diesel fuel
to spill into the bay.
It was the first time a ship had ever hit the Bay Bridge since work
began on the suspension towers 74 years ago.
According to the US Coast Guard, the cause of this accident was
human error, although no individual was blamed.
Neither the Coast Guard nor the National Transportation Safety Board
has released a transcript of the incident, but using information from ship
pilots, captains, mariners who monitored the conversations between the ship
and the Coast Guard vessel traffic service (VTS), and electronic tracks of
the ship’s course, it is possible to recreate the chain of events.
The Cosco Busan also was equipped with radar, a Global Positioning
System, radios and an automatic identification system, a device that
transmits the ship’s position automatically every few seconds. The
identification system made it possible to track and record the Cosco Busan’s
movements.
The track of the ship shows the Cosco Busan making a wide turn to
the southwest, then swinging on a sharp right turn that took it into the
bridge tower.
It was chartered to Hanjin Shipping of Seoul. The vessel had just
changed ownership, and the 21 officers and crew, all Chinese, were making
their first voyage with the ship. Though the navigating officers and the
helmsmen were required to speak English, it is not clear how fluent they
were. Their fluency is an issue, because the accident’s cause may include
what mariners call “Bridge Resource Management,” or how the Pilots and
crew interact.
The Bar Pilot, came aboard about an hour before sailing. He met the
captain of the ship and the officer of the watch. He probably was introduced
to the helmsman, who would actually steer the ship under his orders.
But the ultimate responsibility of the ship is borne by the Master, or
Captain. The Pilot gives advice to the Captain on navigating the ship. It is
rare to disregard this advice, and Captains seldom do.
When the ship departed, the weather was foggy, visibility less than a mile.
The Pilot checked with the vessel traffic service (VTS) using VHF radio.
All commercial vessels monitor VHF radio and are required to check in
with VTS.
According to those familiar with the transmissions, the Pilot told the
Coast Guard traffic service that the fog had lifted a bit, and he was prepared
to get under way for sea. His intention, he stated, was to go through the
Delta-Echo span on the San Francisco side of the Bay Bridge. That passage
is between the two towers closest to Yerba Buena Island. The Cosco Busan
was accompanied by a tug which did not appear to have played any role in
the accident.
First, the Pilot had to get the ship around a dredger which was
anchored in the estuary. Then once in the bay, the approach to the Delta-
Echo span was fairly straightforward in clear weather, according to several
pilots, but the Pilot was in dense fog. He had to rely on his electronic
devices and the bridge team. At some point, according to the automatic
identification system, the ship steered left, away from the course that would
take it to the channel between the two bridge towers. It is not clear why this
happened. Sometimes, the seaman at the helm will misunderstand a bar
pilot’s orders. But, the Pilot was supposed to be checking the helmsman, the
mate was supposed to be checking as well, and the Master observing it all.
The bar pilot was supposed to make sure they understood what he wanted
them to do, because sometimes the men at the helm don’t do what they are
told.
Coming out of the estuary, it was critical that the ship made a right
turn. Instead, the ship went left. Not long afterward, the vessel traffic
service called the Cosco Busan to tell the Pilot that he was on the wrong
course. The ship was heading parallel to the Bay Bridge; instead of on a
course that would take it safely under the bridge. The Pilot at first disputed
the vessel traffic service message, saying, “That’s not what I see here.”
After hitting the bridge, the Pilot proceeded to an anchorage off Treasure
Island and stopped. He then reported the accident in more detail and said
the ship was leaking oil.
A report has since concluded that an ineffective Master, a visually fog-
bound Pilot and poor management all contributed to the Cosco Busan
hitting a San Francisco bridge, causing over $70m worth of damage.
The lack of communication between all involved led the US National
Transportation Safety Board to recommend that the International Maritime
Organization include a segment on cultural and language differences and
their influence on mariner performance during Bridge Resource
Management training.
The NTSB report on the Cosco Busan accident included many
conclusions spreading the blame equally among all parties involved, but it
was ‘cultural differences’ that prevented the Cosco Busan’s Master from
asserting his authority over the Pilot. The report also found fault with the
quality of communications between the two. The crew’s lack of proficiency
with English was also cited as a factor.
Overall, the report cites a pilot who was ‘cognitively degraded’, an
‘ineffectual master’, and an operating company that did not properly train
its crew and the US Coast Guard’s ‘inadequate medical oversight’ of the
Pilot as contributors to the incident.
Other recommendations included a finding that, in its radio
communications, the Vessel Traffic Service needed to identify the vessel
and not just the pilot; and that the US Coast Guard needed to provide
guidance to VTS personnel that ‘defined expectations for when their
authority to direct or control vessel movement should be exercised’.
The NTSB report agreed that the Pilot’s order for ‘hard port rudder’ at
the time of the collision was appropriate, and possibly limited the damage
to the vessel and the fendering system.
The report said the Pilot and the Master ‘failed to engage in a
comprehensive master-pilot information exchange before the ship departed
the dock’, and failed to establish and maintain effective communication
during the voyage.
The interactions between the Pilot and the Master ‘were likely
influenced by a disparity in experience in navigating the San Francisco Bay
and by cultural differences that made the master reluctant to assert authority
over the pilot’.
Nonetheless, the Master also did not implement several procedures
found in the company safety management system related to safe vessel
operations, which placed the vessel, the crew, and the environment at risk.
The report found fault with the company for providing some manuals in
English and not in the ship’s working language, which limited the crew’s
ability to follow all company procedures.
‘Because the Cosco Busan was crewed with mariners who were new
to the vessel, who had not worked together previously, who for the most
part were new to the company, and who were insufficiently trained in vessel
operations and company safety procedures, Fleet Management placed the
vessel and crew at risk when the vessel got under way in South Korea’, the
report concluded.
Despite finding fault with the Pilot for insufficient disclosure of his
medical condition, the NTSB unambiguously named the US Coast Guard as
the final repository of blame. The system of medical oversight of mariners
continues to be deficient because it lacks a requirement for mariners to
report changes in their medical status between medical evaluations.
And finally, to the American Pilots’ Association issued a reminder that
a pilot card is only a supplement to a verbal Master - Pilot exchange, and to
encourage pilots to include vessel Masters and/or the officer in charge of
the navigational watch in all discussions and decisions regarding vessel
navigation in pilotage waters.
Ship’s Pilots are a regular part of vessel operations but, unfortunately
the transfer of authority to the Pilot has been known to contribute to
accidents. Pilots are used primarily in the confined waters of a port during
arrival, berthing, and departure. The Master or Captain is intimately
familiar with the vessel he commands, but the Pilot is intimately familiar
with the surroundings and local port operations. Thus they must work
together closely to bring about a safe operation in confined waters. It is
imperative that ships officers develop good methods of transferring
navigation and operation of the vessel to the Pilot.
A routine handover report, for example, is required to commence the
communication process that will provide safe passage while the Pilot is
commanding operations. It is also important for the ship’s crew, at all
levels, to realize that although the Pilot is temporarily in command, the
Captain is always held responsible for the safety of the vessel, and all must
work together in a coordinated manner to achieve a safe passage.
The Pilot must become a part of the bridge team. He must, while in charge,
be included in briefings and treated like a member of the crew. His
knowledge and experience in the local area is an advantage to the ship’s
operations, and he has to take over a vessel in a relatively short period of
time. It is important to note that a Pilot may not have seen a particular
vessel before and thus will be relying on the bridge crew for input regarding
the specific operation. It is important that the Captain recognizes his own
authority is not diminished on the bridge, but rather enhanced by the
presence of the Pilot. Thus for all concerned, a correct handover report is
necessary for the Pilot to be able to correctly operate the ship, along with a
rigorous communication and cooperation effort between Master and Pilot,
but the ultimate responsibility of the ship is borne by the Master or Captain.
The pilot only gives advice on navigating the ship.
The single most effective tool in the verbal communication process is the
ability to listen effectively. Hearing a spoken message is not sufficient; it
must be understood. Cooperation between the sender of a message (the
speaker) and the receiver of the message (the listener) is essential.
There may be internal barriers to communication such as cultural
differences causing reluctance on the part of the sender to speak to a
superior officer. Or there may be external barriers to communication such as
a noisy environment, or a physical impairment of the receiver. After the
message is received it normally requires the recipient to give feedback to
the sender, after which both parties become aware of the internal or external
barriers to their communication.
This communication is directed towards a specific shared operational goal.
The sender must solicit and give feedback as required. The recipient must
listen carefully, and both parties must focus solely on the communication
process, assuring that the desired outcome of the communication is
achieved.
Increasing personal situational awareness may require asking questions on
the part of the crewmember, who must decide what, to whom, and how to
ask his question. Each question must be clear, concise, and accurate. The
response to a question must only be considered if it provides equally
accurate information. During the communication process, everyone should
keep an open mind.
In summary, the ability of a crew to work together effectively crew
involves several aspects of psychology;
60. Team building and maintaining.
61. Consideration of others.
62. Support of others.
63. Conflict resolution.
With these ‘building blocks’ for crew cooperation in place, and through the
effective use of good communication techniques, Officers on Watch can
achieve safe and efficient operations.
By establishing specific crew duties on the bridge, and with the elimination
of distractions, for example using a sterile bridge concept during which
non-essential communications are not allowed, crew members can become
an effective bridge communication and cooperation team.
There are two ways of identifying stress; it can be identified internally (self-
diagnosed), or it can be identified externally (diagnosed by others). A
Master, Pilot, or Watch Keeper must be good at diagnosing both in order to
judge the stress level of himself and his crew. The ability to make rational
and correct decisions under stress is an important part of a Commander’s
responsibility. Of the types of stress, internally generated stress can be the
most dangerous and hard to deal with.
Such outside problems can keep the individual Master, Pilot, or Watch
Keeper from being able to focus on the job at hand, so therefore internal
stress recognition is a very important element of resource management,
especially when the individual is considered a part of the operation and
management of a vessel.
The individual must recognize the symptoms of stress in himself as well as
others. For example, this can be as simple as knowing that the Chief Mate
has a daughter who is being married in a week’s time, and that he is looking
forward to his shore leave to attend her wedding, only to find that his
replacement missed a connecting flight and will be unable to reach the ship
in time, causing a delay in the Chief Mate’s plans.
The Master, Pilot, or Watch Keeper must be able to maintain composure
and rational decision-making under stress. Calm reaction to external events
such as a rogue wave can make the difference between surviving, or not
surviving.
As individuals facing stress, crew-members must be adaptable to stressful
situations or stressful personalities, and make allowances for the decision-
making process to accommodate them.
The use of stress-management techniques to reduce the effects of stress on
the individual is an important element of an upcoming event, such as
manoeuvring the vessel. This may be something as simple as taking a break,
slowing down breathing and taking a few deep breaths, or stopping for a
moment before beginning, in order to take time to refocus. If weather or
conflicting traffic becomes a major stressing point, then reducing that stress
may require the input of others; whereby the person on duty calls for
assistance to improve the safety level of the ship and its crew.
When under stress it is important that each individual maintains open and
clear lines of communication with others. It may be they will recognize the
stress level of that individual before he does so himself, and keeping the
communication going is an important element of stress relief. During times
of limited or low stress it is important to prevent complacency or boredom
from becoming a factor which could interfere with the safe operation of the
ship.
In all cases, the company standard operating procedures (SOP) must take
precedence over any conflicting information, including any that may arise
from this course. The Master and his crew are obligated to follow company
procedures during standard and non-standard operating conditions and
failure to do so may cause an insurance company to find sufficient cause to
not pay after an accident. The impact of the SOP is much greater than it
would seem.
Companies also should have SOP’s relating to the use and management of
advanced automation and navigation devices on the bridge or in the engine
room. The duties of the bridge crew in regards to the use of these devices
may or may not be clearly defined. Many a vessel has come to grief because
of the misuse of automation. Satellites can, and have, failed, and the
receivers and computers that process their information can, and have, failed.
There must be a constant backup for automation on the bridge to ensure
continuous safe operations, such as using paper chart plotting to maintain a
record of course and speed if the navigation units stop working.
Recognition of failure modes of this equipment must be well documented
and trained.
It is also important to specify the duty of the bridge crew as to the use of
these devices. It is never a good idea to have everyone on the bridge
studying a display screen discussing navigation or hazard avoidance.
Someone must maintain a lookout from the bridge to track what else is
going on. While this seems to be obvious advice, it is frequently violated.
Any changes to the sailing plan entered in the navigation equipment needs
to be discussed and noted.
There must be procedures in place to verify the status of the automation and
navigation equipment, and the Master, Pilot, or Watch Keeper needs to
select the appropriate level of automation to use for the current progress of
the vessel. All programming of automation equipment and navigation gear
should be done well in advance of any manoeuvre.
Instructions:
You may complete the Final Exam in your own time. You may refer to this
manual or online information if needed. Complete the exam as an email
using the answer sheet format provided on the reverse of this page as an
example, then email your answers to:
Your examination will be graded and the results returned to you by E-mail
along with a Certificate of Completion of Bridge Resource Management.
Your name: __________________________________________________
Company/Vessel Name:
________________________________________________________
Postal Address: _______________________________________________
Your E-mail address:
___________________________________________________________
Date of taking the exam:
__________________________________________
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QUESTIONS:
81. How did Bridge Resource Management training come about?
81. Two ships collided in the North Sea.
82. Two airplanes collided in France.
83. An airliner crashed in Florida.
84. The IMO mandated Bridge Resource Management training.
4. Can the error chain be broken and will that increase safety?
1. No, there is no way to see the error chain
2. Yes, any break in the error chain can end an accident happening
5. Clues in the error chain include which of the following?
1. Lack of communications
2. Distraction or preoccupation
3. Non-specific commands
4. All of the above
11. The master can delegate authority, but not responsibility, True
or False?
1. True
2. False
The Rexford Penn Group, LLC
Maritime and Aviation Training Providers
Wilmington, Delaware USA