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89-96% of collisions
75% of allisions
Therefore, if we want to make greater strides towards reducing marine casualties, we must begin
to focus on the types of human errors that cause casualties.
One way to identify the types of human errors relevant to the maritime industry is to study
marine accidents and determine how they happen. Accidents are not usually caused by a single
failure or mistake, but by the confluence of a whole series, or chain, of errors. In looking at how
accidents happen, it is usually possible to trace the development of an accident through a number
of discrete events.
A Dutch study of 100 marine casualties found that the number of causes per accident ranged
from 7 to 58, with a median of 23. Minor things go wrong or little mistakes are made which, in
and of themselves, may seem innocuous. However, sometimes when these seemingly minor
events converge, the result is a casualty. In the study, human error was found to contribute to 96
of the 100 accidents. In 93 of the accidents, multiple human errors were made, usually by two or
more people, each of whom made about two errors apiece. But here is the most important point:
every human error that was made was determined to be a necessary condition for the accident.
That means that if just one of those human errors had not occurred, the chain of events would
have been broken, and the accident would not have happened. Therefore, if we can find ways to
prevent some of these human errors, or at least increase the probability that such errors will be
noticed and corrected, we can achieve greater marine safety and fewer casualties.
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The latest studies on human factors proposed three categories for human factors that contribute to
accidents in the offshore oil industry, including tanker operations: individual factors, group
factors, and organizational factors (in Figure 1.1). Other researchers focus on individual vs.
organizational causes.
Researchers have found that although the majority of immediate causes are attributable to
individuals (e.g. operating personnel), the majority of contributing, or underlying, factors can
be attributed to the organizational context or group dynamics that influence the individual.
Similarly, once an accident sequence has begun, organizational influences may allow the
sequence to continue, resulting in an accident. Therefore, the culture, incentives, operating
procedures, and policies of organizations have important effects on the safety of marine systems.
Individual human factors. Although most researchers recognize the importance of the
organizational safety culture, the role of the individual operator is critical. The competence,
perceptual judgments, stress, motivation, and health risks (such as work over-load) of an
individual operator are critical to the chain of events that may cause an accident or oil
spill. Two of the most recognized and studied individual factors as related to the maritime
industry are described here: inadequate knowledge and fatigue.
Other individual factors. In some studies were contend that people are basically rational, but
their goals and risk attitude may not always match those of the organization, due to
policies that may inadvertently encourage undesirable behavior.
People typically act to receive awards and avoid negative consequences, but more
weight is generally given to potential negative consequences to themselves, such as being
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Inadequate knowledge. A United States National Research Council study cited inadequate
general technical knowledge as the cause of 35% of marine casualties: Mariners often do not
understand how the operation works or under what set of operating conditions it was designed to
work effectively.
In the same study, 78% of mariners ascribed a lack of understanding of the overall system
of the ships they work on as a contributing factor to accidents. Moving among different
sizes and types of vessels can cause confusion and compromise decision-making abilities if
mariners are not familiar with the ship-specific systems.
When people take actions that increase the risk of failure, it is often because they have
encountered a rare event that is not part of their training or general awareness, and they are
unaware of how their actions will affect the system or are unaware that they are contributing
to accident risk.
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Figure 1.3 encapsulates four high-level elements that influence safety and efficiency in job
performance:
o vessel or offshore installation design and layout considerations,
o workplace ambient environmental elements,
o management and organizational issues related to operations, and
o the personnel who operate the vessel or offshore installation.
Insufficient attention to any of these elements may adversely affect safety, productivity, and
efficiency. It is important that these elements be at the core of any HFE implementation effort.
The structure and selection of activities described herein help promote this model and associated
elements.
Management and organizational considerations. This aspect of the model covers management
and organizational considerations that impact human performance and safety throughout a
systems lifecycle. The implementation of an effective design and safety policy that includes
human factors engineering and ergonomics will help create an environment that helps to
minimize risks and reflects a good corporate safety culture for both system operations and to
personnel. The commitment of top management is essential if this policy is to succeed. This
commitment throughout the lifecycle means that it begins in early development with adequate
resources to address HFE in design as well as the policy and personnel management required
once the installation is operational.
A study performed by the University of California at Berkeley found that 80% of all offshore
accidents in U.S. waters were due to human error, and 80% of those occurred during operations.
In 1995, the USCG launched a major initiative, called Prevention-Through-People (PTP), to
reduce human error as a causative factor in maritime accidents when its research found that from
75-90% of all at-sea accidents were human-induced. This report also introduced the term
human element to describe those factors which cause or contribute to human error. The
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In order to address human factors in workplace safety settings, peoples capabilities and
limitations must first be understood. The modern working environment is very different to the
settings that humans have evolved to deal with. Below are provided details on the main factors
involved, including:
Attention - the modern workplace can overload human attention with enormous
amounts of information, far in excess of that encountered in the natural world. The way
in which we learn information can help reduce demands on our attention, but can
sometimes create further problems.
Perception - in order to interact safely with the world, we must correctly perceive it and
the dangers it holds. Work environments often challenge human perception systems and
information can be misinterpreted.
Memory - our capacity for remembering things and the methods we impose upon
ourselves to access information often put undue pressure on us. Increasing knowledge
about a subject or process allows us to retain more information relating to it.
Logical reasoning - failures in reasoning and decision making can have severe
implications for complex systems such as chemical plants, and for tasks like maintenance
and planning.
Attention. Attention on a task can only be sustained for a fairly short period of time, depending
on the specifications of the task. The usual figure cited is around 20 minutes, after which, fatigue
sets in and errors are more likely to occur. This is why air traffic controllers are obliged to take
breaks from their attention-intensive work at regular intervals. However, there are a number of
other reasons why the attentional system is responsible for errors. These include:
Information bottleneck it is only possible to pay attention to a small number of tasks at once.
For example, if an air traffic controller is focussed on handling a particular plane, then it is likely
that they will be less attentive to other aspects of safety, or other warning signals (although this
depends on the nature of the signal).
Habit forming - if a task is repeated often enough, we become able to do it without conscious
supervision, although this automatisation of regular and repetitive behaviour can force us into
mistakes.
Perception. Interpreting the senses - one of the biggest obstacles we face in perceiving the world
is that we are forced to interpret information we sense, rather than access it directly. The more
visual information available to the perceiver, the less likely it is that errors will be made. Bearing
this in mind, systems that include redundant information in their design may cause fewer
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The types of problems caused by these factors are often unavoidable. In certain situations,
human beings will always make mistakes, and there is a limit to what can be done to modify
behaviour itself.
As it is inevitable that errors will be made, the focus of error management is placed on reducing
the chance of these errors occurring and on minimising the impact of any errors that do occur. In
large-scale disasters, the oft-cited cause of human error is usually taken to be synonymous
with 'operator error' but a measure of responsibility often lies with system designers. For
instance, during the Second World War, designers attempted to introduce a new cockpit design
for Spitfire planes. During training, the new scheme worked well, but under the stressful
conditions of a dogfight, the pilots had a tendency to accidentally bail out. The problem was that
the designers had switched the positions of the trigger and ejector controls; in the heat of battle,
the stronger, older responses resurfaced.
Recent research has addressed the problem of how to design systems for improved safety. In
most safety-critical industries, a number of checks and controls are in place to minimise the
chance of errors occurring. For a disaster to occur, there must be a conjunction of oversights and
errors across all the different levels within an organisation. This is shown in the figure below
from which it is clear that the chances of an accident occurring can be made smaller by
narrowing the windows of accident opportunity at each stage of the process.
Factors such as training and competence assurance, management of fatigue-induced errors and
control of workload can eliminate some errors. But errors caused by human limitations and/or
environmental unpredictability are best reduced through improving system interface design and
safety culture.
System design. A good system should not allow people to make mistakes easily. This may sound
obvious, but all too commonly system design is carried out in the absence of feedback from its
potential users which increases the chance that the users will not be able to interact correctly
with the system. A set of design principles has been proposed which can minimise the potential
for error.
Accurate mental models. There is often a discrepancy between the state of a system and the
user's mental model of it. This common cause of erroneous behaviour arises because the user's
model of the system and the system itself will differ to some extent, since the user is rarely the
designer of the system. Problems that can arise as a result of this discrepancy are illustrated by
the Three Mile Island incident. In this incident, the system had been designed so that the display
showed whether the valves had been instructed to be open or closed. The most obvious
interpretation to the user was that the display reflected the actual status of the system.
Designers need to exploit the natural mappings between the system and the expectations and
intentions of the user.
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Another example of the importance of user familiarity with the working system is demonstrated
by a laboratory study which examined how useful it was to give staff an overview of a fictitious
petrochemical plant's structure and day-to-day functioning. One group was given rules about
which buttons to press if a dangerous situation arose; another was given the rules and an
overview of the workings of the plant. Both groups were equal in their ability to deal with the
expected problems, but when new problems arose, only the group which understood the plant's
functioning were able to deal with the situation.
Managing information. As our brains are easily distracted and can overlook necessary tasks, it
makes sense to put information in the environment which will help us carry out complex tasks.
For example, omission of steps in maintenance tasks is cited as a substantial cause of nuclear
power plant incidents. When under time pressure, technicians are likely to forget to perform
tasks such as replacing nuts and bolts. A very simple solution to this problem would be to require
technicians to carry a hand-held computer with an interactive maintenance checklist which
specifically required the technician to acknowledge that certain stages of the job had been
completed. It could also provide information on task specifications if necessary. This would also
allow a reduction in paperwork and hence in time pressure.
Reducing complexity. Making the structure of tasks as simple as possible can avoid overloading
the psychological processes outlined previously. The more complex the task specifications, the
more chances for human error. Health-care systems are currently addressing this issue. With the
that a leading cause of medical error in the United States was related to errors in prescribing
drugs, a programme was undertaken to analyse and address the root causes of the problem. A
computerised system of drug selection and bar-coding reduced the load on memory and
knowledge on the part of the prescriber, and errors of interpretation on the part of the dispenser,
resulting in an overall reduction in prescription errors. Examples such as this emphasise the fact
that reducing task complexity reduces the chance of accidents.
Visibility. The user must be able to perceive what actions are possible in a system and
furthermore, what actions are desirable. This reduces demands on mental resources in choosing
between a range of possible actions. Perhaps even more important is good quality feedback
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Vision. Vision is vital in maritime activities, think of the number of activities under visual
supervision. Vision can be improved by ensuring you have appropriate environmental
conditions, like illumination of working area, and ensuring that protective eyeware is clear and
suitable for use when is necessary. An individuals lack of colour discrimination, or defective
color vision, may make it difficult to distinguish between red and green. This can lead to error in
tasks where color discrimination is necessary.
Hearing. Continuous exposure to high levels of noise can be very fatiguing. It affects cognitive
tasks such as memory recall. Whenever possible, you should try to remove or eliminate the
source of noise, rather than attempting to reduce it by such things as wearing ear protection. In
noisy environments, use appropriate communication headsets where possible, bearing in mind
that ear plugs and headsets may restrict you from hearing warnings from other team members, or
being aware of approaching hazards. If you are wearing headsets or ear defenders, exercise
caution and keep a very good lookout.
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Memory is the ability to store and retrieve information, and is part of our normal learning
process. It allows us to develop consistent responses to previously memorized data. We compare
sensory data so that we can decide what to do, based on our previous experiences. Because of
this, our memory stores are vital to the decision-making process. It is generally agreed we have
three types of memory: sensory memory, short-term memory, long-term memory.
Sensory memory. Our sensory memory only retains information for a second or two; for
example, an image or photograph may be retained briefly before it is overwritten by something
new.
Short-term memory. Our short-term memory allows us to store information long enough to use
it, hence why we often call it our working memory. Short-term memory holds information for
about 15-30 seconds. Information in short-term memory can be lost very quickly through
interference, distraction, or simply by being replaced with new information.
The short-term memory can be improved by:
Mental repetition one way to increase our ability to recall information from short-term
memory is to revise it regularly to keep it top-of-mind.
Chunking this involves putting gaps between, or grouping, three to four letters or digits.
Chunks are much easier to remember than a long, unbroken string.
Linking link the data from short-term memory to something you know from your longterm memory.
Record the data the best way to be able to ensure accurate recall from short-term
memory is to write information down for future reference.
Long-term memory. Our long-term memory enables us to store a vast amount of information. It
stores general information, factual knowledge, and memories of specific events. Long-term
memory is classified in two types, semantic memory and episodic memory.
Semantic memory. Semantic memory is our store of factual knowledge about the world, such as
learnt concepts and relationships. It does not relate to time and place, but rather refers to the rules
by which we understand the things around us. This type of memory involves knowledge
associated with data, skills, knowledge and things we are able to do for a purpose. It is our
memory for meaning. It is generally believed that once information has entered semantic
memory, it is never lost. Occasionally, it may be difficult to locate, but it is always there.
Episodic memory. Episodic memory refers to our store of events, places and times, and may
include people, objects, and places. It is almost automatic, allowing us to place our experiences
in context.
The improvement of the long-term memory can be done using:
Pre-active the knowledge think about the procedure before carrying it out. Go through
it in your mind and mentally rehearse the steps you are going to perform.
Use visual imagery to learn new information information can be remembered by
associating it with a familiar place or person. This might sound a little out there, but
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The senses can be affected by personal protective equipment, or by extremes of stimulus such as
low light or excessive noise. Before to begin any activity should consider how protective
equipment might affect whether you complete the task successfully.
Maritime activities require a reasonable standard of eyesight. To ensure good eye health, have
frequent eyesight checks. Colour discrimination is also important, especially if the tasks are to be
performed in low or poorly lit areas.
Colds, flu and ear infections can affect our hearing capability. Generally, we have poor control
over vestibular input. Use communication equipment such as headsets in noisy environments.
Continued exposure to very loud noise leads to fatigue and therefore a higher potential for error.
Our attention mechanism is limited, once its capacity is exceeded, performance will degrade. It is
important therefore, that physical and mental workloads are maintained within reasonable levels.
It can also be difficult to maintain attention for long periods on complex tasks. Think about
scheduling appropriate breaks during the task, and ensuring workload is maintained at an
appropriate level.
It is very easy for our perception to be fooled, for example through visual illusions. Our
assumptions can also lead us to an incorrect perception. One example of this is carrying out an
inspection. The person in charge is normally checking to ensure that everything is correct.
Because of this can sometimes see what expect to see. In reality, is expected to find something
wrong, rather than simply checking that everything is as expect it to be.
Effective decision making for seafarers starts with good situational awareness and a realistic
assessment of the data and/or feedback. The next step is evaluating your available options and
selecting and implementing the best/safest/most efficient option. This is not simply a one-off or
stand-alone process, but rather a continuous cycle involving the updating of situational
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Team types
Teams are complex in nature, and there is a lack of consensus around the typology of teams.
Some researchers proposed integrated teamwork skill dimensions, that is supposed to be
common for all types of teams. In general, previous research tends to share this focus on teams:
that there are factors common for all team types. This research does not distinguish between the
different types of work that teams perform, and act as if one common model is applicable for all.
However, there is reason to assume that there are different types of teams working within the
same organization or in different organizations and domains. Another study identified different
team types based on the kind of work and tasks the teams are engaged in. In different team types,
factors relevant for team performance will vary. Also was argued that there is a division between
team specific factors, team generic factors, task specific factors, and task generic factors. Team
and task generic factors are factors that can be applied across team types. Team and task specific
factors, on the other hand, depend on team type characteristics and team members.
The Big Five in teamwork Model. As previously mentioned, in different organizations there are
various types of tasks and teams. Nevertheless, was claimed that there are several common
features that facilitate teamwork across domains, team goals, and tasks. Based on this review
they derived the Big Five in Teamwork Model (Big Five model), a model that consists of five
core components of teamwork and three coordinating mechanisms (eight components). The three
coordinating mechanisms are necessary to get the optimal value of the core components.
The factors of teamwork in the Big Five model are team leadership, mutual performance
monitoring, backup behavior, adaptability and team orientation. The coordinating mechanisms
are shared mental models, mutual trust, and closed-loop communication. Some of these factors
are very similar to the factors important for safe teamwork in the shipping industry.
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Team building
With good team-building skills, you can unite employees around a common goal and generate
greater productivity. Without them, you limit yourself and the staff to the effort each individual
can make alone.
Team building is an ongoing process that helps a work group evolve into a cohesive unit. The
team members not only share expectations for accomplishing group tasks, but trust and support
one another and respect one another's individual differences. Your role as a team builder is to
lead your team toward cohesiveness and productivity. A team takes on a life of its own and you
have to regularly nurture and maintain it, just as you do for individual employees.
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The two main motivational forces are approach (seeking) and avoidance (escape). Approach is
described to be seeking intrinsic rewards, and avoidance to be escaping surrounding
environments. The main aim of this model was to emphasise how it is ineffective to categorise
factors into reasons and benefits.
According to different researchers, it might be more sensible to analyse motivational factors and
their means ends, rather than sort them into rigid motivation groups. However the basic idea
behind theories is similar: They both declare tourism motivation as combination of two basic
factors, escaping life (push) and seeking experience (pull).
Moreover, there seems to be basic needs that push consumer to initiate decision-making process.
Therefore despite the stiff motivation classification, categorising motivational factors into push
or pull group might be beneficial for an overall understanding of consumer decision-making.
However to gain a more comprehensive view on the motivational factors, the categorisation
should integrate aspects from escaping and seeking, as well as cognitive and behavioural
motivation to make the analysis constructive.
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The task analysis techniques described in the previous section are mainly oriented towards
observable actions, although Hierarchical Task Analysis allows it to address functional
requirements as well as the specific actions that are required to satisfy these requirements.
Cognitive task analysis techniques attempt to address the underlying mental processes that give
rise to errors rather than the purely surface forms of the errors. This is particularly important
where the analysis is concerned with higher level mental functions such as diagnosis and
problem solving.
As plants become more automated, the job of the process plant worker is increasingly concerned
with these functions and it is therefore necessary to develop analytical methods that can address
these aspects of plant control. For example, the worker is often required to deal with abnormal
plant states which have not been anticipated by the designer. In the worst case, the worker may
be required to diagnose the nature of a problem under considerable time stress and develop a
strategy to handle the situation. It is clearly desirable in these situations to provide appropriate
decision support systems and training to improve the likelihood of successful intervention. It is
also necessary to be able to predict the types of decision errors that are likely to occur, in order to
assess the consequences of these failures for the safety of the plant. In all of these areas, task
analysis techniques which address the covert thinking processes, as opposed to observable
actions, are necessary.
The problems associated with the analysis of cognitive processes are much greater than with
action oriented task analysis methods. The causes of cognitive errors are less well understood
than action errors, and there is obviously very little observable activity involved in decision
making or problem solving. These difficulties have meant that very few formal methods of
cognitive task analysis are available.
Despite these difficulties, the issue of cognitive errors is sufficiently important that we will
describe some of the approaches that have been applied to systems. These techniques can be
used in both proactive and retrospective modes, to predict possible cognitive errors during
predictive risk assessments, or as part of an incident investigation.
Critical Action and Decision Evaluation Technique (CADET). This method is based on the
Rasmussen step ladder model. The basic units of CADET are the critical actions or decisions
(CADs) that need to be made by the operator usually in response to some developing abnormal
state of the plant. A CAD is defined in terms of its consequences. If a CAD fails, it will have a
significant effect on safety, production or availability.
The following approach is then used to analyze each CAD. The first stage consists of identifying
the CADs in the context of significant changes of state in the system being analyzed. The
approach differs from the OAET in that it does not confine itself to the required actions in
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The Task Analysis methods described so far can be evaluated in terms of their focus on different
aspects of the human-machine interaction. To facilitate the process of selection of appropriate
Task Analysis methods for particular research interests, Figure 6.1 describes ten criteria for
method evaluation.
In general, HTA and CADET fulfill most of the ten criteria hence they can be used jointly as a
framework for carrying out both action and cognitive task analysis. Another way of classifying
the various Task Analysis methods is in terms of the application areas in which they might be
seen as most useful. Figure 6.2 provides such a classification in terms of seven human factors
applications.
It is worth pointing out that Figures 6.1 and 6.2 present only a broad qualitative classification
along a number of criteria. It is conceivable that some methods may fulfill a criterion to a greater
extent than others.
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Figure 6.1. Criteria for evaluating the sustainability of various Task Analysis methods
Figure 6.2. How to use various Task Analysis in Human Factors Applications
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7.1.
Individual errors are errors which are made by individuals. That is, an individual alone makes
an error without the participation of any other team member. Individual errors may be further
sub-divided into independent errors and dependent errors. Independent errors occur when all
information available to the perpetrator is essentially correct. In dependent errors, however, some
part of this information is inappropriate, absent or incorrect so that the person makes an error
unsuitable for a certain situation.
Shared errors - are errors which are shared by some or all of the team members, regardless of
whether or not they were in direct communication. Like individual errors, shared errors may also
be sub-divided into two categories: independent and dependent.
7.2.
The error recovery process may fall into any one of three stages: detection, indication and
correction.
1. Failure to detect the first step in recovering errors is to detect their occurrence. If the
remainders of the team do not notice errors, they will have no chance to correct them. Actions
based on those errors will be executed.
2. Failure to indicate once detected, the recovery of an error will depend upon whether team
members bring it to the attention of the remainder. This is the second barrier to team error
making. An error that is detected but not indicated will not necessarily be recovered and the
actions based on those errors are likely to be executed.
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Performance Shaping Factors and their estimation. The next question is why team errors are
made. An error is usually the result of some influencing factors which are called Performance
Shaping Factors.
Generally, there are two kinds of Performance Shaping Factors: External Performance Shaping
Factors and Internal Performance Shaping Factors. These to kinds are probably enough to
discuss why individuals made human errors. However, as described before, most human work is
performed by teams rather than individuals. Especially when the remainder of a team failed to
indicate or correct individual or shared errors in spite of their notices, there must have been
influences of human relations between them. For that, has identified three classes of Performance
Shaping Factors: external, internal and team performance shaping factors.
External Performance Shaping Factors are, for example, darkness, high temperature, excessive
humidity, high work requirement. These factors are shared by people working within the same
working environment.
Internal Performance Shaping Factors include high stress, excessive fatigue, deficiencies in
knowledge, skills and experience. There are ideas that the internal Performance Shaping Factors
are results of external Performance Shaping Factors. Although internal Performance Shaping
Factors are not necessarily independent of external Performance Shaping Factors, the adverse
impact of an external Performance Shaping Factors depends, in part, upon the individual.
Team Performance Shaping Factors are defines as factors arising from a group of people
working together on a common project or task. They include lack of communication,
inappropriate task allocation, excessive authority gradient, over-trusting and others. It could be
argued that team Performance Shaping Factors is a subset of internal Performance Shaping
Factors. However, it is believed that the purposes of this study are better served by treating them
as separate categories.
Relations between Performance Shaping Factors and Team Errors. In order to identify why
teams make team errors, it is probably best to see the relation to the categories defined earlier. As
describe above, the data have biases so that some categories are largely unrepresented.
Accordingly, we will focus upon the relations between Performance Shaping Factors and
individual errors, shared errors, failures to detect or failure to indicate and correct combined.
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External
Performance
Shaping Factors
Seriousness
Deficiency
in
human
machine interface
High workload
Deficiency in procedures
Deficiency in training
High level activity
Routine task
Regulation
Time pressure
Insufficient visibility
Others
Shared errors
Individual errors
21
24
20
16
9
9
6
6
3
3
3
4
7
19
8
7
4
0
0
4
2
24
Total
100(%)
100(%)
Table 7.1. . External Performance Shaping Factors observed in the shared and individual errors
Table 7.1 shows the external Performance Shaping Factors associated with shared errors and
individual errors. Major differences were not found between the external Performance Shaping
Factors provoking the shared and the individual errors. This table suggests that deficiencies in
the human machine interface exert a larger influence upon shared errors.
Shared errors and internal Performance Shaping Factors. Table 7.2 shows the internal
Performance Shaping Factors associated with shared errors and individual errors. Low
situational awareness, low task awareness and excessive adherence (on their own ideas, opinion,
decisions, actions)/over-reliance (on indicators, warnings) are observed more frequently in the
shared errors than in the individual errors.
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Shared errors
Individual errors
22
21
20
16
17
22
6
8
13
3
3
2
4
18
6
19
Total
100(%)
100(%)
Table 7.2. Internal Performance Shaping Factors observed in the shared and individual errors
Team PSFs
Deficiency
in
communication
Excessive belief
Excessive professional
courtesy
Excessive
authority
gradient
Friendship
Deficiency
in
resource/task
management
Organizational factors
Subtotal
TOTAL
External PSFs
Seriousness
Deficiency in human
machine interface
High workload
Deficiency
in
procedures
Deficiency in training
High level activity
Routine task
Regulation
Time pressure
Insufficient visibility
Others
Subtotal
%
9
Internal PSFs
High arousal
7
Deficiency
in
6
knowledge/
7
experience
4
6
Low
situation
awareness
2
4
Low
task
2
awareness
4
Excessive
2
adherence/over2
2
reliance
1
1
Inadequate
1
attitude
1
Low confidence
1
Others
24
38
Subtotal
100%
Table 7.3. Team Performance Shaping Factors in the shared errors
%
9
9
7
6
4
1
1
1
38
Table 7.3. shows Performance Shaping Factors observed in the shared errors. Earlier, we argued
that shared errors are defined as errors shared by some or all members, regardless of whether or
not they were in direct communication. Therefore, we expected that the influences of team
Performance Shaping Factors observed in the shared errors are very small. Deficiencies in
communication and excessive belief have the equivalent percentages to some external and
internal Performance Shaping Factors.
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External
%
Performance
Shaping Factors
Seriousness
8
High workload
5
Distance
4
Duty hours
4
Deficiency
in
training
1
Internal
Performance
Shaping Factors
High arousal
Low
task
awareness
Deficiency
in
knowledge/
experience
Team Performance %
Shaping Factors
11
Deficiency
in
communication
Excessive belief
Deficiency
in
resource/
task
management
Excessive authority
gradient
Excessive
professional courtesy
Over-trusting
Air of confidence
Friendship
Organizational
factors
Subtotal
14
9
9
6
5
5
4
2
1
Subtotal
22 Subtotal
23
55
TOTAL
100 %
Table 7.4. External, Internal and Team Performance Shaping Factors observed in team errors
with failure to detect
Table 7.4 lists observed Performance Shaping Factors surrounding the remainder of teams who
failed to detect errors. In most cases, the remainder of a team was in the common situation where
the people made errors. The analysis found some external and internal Performance Shaping
Factors which were found in shared and individual errors as well. The most common team PSF is
deficiency in communication.
7.6.
Table 7.5 lists the observed Performance Shaping Factors surrounding the remainder of teams
who detected errors but failed to indicate or correct them. This table does not show major
differences in external Performance Shaping Factors. Important differences in internal
Performance Shaping Factors were observed in this table. Low task awareness and low
situational awareness disappeared in the failures to indicate/correct and the ratio of high arousal
increased. This table suggests that arousal levels and low confidence make significant
contributions to the indication and correction of errors.
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Internal
Performance
Shaping Factors
High arousal
Low confidence
9
2
24
9
9
7
2
2
2
Subtotal
34 Subtotal
11 Subtotal
55
TOTAL
100 %
Table 7.5. External, Internal and Team Performance Shaping Factors observed in team errors
with failures to indicate/correct
7.7.
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In a recent human factors study, the US Office of Marine Safety, Security and Environmental
Protection and the Office of Navigation Safety and Waterway Services found that fatigue was
among the top three causes of marine accidents.
In an Australian report that analyzes reporting methodologies and the relationship between
sleep, fatigue, and accidents in Incident at Sea Reports was found that 86% of the reports
analyzed made some reference to sleep, although many of these references described sleep loss
as a way of life onboard ships rather than as a direct causal factor. Thirty-nine per cent of the
reports considered sleeping or sleepiness as a contributing causal factor. The report noted
that accident investigators were able to identify sleep loss as a critical factor in cases where
there was a "frank-sleep" episode (e.g. watchstander fell asleep) but had a harder time
identifying the more subtle deficiencies in cognition and judgment that resulted from
fragmented or deficient sleep. In the same study was developed a diagram to describe the
relationship between fatigue, sleep and accidents and recommended additional study to "identify
and quantify the manifestations of fatigue other than that of reduced alertness."
Although there is an emerging recognition that neurobiologically based sleepiness or fatigue
contributes to human error as a root cause of many accidents in industrialized, technologyrich societies, the concept of fatigue does not have a clear definition. Thus, prevalence data
are always dependent on the particular definition used.
The International Maritime Organization has, however, formulated a definition of fatigue in
which fatigue is conceptualized as a 'reduction in physical and/or mental capacity as the result
of physical, mental, or emotional exertion which may impair nearly all physical abilities
including: strength, speed, reaction time, coordination, decision making or balance'. The
International Maritime Organization thus acknowledges the relation between fatigue and
human error as indicated above.
Fatigue can be divided into categories in many different ways. However, systematic studies
seem to find between three and five dimensions, including general fatigue (tired, bushed,
exhausted), mental fatigue (cognitive impairment), physical fatigue, and sleepiness (tendency
to fall asleep), and sometimes motivation or lack of activity.
The distinction between acute fatigue and cumulative or chronic fatigue may be an
interesting one with regard to prevention. Acute fatigue is limited to the effects of a single
duty period, such as a 9 to 5 hours working day, which may result in a micro sleep (just
being away for a split second) or actually falling asleep. Cumulative fatigue occurs when
there is inadequate recovery between these duty periods. Thus, cumulative fatigue usually
presents a picture of day-to-day changes for the worse. It is clear that causal factors as well as
preventive measures may be very different, dependent on the type of fatigue. In order to
actually fall asleep, one often is chronically fatigued and has accumulated a sleep deficit
over time. Chronic fatigue therefore, is considered to be a precursor of acute fatigue, but
environmental factors may additionally be important. Falling asleep will occur sooner when
the tasks and working conditions are dull, monotonous, and when the temperature is high.
On the other hand, it is unlikely to fall asleep in a hectic environment, and when a lot of
activity takes place. Ergonomic equipment, machines and software that is designed according
to ergonomic standards may also limit negative consequences when the seafarers behavior is
impaired due to fatigue.
The situation of managing chronic fatigue is quite different from that of managing acute
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Task demands
Health consequence
Physical
Environmental
Mental
Perceptual
Coping capacity
Health problems
Life style
Concentration
problems
Fatigue
Effect on
performance/behavior
Mistakes
Fires
Occupational
accidents
Collisions/
groundings
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Physical load
Environmental load
Mental load
Perceptual load
Energetic load
Lifting
Carrying
Pushing
Pulling
Static load
Repetitive
movements
Skin
Smell, type of material
Sensation temperature
Hearing damage, noise
Vibration
protective,
clothing, safety means
Aggression
Tension
Human suffering
Time pressure
Irregular/continuous work
Uncomplete job
Short cycled tasks
Decision latitude/
autonomy
Opportunities for contact
Alertness
Perception
Concentration
Assessment
Reaction time
Causes of fatigue. According to a report published in 2004, the causes of collisions and
groundings can be classified into three categories:
Watch keeping: no proper Look Out, or sailing too speedy.
Navigation: improper preparation of the journey, improper organization at the
bridge.
The manning system: No Look Out, fatigue.
With respect to the causes of fatigue, the International Maritime Organization adopts a much
broader view, and states that: It must be recognized that the seafarer is a captive of the work
environment. Firstly, the average seafarer spends between three to six months working and
living away from home, on a moving vessel that is subject to unpredictable environment
factors (i.e. weather conditions). Secondly, while serving on board the vessel, there is no
clear separation between work and recreation. Thirdly, todays crew is composed of
seafarers from various nationalities and backgrounds who are expected to work and live
together for long periods of time. All these aspects present a unique combination of potential
causes of fatigue.
Additionally, the majority of ships now spend less than 24 hours in port. Time in port was
traditionally a time for crews to rest ashore prior to leaving port. In many cases crews are
now expected to unload/load a vessel, prepare the vessel to sail and then sail the vessel from
port all within a very short time frame. Demands for quick turnaround times for ships in port,
combined with inadequate crew levels, clearly have the potential to present a significant
fatigue risk for crews, particularly those who have been engaged in loading and unloading
duties.
In a recent study was stated that in comparison to other freight transportation modes, merchant
shipping is characterized by longer than average working weeks, non-standard 'work days',
extensive night operations, and periods of intense effort, pre- ceded by periods of relative
inactivity. They arrange the causes of fatigue in this trade into:
Organizational factors (relating to how ships are managed, crew continuity, work
rules, paperwork etc.).
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Two-shift system
Three-shift system
Differences of shift system according to job at
sea-versus-in harbor
3
Shift system unknown
12
6
Total
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13
Table 8.2. An overview of the two and three shift system and the attribution
of fatigue as a cause of the maritime accidents
Issues that came forward in those 13 cases where fatigue played a role were no mandatory
look-out, falling asleep/being absent for a while, no watch alarm was set, and no proper
navigation. Alcohol was involved on several of these occasions as well.
Other aspects that played a (causal) part in the collisions and groundings studied were:
no proper preparation of the voyage;
no proper manning of the bridge;
no proper outlook;
not a proper navigation;
insufficient communication with other ships;
too high speed at restricted view.
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9.1.
The maritime system is a people system (Figure 9.1). People interact with technology, the
environment, and organizational factors. Sometimes the weak link is with the people
themselves; but more often the weak link is the way that technological, environmental, or
organizational factors influence the way people perform. Lets look at each of these factors.
Environment
Technology
Organization
First, the people. In the maritime system this could include the ships crew, pilots, dock
workers, Vessel Traffic Service operators, and others. The performance of these people will be
dependent on many traits, both innate and learned (Figure 9.2).
As human beings, we all have certain abilities and limitations. For example, human beings are
great at pattern discrimination and recognition. There isnt a machine in the world that can
interpret a radar screen as well as a trained human being can. On the other hand, we are fairly
limited in our memory capacity and in our ability to calculate numbers quickly and accurately-machines can do a much better job. In addition to these inborn characteristics, human
performance is also influenced by the knowledge and skills we have acquired, as well as by
internal regulators such as motivation and alertness.
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K n o w le d g e
S k ills
A b ilitie s
M e m o ry
M o tiv a tio n
A le r tn e s s
The design of technology can have a big impact on how people perform (Figure 9.3). For
example, people come in certain sizes and have limited strength. So when a piece of equipment
meant to be used outside is designed with data entry keys that are too small and too close
together to be operated by a gloved hand, or if a cutoff valve is positioned out of easy reach,
these designs will have a detrimental effect on performance. Automation is often designed
without much thought to the information that the user needs to access. Critical information is
sometimes either not displayed at all or else displayed in a manner which is not easy to interpret.
Such designs can lead to inadequate comprehension of the state of the system and to poor
decision making.
Anthropometry
Equipment layout
Perception &
comprehension
Information display
Decision-making
Maintenance
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Temperature, noise
Sea state, vibration
Regulations
Economics
Finally, organizational factors, both crew organization and company policies, affect human
performance (Figure 9.5). Crew size and training decisions directly affect crew workload and
their capabilities to perform safely and effectively. A strict hierarchical command structure can
inhibit effective teamwork, whereas free, interactive communications can enhance it. Work
schedules which do not provide the individual with regular and sufficient sleep time produce
fatigue. Company policies with respect to meeting schedules and working safely will directly
influence the degree of risk-taking behavior and operational safety.
As you can see, while human errors are all too often blamed on inattention or mistakes on
the part of the operator, more often than not they are symptomatic of deeper and more
complicated problems in the total maritime system. Human errors are generally caused by
technologies, environments, and organizations which are incompatible in some way with optimal
human performance. These incompatible factors set up the human operator to make mistakes.
So what is to be done to solve this problem? Traditionally, management has tried either to cajole
or threaten its personnel into not making errors, as though proper motivation could somehow
overcome inborn human limitations. In other words, the human has been expected to adapt to
the system. This does not work. Instead, what needs to be done is to adapt the system to the
human.
The discipline of human factors is devoted to understanding human capabilities and limitations,
and to applying this information to design equipment, work environments, procedures, and
policies that are compatible with human abilities. In this way we can design technology,
environments, and organizations which will work with people to enhance their performance,
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W o rk s c h e d u le s
F a tig u e
C re w c o m p le m e n t
K n o w le d g e & s k ills
T ra in in g
W o rk p ra c tic e s
C o m m u n ic a tio n
T e a m w o rk
S a fe ty c u ltu re
R is k -ta k in g
9.2.
What are some of the most important human factors challenges facing the maritime industry
today? A study by the United States Coast Guard found many areas where the industry can
improve safety and performance through the application of human factors principles. The three
largest problems were fatigue, inadequate communication and coordination between pilot and
bridge crew, and inadequate technical knowledge (especially of radar). Below are summaries of
these and other human factors areas that need to be improved in order to prevent casualties.
Fatigue. Fatigue has been cited as the number one concern of mariners in two different
studies. A new study has objectively substantiated these anecdotal fears: in a study of critical
vessel casualties and personnel injuries, it was found that fatigue contributed to 16% of the
vessel casualties and 33% of the injuries. More information on fatigue and how to prevent or
reduce it can be found in subsequent chapters in this book.
Inadequate Communications. Another area for improvement is communications between
shipmates, between masters and pilots, ship-to-ship, and ship-to-VTS. Is stated that 70% of
major marine collisions and allisions occurred while a State or federal pilot was directing one or
both vessels. Better procedures and training can be designed to promote better communications
and coordination on and between vessels. Bridge Resource Management (BRM) is a first step
towards improvement.
Inadequate General Technical Knowledge. In one study, this problem was responsible for 35%
of casualties. The main contributor to this category was a lack of knowledge of the proper use of
technology, such as radar. Mariners often do not understand how the automation works or under
what set of operating conditions it was designed to work effectively. The unfortunate result is
that mariners sometimes make errors in using the equipment or depend on a piece of equipment
when they should be getting information from alternate sources.
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10.1.
Safety culture
Since organizational errors and failures are cited as important components of human factors,
prevention measures that seek to improve both individual and organizational attitudes and
policies toward safety are considered an important component of spill prevention. The term
safety culture has been used to describe an organizational environment that promotes selfregulation by ensuring that each individual within the organization takes responsibility for
actions to improve safety and performance. This requires active support and encouragement at
all levels of an organization, from the very top management levels down to the equipment
operators.
A major initiative, known as Prevention through people, has been implemented to address
human factors in oil spills and accidents and promote a safety culture within companies and
across the industry. According to the United Stated Coast Guard, Prevention through people is
a people - focused approach to marine safety and environmental protection that
systematically addresses the root cause of most accidents: the human element.
This approach recognizes that safe and profitable operations require the constant and balanced
interaction between the management, the work environment, the behavior of people, and the
appropriate technology. People through people itself promotes a cultural change within a
company to improve their safety posture.
Importance of management and organizational factors. In a study of safety culture and
accidents the authors consider the relative importance of accident prevention measures that
influence individual behavior vs. organizational culture and find that improvements to the safety
culture at the organizational level lead to more significant reductions in accident occurrence
rates and severity.
In order to counter the phenomenon of iron men, organizations must be attuned to the
attitudes onboard vessels, which can be difficult due to physical distance and separation.
Informal reward systems for safe behavior and negative consequences for risk-taking can help to
overcome at least part of the iron men culture. Social approval or disapproval of peers is a
powerful contributor to human behavior; however, it requires significant and ongoing efforts on
the part of organizations to affect such an informal rewards system.
A safety culture can be enhanced if management reacts to accidents by considering the
organizational policies, both overt and implied, that may have contributed to the operator errors.
Similarly, when management sets time or budget constraints, they must consider whether
operators may be inadvertently encouraged to cut corners or violate safety policies in order to
meet those constraints. Productivity and safety often conflict in the short term; therefore,
organizations should offer active incentives that back up stated safety policies.
In the study of organizational safety across industries, researchers have considered high
reliability organizations, which are defined as organizations that are involved in dangerous
operations, such that failure in the operation results in severe consequences. High reliability
organizations have, over long periods of time, had very few accidents.
Five attributes have been identified that characterize high reliability organizations: process
auditing; appropriate reward systems; high standards of quality; appropriate risk perception; and
command and control functions. These principals generally align with the findings regarding
safety cultures.
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Situational awareness
The simple view about situational awareness is that it basically involves paying attention to your
surroundings. Commentators on the subject suggest that having good situational awareness
allows us to respond faster to changing circumstances, by knowing what is going on around us
and predicting how things will change.
From the maritime perspective, can define situational awareness as:
the accurate perception of the factors and conditions affecting the safe operation of the ship,
now and in the future.
Developing situational awareness. To develop situational awareness throughout a task, involved
personnel must:
Start off with a full and accurate knowledge of the situation and the environmental status;
Consider what they intend to do, and in particular, how appropriate that is in the given
circumstances;
Think about how what they intend to do will affect or change the environment and other
personnel working around.
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There is well-established research both in the maritime and other hazardous industries that
confirms the huge impact of leadership on the safety of operations. Whilst the International
Safety Management (ISM) code has been a major step forward in improving safety standards, its
effectiveness depends heavily on how leaders approach its implementation, and this in turn
depends heavily on the skills and qualities of leaders both at sea, at the ship-shore interface,
and on-shore.
Virtually all maritime leaders want to do their best for safety, this is not in doubt. But sometimes
real life makes things difficult time pressures, economic constraints and everyday
circumstances sometimes seem to conspire against good safety leadership.
12.1. The ten core safety leadership qualities
A.
Confidence and Authority
1. Instill respect and command authority
2. Lead the team by example
3. Draw on knowledge and experience
4. Remain calm in a crisis
B.
Empathy and Understanding
5. Practise tough empathy
6. Be sensitive to different cultures
7. Recognise the crews limitations
C.
Motivation and Commitment
8. Motivate and create a sense of community
9. Place the safety of crew and passengers above everything
D.
Openness and Clarity
10. Communicate and listen clearly
Instill respect and command authority. The ability to instill respect from, and command
authority over, the crew is probably the first thing that comes to mind when people think of
leadership.
In many ways it happens on its own when you get everything else right.
Leaders get respect and command authority when crews believe that you:
Are willing to exercise the power vested in your position
Possess the necessary knowledge and competence
Understand their situation and care about their welfare
Are able to communicate clearly
Are prepared to act confidently and decisively.
Without authority and respect it is difficult for leaders to influence the behaviour of their crews,
including safety-related behaviour. Crews may establish their own individual or group values,
attitudes and behaviours, or else follow other de-facto leaders lower down in the hierarchy. This
can lead to poor compliance with standards and excessive risk-taking.
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Organizational behavior is a misnomer. It is not the study of how organizations behave, but
rather the study of individual behavior in an organizational setting. This includes the study of
how individuals behave alone, as well as how individuals behave in groups.
The purpose of organizational behavior is to gain a greater understanding of those factors that
influence individual and group dynamics in an organizational setting so that individuals and the
groups and organizations to which they belong may become more efficient and effective. The
field also includes the analysis of organizational factors that may have an influence upon
individual and group behavior. Much of organizational behavior research is ultimately aimed at
providing human resource management professionals with the information and tools they need to
select, train, and retain employees in a fashion that yields maximum benefit for the individual
employee as well as for the organization.
Organizational behavior is a relatively new, interdisciplinary field of study. Although it draws
most heavily from the psychological and sociological sciences, it also looks to other scientific
fields of study for insights. One of the main reasons for this interdisciplinary approach is because
the field of organizational behavior involves multiple levels of analysis, which are necessary to
understand behavior within organizations because people do not act in isolation. That is, workers
influence their environment and are also influenced by their environment.
Individual level of analysis. At the individual level of analysis, organizational behavior
involves the study of learning, perception, creativity, motivation, personality, turnover, task
performance, cooperative behavior, deviant behavior, ethics, and cognition. At this level of
analysis, organizational behavior draws heavily upon psychology, engineering, and medicine.
Group level of analysis. At the group level of analysis, organizational behavior involves the
study of group dynamics, intra- and intergroup conflict and cohesion, leadership, power, norms,
interpersonal communication, networks, and roles. At this level of analysis, organizational
behavior draws upon the sociological and socio-psychological sciences.
Organization level of analysis. At the organization level of analysis, organizational behavior
involves the study of topics such as organizational culture, organizational structure, cultural
diversity, inter-organizational cooperation and conflict, change, technology, and external
environmental forces. At this level of analysis, organizational behavior draws upon anthropology
and political science.
Other fields of study that are of interest to organizational behavior are ergonomics, statistics, and
psychometrics.
A number of important trends in the study of organizational behavior are the focus of research
efforts. First, a variety of research studies have examined topics at the group level of analysis
rather than exclusively at the individual level of analysis. For example, while empowerment has
largely been investigated as an individual-level motivation construct, researchers have begun to
study team empowerment as a means of understanding differences in group performance. Similar
research has focused on elevating the level of analysis for personality characteristics and
cooperative behavior from the individual level to the group level.
Another research trend is an increasing focus on personality as a factor in individual- and grouplevel performance. This stems from the movement toward more organic organization designs,
increased supervisory span of control, and more autonomous work designs. All of these factors
serve to increase the role that personality plays as a determinant of outcomes such as stress,
cooperative or deviant behavior, and performance.
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Today, teams and organizations face rapid change like never before. Globalization has increased
the markets and opportunities for more growth and revenue. However, increasingly diverse
markets have a wide variety of needs and expectations that must be understood if they are to
become strong customers and collaborators. Concurrently, scrutiny of stakeholders has increased
as some executives have been convicted of illegal actions in their companies, and the
compensation of executives seems to be increasing while wages of others seems to be decreasing
or leveling off. Thus, the ability to manage change, while continuing to meet the needs of
stakeholders, is a very important skill required by today's leaders and managers.
Significant organizational change occurs, for example, when an organization changes its overall
strategy for success, adds or removes a major section or practice, and/or wants to change the
very nature by which it operates. It also occurs when an organization evolves through various
life cycles, just like people must successfully evolve through life cycles. For organizations to
develop, they often must undergo significant change at various points in their development.
That's why the topic of organizational change and development has become widespread in
communications about business, organizations, leadership and management.
Leaders and managers continually make efforts to accomplish successful and significant change
-- it's inherent in their jobs. Some are very good at this effort (probably more than we realize),
while others continually struggle and fail. That's often the difference between people who thrive
in their roles and those that get shuttled around from job to job, ultimately settling into a role
where they're frustrated and ineffective. There are many schools with educational programs
about organizations, business, leadership and management. Unfortunately, there still are not
enough schools with programs about how to analyze organizations, identify critically important
priorities to address (such as systemic problems or exciting visions for change) and then
undertake successful and significant change to address those priorities.
Organizational change is undertaken to improve the performance of the organization or a part of
the organization, for example, a process or team.
To really understand organizational change and begin guiding successful change efforts, the
change agent should have at least a broad understanding of the context of the change effort. This
includes understanding the basic systems and structures in organizations, including their typical
terms and roles. This requirement applies to the understanding of leadership and management of
the organizations, as well.
Organizational change should not be conducted for the sake of change. Organizational change
efforts should be geared to improve the performance of organizations and the people in those
organizations. Therefore, it's useful to have some understanding of what is meant by
"performance" and the various methods to manage performance in organizations.
The past few decades have seen an explosion in the number of very useful tools to help change
agents to effectively explore, understand and communicate about organizations, as well as to
guide successful change in those organizations. Tools from systems theory and systems thinking
especially are a major breakthrough. Even if the change agent is not an expert about systems
theory and thinking, even a basic understanding can cultivate an entire new way of working.
The field of Organization Development is focused on improving the effectiveness of
organizations and the people in those organizations. Organization Development has a rich history
of research and practice regarding change in organizations. Why not learn from that history?
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