Why do people make mistakes?

Aug 04, 2010, 3:53PM EST
Mistakes cause accidents. That is the inevitable sequence of events and we humans are the people making the mistakes, but why? What are the reasons that people make mistakes? NK’s guidelines covers how to prevent them, it focused mainly on design of equipment and operator training. Why people make mistakes? - some opinions and answers were given during the June 2010 Members Day of the marine insurance organization Swedish Club. Firstly the world crew shortage estimated at 50,000 seafarers isn’t helping the industry. Good relations, communication and training are conducive to people making the right decisions yet having the confidence to challenge questionable decisions. Capt Gustav Groenberg of Star Cruises, Malaysia pointed out the importance of recruiting the right people, offering them good working conditions to motivate and retain them. Peter Groenwoldt, MD of Harren & Partner Ship Management, Bremen’s opinion is that the reason for a mistake is always, without exception, human error caused by: lack of or poor training, ignorance or an over estimation of their skill and experience. Martin Hernqvist, MD of the Swedish Club Academy touched on the sensitive issue of culture on the individual’s ability to challenge mistakes and unsafe acts quoting the Power Distance Index as a measure of different cultures and their behavior.

Mistakes cause accidents. That is the inevitable sequence of events and we humans are the people making the mistakes, but why? What are the reasons that people make mistakes? Following on from my earlier blog on accidents and NK’s guidelines how to prevent them, it focused mainly on design of equipment and operator training. This blog looks into the subject of why people make mistakes? Some opinions and answers were given during the June 2010 Members Day of the marine insurance organization Swedish Club.

Firstly the world crew shortage estimated at 50,000 seafarers isn’t helping the industry. Good relations, communication and training are conducive to people making the right decisions yet having the confidence to challenge questionable decisions. One of the four panelists Rob Grool, MD of Wallem Shipmanagement, Hong Kong said that , “crews must feel that they can always call for help and the only stupid questions is the one you dare not ask!”

Capt Gustav Groenberg of Star Cruises, Malaysia pointed out the importance of recruiting the right people, offering them good working conditions to motivate and retain them. “A high staff turnover is a serious threat to safety,” he said. Commenting on the lower casualties involving cruise ships he said, “many cruise companies have adopted the pilot co-pilot system for their bridge operations and have implemented Standard Operating Procedures that are designed to reduce the risk of a ‘one person error’ accident. These SOPs have been developed to detect and trap an error before it leads to serious consequences. Errors are acceptable but negligence or carelessness is not!”

Peter Groenwoldt, MD of Harren & Partner Ship Management, Bremen is in no doubt as to why people make mistakes. His opinion is that the reason for a mistake is always, without exception, human error caused by one of the three reasons: lack of or poor training, ignorance or an over estimation of their skill and experience. He continued, “we see too many crew members who obviously got their licenses and certificates under the Christmas tree ….. and who pass medical examinations (when) seriously ill (yet are) testified fit for service.

Martin Hernqvist, MD of the Swedish Club Academy touched on the sensitive issue of the influence of culture on the individual’s ability to challenge mistakes and unsafe acts quoting the Power Distance Index as a measure of different cultures and their behavior.
Following a question and answer session the meeting was closed by Lars Rhodin, MD of the Swedish Club.
 
 
 
Filed under: Club, error, human, mistakes, Swedish
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Comments
Jeff Cowan
A mariner shortage? How about -"If you pay them, they will come!" Lets face it, its not easy getting all of the required classes and/or certifications. Then to be away from the wife and home.... There are other jobs that pay almost as much for entry level so why put up with the grief in this zero tolerance shipping culture?
8/4/2010 4:30:57 PM
 
Chris Parker
I must adamantly disagree with the conclusions of this article and specifically the opinion that "the reason for a mistake is always, without exception, human error caused by one of the three reasons: lack of or poor training, ignorance or an over estimation of their skill and experience." I could not disagree more. Human Factors Engineering (HFE) research has shown that poor design is most often the root of human error. Understanding the user needs and principles of human behavior must be reflected in design and then training and organizational factors are there to supplement and further encourage desired behavior but will not illicit the greatest impact on error prevention. Nor should training be relied upon as the single source of directing a preferred behavior. We must stop holding the operators and users accountable for natural behaviors that result from poor design.
8/5/2010 11:59:55 AM
 
Daniel Fontenot
There are indeed mistakes made at many different levels, from operational man power whom provide the physical and mental needs, thru middle management, all they way up to upper management whom choose, make the choices and selections. Also it is possible that equipment manufacturing, construction of and application of the same, could indeed be relevant in regards the direct cause of the mistake/problems as well. It is also noted that poor quality equipment or the lack of the proper equipment would also have a direct effect on the vessels ability, as well as the crews. It seems that at times decission makers mental ability/knowledge often clouds and often over rules the possibility for a more knowledgeable, wiser out come. Even the best sea salted operators have to deal with the equipment and conditions they are given to operate in. Mature knowledgeable adult communication about relevant matters would work wonders for making needed corrections and resolvement of issues. Sometimes even actual cost will be the reason to turn a blind eye, until lawyers arrive for libility issues/matters. Taking the time to do real, quality and factual discovery to make the best choices, would be most productive. Consider and compare the relevant issues. If a better plan is available, take the time to try it out, before it is shut down and tossed in the can. There are systems/knowledge available to help, assist and improve operations as well as the equipment, all while saving operational cost and profits. There are still a few experienced, quality, knowledgeable seaman around. There are younger seaman that in time, with proper training will also possess that desired knowledge/experience needed to lead. There are also many whom claim to know volumns, yet have no or lettle hands on experince at all. However, if one does choose not to select the quality that is available nor ask for something that would work better, who really suffers most. Locating the core problem must be paramount and corrected first, before anything positive, productive and constructive can be reached. As one knows, many of the core problems are in places of control and making those changes could be the 600lb gorilla.
8/5/2010 7:14:16 PM
 
Keith Henderson
Chris, these words were quotations from others not my own opinion! As my earlier blog based on the NK Report showed, poor design is a major if not the major contributor to accidents. No matter how well designed an item is, if the operator doesn't know how to use it, then misuse is inevitable and that's when accidents occur. Secondly, is the equipment being properly maintained? Training is just another part of the story, if it's equipment that is seldom used, people forget, crews change, so is there documentation - a manual, readily available in a language the crews understand? Accidents don't normally happen because of one thing going wrong, it is a combination of circumstances. Vigilance at all levels goes a long way to eliminating mistakes and reducing accidents.
8/16/2010 9:13:49 AM
 

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