Take 10 #13: Error management
In this issue of The Navigator, we look at the crucial area of error management and learning how to minimise our mistakes.
1 To err is human…
We all make errors. It is part of our human nature – and, on a positive note, how we learn and gain wisdom. However, it’s best if human errors are caught before they cause accidents.
2 Managing mistakes
Once it’s recognised that it is natural for humans to make errors, a management strategy should be considered. Training, skills, competency and procedures are essential, but so is a plan for ‘capturing’ error as they occur.
3 Call for back-up
It is claimed that having two professionals agreeing a decision can improve safety by a factor of 10 (reduction of single person error). When in doubt, call the Master!
4 Look out for your look-outs
Look-outs, or ‘bridge assistants’, are a vital aspect of error management. A well-trained and respected look-out can be invaluable in helping to identify risk and capturing human error, particularly if you are the sole officer on watch.
5 All available means
Professional navigators will use ‘all available means’ to manage errors. This should include knowledge, skills, common sense, teamwork and technology.
6 Happy talk
Good communication is key within a bridge team for managing error. Good language skills, closed-loop communication techniques, the use of hand signals for rudder commands and even the verbalisation of actions when alone will all help improve safety.
7 Risk factors
Errors are more likely when there is fatigue, distraction, complacency, unusually high or low workload and so on. Good passage planning should identify these risks and introduce contingency plans.
8 Plan to fail
Navigators must be alert to ‘single point failures’ of equipment that can lead to errors. They must continually use both proactive and reactive techniques to monitor the plausibility of technically derived information. Do visual clues agree with radar/ECDIS or vice versa?
9 More than words
When things are going wrong, people often perceive this before they voice their concerns. A professional navigator can often pick up ‘concerns’ in body language from any member of the bridge team, including the helmsman, OOW, Master or Pilot. Trust your instinct – never underestimate the contribution you can make!
10 Pass it on
Learning the art of error management is an ongoing task. Reflect on it often and pass on your wisdom to others. Your life and career may depend on it one day. Don't forget to share this and other issues of The Navigator.