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1 INTRODUCTION
The safety performance of marine transportation is
enormously significant since it affects humans,
societiesandnaturalenvironmentglobally(Anderson
2003). Despite safeguards, barriers and defences
developed by modern technologies, the maritime
accidents continue to occur, and their investigations
arerequiredinordertounderstandhowtheydevelop
and
toundertakemeasureswhichcouldpreventthem
(Cassama, 2015). Analyses of maritime accidents
show that human failure, inadvertent or deliberate
unsafe act, is the most common contributing factor
(Baalisampang et al., 2018; Batalden and Sydnes,
2014). Therefore significant efforts by various
stakeholders in maritime industry have been put to
decrease
human and organisational error (Valdez
BandaandGoerlandt,2018).However,thehistoryof
maritime safety is characterized by prescriptive
standards and reactive approaches (Schröder‐
Hinrichsetal.,2016).
The complexity of human and organizational
factors in shipping calls for proactive approach in
maritime safety, such as adopting the 2010 Manila
Amendments
to the STCW Convention (Schröder‐
Hinrichs et al., 2013). Among numerous changes
resultingfromtechnologicaldevelopmentofmodern
ships, human element‐related changes were
introduced(IMO2011). Tobuildimportant
nontechnical skills new requirements related to
traininginleadershipandteamworkwereadopted.
Teams are considered to be more
efficient in
tackling tasks and offer greater adaptability,
productivityandcreativitythanindividuals(Xyrichis
and Ream, 2008). Recognizing the special
competenciesandtalentsofeachindividualemployee
(Pantouvakis and Karakasnaki, 2018) and assigning
appropriate tasksenables improving team work.
Team performance depends on team characteristics
such as familiarity (the level of
knowledge team
members hold about one another), virtuality (extent
of coordination and communication via electronic
Problems that Occur in a Team: Learning From
Maritime Accidents via Simulation Training
M.Barić,J.Čulin&T.Bielić
UniversityofZadar,Zadar,Croatia
ABSTRACT:Despitetheeffortsofallstakeholdersmaritimeaccidentsstilloccur,mostcommonlycausedby
human failure. Efficient team work is a vital tool in preventing occurrence or rectifying the errors and
violations.ThereforeBridgeResourceManagementcoursefocusesondevelopingandsustainingworkteams.
Unfortunately,
teamworkcanbehamperedbymanyfactors,includingpoororganisation,culturaldifferences,
improperattitudesandbehaviours,asshownbyanalysisofmanyaccidentsanditisimportanttoaddressthese
issuesduringtrainings.Asastartingpointforadiscussionsimulationtrainingcanbeused.Inthispaperwe
propose three scenarios based on real accidents, which address problems that are usually not familiar to
students:authoritygradient,desireforharmonyinagroupandantagonismbetweenspecialties.
http://www.transnav.eu
the International Journal
on Marine Navigation
and Safety of Sea Transportation
Volume 12
Number 4
December 2018
DOI:10.12716/1001.12.04.09
710
tools), and leadership structure (shared or
hierarchical), which are intertwined and affect other
importantfactors, such as communication(Marlow
etal.,2018).
Simulationsare effectiveeducational tool usedto
acquire knowledge, skills and attitudes needed for
performingjobsindifferentindustries(Havoldetal.,
2015). Combined with the training on
actual
equipment and training on board ships, usage of
simulators helps to increase training effectiveness
(Mindykowski, 2017). Incorporation of simulation
basedmodulesinmaritimetrainingunitsandcourse
schemes provides a way to attain experience and to
gainthenecessaryskills(Felsensteinetal.,2013).For
example,astudydescribing
simulationtrainingwith
scenarioinvolvingthefireon‐boardtheRo‐RoFerry
showed that the training and learning experience of
traineescanbeimprovedbysimulationenvironment
(Baldaufetal.,2016).Theship`snavigationsimulators
canbeusedtoconductBridgeResourceManagement
(BRM)courses.Forexample,thedevelopmentof
the
mostrelevant nontechnicalskillsinbridgesimulator
and design of the appropriative behavioural marker
system for their rating have been described by da
Conceicaoetal.(2017).
In order to be effective, BRM training should be
carefullydesignedandimplemented(Roettger et al.,
2016). NauticalstudentsatUniversityof
Zadarbridge
resource management competencies in general, and
leadership and team work in pa rticular, acquire
mainly through Shipboard Organization and
Managementcourse.Thecourseismainlyclassroom‐
basedandtoimproveitseffectivenesssimulatorscan
be used. The aim of this paper is to present three
scenarios that can be used
as a way to teach or
reinforce the learning of topics such as
communication, leadership, decision making and
cooperation. Scenarios of real accidents are selected
andadaptedtothecontextofuse,takingintoaccount
characteristicsofstudentgroups.
All scenarios, which are used as example in this
paper, are
developed and prepared using Transans
NaviSailor Full mission bridge simulator v5.35. This
type of simulator enables recreating most of
conditions as in real situation. Conducted exercises
aresavedandcanbereplayed,alongwiththeCCTV
cameras, provide the whole picture of actions and
behaviourduringexercises.
2 AUTHORITYGRADIENT
Sometimes
leaders are more concerned with their
status and reputation than with making a good
decision (Bang and Frith, 2017). Therefore team
members do not voice valid concerns or question
arrangementsmadebytheirsuperiors.Consequently,
in complex sociotechnical systems such as medical
care, aviation, railway, energy sector, accidents that
could
have been prevented occur (Kyriakidis et al.,
2018).Therearenumerousmaritimeaccidentswhere
the authority gradient played a role (Schroder‐
Hinrichsetal.,2012).WeusegroundingofHamburg,
sinceitinvolves cadet,arankonboardthatstudents
first will achieve. According to report by MAIB “at
13:28:21
on 11
th
May 2015, the Bahamas registered
passengervesselHamburggroundedonchartedrocks
near the New Rocks buoy in the Sound of Mull,
Scotland. The accident caused considerable raking
damageto the hull and rendered the port propeller,
shaft and rudder unserviceable. There were no
injuries and the vessel continued on
its passage to
Tobermory.Theinvestigationfoundthat,havingbeen
unabletoenterTobermoryBayonarrival,thepassage
plan was not re‐evaluated or amended. Combined
withpoorbridgeteammanagementandnavigational
practices, this resulted in the vessel running into
danger and grounding” (MAIB 2016). An
investigationrevealedthat
“Sevenminutesbeforethe
grounding,boththeofficerofthewatch(OOW)and
the cadet plotted the vessel’s position on the chart.
Despite both plotted positions being incorrect, the
cadet’s fix did at least indicate that the vessel was
running into danger. Unfortunately he did not feel
empowered to challenge
the OOW and chose to
silently erase his own position, leaving the OOW’s
incorrectpositiononthechart.”
In order to illustrate danger that can result from
steep authority gradient we developed following
scenariobasedonaforementionedaccident.
The scenario is developed using full mission
navigational simulator. Since the simulator has
the
ECDIS integrated with GPS/GLONASS position, the
first step was to disengage satellite position on
ECDIS. This enables recreating the situation that
happened in real scenario, since the position can be
determined plotting lat/long obtained using satellite
position receiver or using RADAR/visual bearing
eitheronpaperchartoronECDIS.
First step includes preparing the exercise, which
means loading proper area, choosing appropriate
vessel, matching prevailing weather conditions and
plotting course as in scenario. All of this has to be
explainedto“simulatorbridgeteam”duringexercise
briefing.
Second step is running exercise and recreating
situation which involves authority gradient. This
is
obtained by employing exercise leader (usually
instructor) as a team member. As the exercise is
carried out, the bridge team and exercise leader
separately plot ship position. However, the exercise
leader,intentionally,isplottingthewrongpositionof
theshipatthepositionwithadequatedepth.Thegoal
is
toseewhowillnoticethatshipislocatedinshallow
water and say that exercise leader plotted wrong
positionoftheship.
Third step is exercise debriefing. Exercise stops
whenthewrongposition,plottedbyexerciseleader,
is noticed and corrected or when the ship grounds.
During the debriefing, exercise
is replayed and the
authoritygradientisexplainedusingthisexample.
Theexercisescriptisfollowing:
Preparingsimulation
DisengagingsatellitepositiononECDIS
Bridgeteam:
Leader(Instructor)
Bridgeteam(studentsorseafarers)
Plottingshipposition
Onpaperchart
OnECDISusingLOP
Instructorintentionallyplotswrongposition
711
Endofscenario
Noticingwrongposition
Grounding.
3 DESIREFORHARMONYINAGROUP
Hostile work environment is readily identified by
students as a cause for problems in developing and
sustainingworkteam.Usually,theydonotrecognise
goodrelationshipswithteammembersasapotential
issue.
However, group think, including direct
pressure on dissenters (group members are under
social pressure to not oppose the group consensus),
self‐censorship (doubts and deviations from the
perceivedgroupconsensusarenotaccepted)andthe
illusionofunanimitymaycausedistortionofdecision
making, eventually triggering accidents (Murata et
al.,
2015). For example, poor decision‐making based
upon an emotional response to peers has been
recognised as pilots´ behavioural trap (Velazquez,
2018). Similarly, the desire for harmony in a group
manifestedasreluctancetochallengetheassessments
and decisions made by their colleagues has been
listed as a factor that do
not receive sufficient
attention during maritime accident investigations
(Schroder‐Hinrichsetal.,2012).
As an example of accident which involves desire
tofitintothegroup,groundingofDouwenthasbeen
chosen. “At 02:54 on 26 February 2013, the United
Kingdom(UK)registeredgeneralcargoshipDouwent
grounded on Haisborough
Sand in the North Sea.
Therewerenoinjuriesandnopollution.
TheMAIBinvestigationestablishedthatthevessel
had followed a navigation track displayed on the
global positioning system (GPS) receiver and on the
radar.Theofficerofthewatch(OOW)didnotnotice
thatthe vessel washeading into
danger until it was
toolateforeffectiveactiontobetaken.Contributory
factorsincluded:The OOWwasalone onthe bridge
andprobably fell asleep” (MAIB2014). However, as
investigation also found out: “An able seaman (AB)
wasalsoonwatchbuthewastoldbythechiefofficer
thathewasnotrequiredtoremainonthebridgesohe
returned to the accommodation below.” It is highly
probable that the presence of the AB on the bridge
would have prevented this accident. MAIB`s report
doesnotaddressesreasonsforsendingABawayfrom
thebridge,butitis
highlylikelythatOOWactedout
ofsympathyand/orthatABobeyedasagoodmatein
a team. Following description involves preparing
exercisescenarioandactionscript.
First step is preparing scenario on navigational
simulator, which includes loading proper area,
choosing appropriate vessel model, preparing
weather conditions and establishing
vessel route. In
thisscenario,vesselisonautopilotsteering(heading
control)throughtheexercise.
Second step is performing the exercise. In this
scenario first officer can be played by one of the
studentsorinstructor.Itisimportanttoproperlyand
separately brief the bridge team and “first officer”.
During
the exercise, “first officer” sends the rest of
bridge team away from the bridge. The key of this
exercise is to see if the participants will go off the
bridgeandwhoandwhywillremain.
Last step is exercise debriefing. After the “chief
officer” order and the reaction of
bridge team the
exercise is stopped. Using simulation replay, which
means showing possible consequences and the
importanceofovercomingdesireforharmonyinthe
group during decision making is shown and
explained.
Theexercisescriptisfollowing:
Preparingsimulation
Determining the point when the rest of bridge
teamwill
besentaway
Choosing“firstofficer”
Instructoror
Oneofthestudents
Runningtheexercise
Sendingrestofthebridgeteamaway
Endofscenario
Whoremainedonthebridgeandwhy
4 ANTAGONISMBETWEENSPECIALTIES
Effective communication and coordination between
Master,Chief
Engineeranddeckandengine officers
are preconditions for productive team work which
canensuresafeandenvironmentallysoundshipping.
For example, knowledge sharing for a mutual
understanding between bridge and engine
departmentiscriticaltoenergyefficiency(Manetal.,
2018).
However, relationship between the Master and
Chief Officer can
be characterized by strict
subordinationbasedontheprincipleofrankandthe
level of responsibility, especially within vertical,
strictlycentralizedshippingcompanies(Bielić,2009).
A study investigating bridge‐engine control room
collaborative team communication (Kataria et al.,
2015)showedthatlackofunderstandingoftheother
group’sjob
andcontext,notknowingwhatwasgoing
on in the other department and inter‐departmental
culture clashes can inhibit communication and
collaboration. An antagonism between specialties, a
rivalryorstatusconflictcanbesignificantlypresent,
as described by a participant in aforementioned
study,whomentioned“hugeBerlinwall”.
An example of
the accident where lack of
communication between bridge and engine officers
playedaroleisaheavycontactwithberthoftheferry
SirenaSeaways(MAIB2014).“At1254on22June2013,
the ferry Sirena Seaways made heavy contact with
berth 3 at Harwich International Port. The impact
caused
considerable damage to the fore‐end of the
vessel, including penetrations below the waterline.
Thelinkspanatberth3collapsedintothewater;the
supporting structures were severely damaged and
werenolongeruseable.Noonewasinjuredandthere
was no pollution. Sirena Seaways was subsequently
movedtoanother
berthtodisembarkthepassengers
and vehicles. Sirena Seaways’s propulsion control
recordsshowedthatthestarboardpropulsionsystem
remained set at about 63% ahead throughout the
accident.Nodefectswerefoundwiththepropulsion
controlsystemsanditwasconsideredmostlikelythat
712
thebuttontoactivatetheback‐upcontrolsystemfor
the starboard propulsion system was inadvertently
pressedduringthe early stages of the entryinto the
port. This bypassed normal control of the starboard
propulsionsystem.Theerrorwasnotnoticedbythe
bridge team and the starboard propulsion system
continued at 63% ahead for nearly 2 hours after the
accident,hamperingattemptstopullthevesselfrom
the damaged berth.” However, an investigation has
revealedthatunlikebridgeteam,theengineersinthe
enginecontrolroomnotedtheoperationoftheback‐
up control system 13 minutes before Sirena
Seaways
struckthe berth butthey did not communicate with
thebridgeteam.Moreover,aftercollision discussion
betweenseniordeckandengineeringofficerscentred
aroundevaluatingtheeffectsofthedamageand the
mostappropriateresponse,butinformationnecessary
to realise that back‐up button was incorrectly
operatedwasnotdelivered.
Hadtheycommunicated
effectively, this accident could have been prevented
oratleastemergencybettermanaged.
In our scenario the exercise is performed two
times. First time the error with propulsion is not
reportedandsecondtimetheerrorisreportedtothe
bridgeteam.
First step is preparing the
exercise, by choosing
appropriate area and vessel model (with pitch
propellers).Also,thisscenariorequiresjointrunning
ofNauticalandEngineroomsimulator.Thistypeof
exercise if appropriate for Bridge team management
andEngineroomresourcemanagementcourses.The
key in this exercise is to time delay error which
disables
oneofthepitchpropellers.
Secondstepistobriefthebridgeandengineroom
team separately for each scenario. In first scenario
engine room team doesn’t report the pitch problem
and in second the problem is reported. In both
scenarios bridge team is not familiar with the
problem.
Third
step is debriefing. Running the exercises
replaytothebothteams,bridgeandengineroom,the
importanceofcooperationandpossibleconsequences
ofantagonismsareshown.
Theexercisescriptisfollowing:
Preparingsimulation
Determiningthepointwhentheproblemwithone
ofpithpropellersoccurs
Timedelay
In1
st
scenario
Engineroomteamdoesn’treporttheproblem
Bridgeteamcontinueswiththeexercise
Theexerciseisstopped
Aftertheaccidentor
Aftertheproblemisnoticedbybridgeteam
In2
nd
scenario
Engineroomteamreportstheproblem
Bridge team suspend following actions in
scenariountilproblemissolved
Successfully completing the scenario after
solvingproblem
Endofscenario
5 CONCLUSIONS
Analysesof the recentmaritime accidents show that
that, despite various preventive measures, problems
in team,
at bridge and engine room, still occur.
Thereforeitisimportanttoaddressfactorshampering
teamwork during Bridge Resource Management
courses.
In this paper examples of three accidents, which
included authority gradient, harmony in the group
and antagonism between specialities, were used to
createsimulatorscenarios.Usingsimulatorscenarios,
with an
exercise script based on real‐life case,
facilitatesdemonstrationoftheseissuesandsituation
thatmayresultandleadtoaccident.
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