Safety & The Human Factor

[English translation]

REPORT: CSMART Academy is a training center based on human judgement as a prerequisite for maritime safety. Here, seafarers from across Carnival Corporation’s entire fleet come to train.

TEXT AND PHOTO: ANNA LUNDBERG June 2017 | Sjofartstidningen

The development of safety procedures has often been a story of stops and starts, where each surge is preceded by an unfortunate incident. In the maritime world, milestones like Titanic, Herald of Free Enterprise and Estonia are tragic events but, at the same time, they have made seafaring safer and safer. We define our basic ability for survival as ‟trial and error.” Do it again and do it right.
When building a system, whether it consists of a simple tool or an entire ship, the traditional idea is to have a safe and perfect system, until a user comes along and jeopardizes the safety of it all.

But is it true that humans can only learn by making mistakes? Is the human factor always the unreliable one?

Hans Hederström, founder and director of Carnival Corporation’s CSMART Academy is a remarkably gentle man… until he gets started on the argument about the human factor. His pathos breaks through along with his frustration:
“The problem is not with humans; it is with the system. The mechanisms are complex and cannot be described in detail. A human must constantly adapt to the complex world and that’s what we call ‘good seamanship’. However, it is very difficult to adapt if you don’t have the required skills and experience as a base.”

Safety: The Human Factor

He describes the areas covered by the training at Carnival Corporation’s CSMART Academy: technical skills, leadership and cooperation, as well as human factors. He has a gift he uses to share this concept with his visitors: Sidney Dekker’s book ‟The Field Guide to Understanding Human Error.” It reverses the concept of human error and emphasizes that the human factor is not the problem. Rather, the human factor should be considered a necessity for making systems work effectively.
“The human factor is the asset that must provide the necessary skills in these areas and develop adaptability in different situations. Humans can achieve safety when these areas work together.”
He also describes how much more effective it is to learn and practice when things go well, not just by watching and reviewing the mistakes. Things go right many more times than they go wrong, but the successes are often considered as the “normal” and consequently forgotten. We must also emphasize and understand why things go right, in order to increase our successes.

“This is still a new approach for the maritime industry. We concentrate far too much on ‘human error’.”

CSMART Academy

– Opened in 2008 in Almere, the Netherlands. The new facility in Almere opened in 2016.
– Owned by Carnival Corporation, the world’s largest cruise line company with 103 vessels sailing under the following brands:
Carnival Cruise Line, Princess Cruises, Holland America Line, Seabourn, Cunard, AIDA Cruises, Costa Cruises,
P&O Cruises UK and P&O Cruises Australia.
– CSMART Academy’s operations are financed by a fixed amount per year and vessels in Carnival Corporation’s fleet.
– In 2017, CSMART is expected to host about 6,500 officers.
– Beginning in 2017, all deck and engine officers in the fleet must undergo annual training at CSMART Academy.
– The center also features a twelve-floor hotel with 176 rooms.
– The staff consists of
- * 46 permanent instructors and operators
- * 27 line instructors – active officers with onboard experience who have been instructed at CSMART for four years
- * 10 fleet captains and 10 fleet chief engineers who work to ensure that the goals of the training are realistic and applicable.
- * In addition, technical staff, business support as well as assessors and consultants are there to help.
- * In total, 130-140 people work in the facility, of which, more than half are permanent staff.

“This is still a new approach and thinking for the industry, because at the moment we focus too often on ’human error.’ But the problem does not lie in the fact that one person errs, which is to be expected. The problem is when a team of two or three people allow a mistake to pass without taking a corrective action. Such issues have to be addressed and solved at the organizational level. I’m trying to put in the maritime thinking on that, but it is tough.”

The magazine visited Hans Hederström in Almere, a bit east of Amsterdam. The newly built CSMART Academy consists of two buildings, a hotel and the building where the training and teachings take place. There is a tunnel underground between the locations in case guests are looking to avoid the slightly windy surroundings.

The area has natural beauty. CSMART Academy is situated on a manmade hill next to Ijmeer, the first of the fourteen border lakes, Randmeren, bordering the dry marshland, so key for the Netherlands. When the construction projects in the region are complete, the area will become more beautiful. For the moment, the construction is significant. The wind is constant, according to Hans Hederström.

A Facility Beyond Rival

CSMART’s overall simulator resources are unmatched around the world and consist of approximately equal parts engine and bridge simulators. The course programs are extensive, with emphasis on the organization and teamwork in courses such as Bridge Resource Management (BRM), Ship Handling and Engine Room Management (ERM). In recent years, courses in leadership, environment and sustainability have been introduced, as well as technical courses in, for example, high-voltage and Exhaust Gas Cleaning Systems (EGCS).

Growing from a small start

This year, 6,500 seafarers are expected to learn and train at the 11,000 square-meter facility. To maximize opportunity, the trainings will last from 7 in the morning until 11 in the evening, divided into three phases. Each group undergoing a simulator course gets five hours in the simulator and three hours for briefing and debriefing in classrooms per day.

It started on a slightly smaller scale.

“In 2008, I left Chalmers University of Technology, moved here and managed the buildup of the old place. This was just an empty warehouse and an office building, we had 10,100 square feet of warehouse space and 8,000 square feet for the office space. At that time, I thought ‘we will never fill this space.’

“My wife accompanied me to Almere and worked here until a year ago. She has now returned to Gothenburg.”
“She had to take on the responsibility to run the lunch restaurant. She is a very good chef. There were not as many people in the beginning, about thirty people, 24 participants and six employees.”

“In principle, we only had two courses, a BRM course and an ECDIS course in the beginning, but the number increased by the years. In 2014, it was clear that the demand for CSMART’s trainings exceeded our capacity and we made a decision to make the arrangements for a larger training center. Behind the huge increase in demand in recent years, there is a tragic jerk, a catastrophe that put Carnival Corporation on its heels.”

The demand exploded

“We grew slowly until 2013. After Costa Concordia, the demand for our courses grew somewhat enormous,” says Hans Hederström.

“P&O Cruises and Princess Cruises made sure that CSMART was created. After that, all other Carnival Corporation companies have participated in CSMART’s training, but on a voluntary basis. Today, all nautical and engineering officers at all levels are required to come to CSMART for training or for a proficiency assessment.”

“We don’t say this is the result of Costa Concordia, because that isn’t really the case. We had the training before, but the demand grew higher and higher until we reached our maximum capacity,” says Hans Hederström.
In 2013, management came to him and said that capacity had to expand. The quest for new facilities began. The search to find specifically what we were looking for was difficult.

Payoff

“We went around looking at warehouses when one of the senior managers asked ‘Hans, is this really your vision?’. He was not particularly impressed with that warehouse. ‘No,’ I replied, ‘My vision is to build a completely new training center that is truly tailored for the training, a real CSMART Academy.’ ‘Well, why don’t you do that then?’ he replied.”
Then everything went fast. The Board of Directors of Carnival Corporation decided in early 2014 to build a new state-of-the-art facility, and the process began. The building was ready in 2016, and every officer in Carnival Corporation’s enormous fleet is now able to come for training at CSMART every year.

For Hans Hederström, this means that he has achieved his goals in several ways. The improvement of maritime safety is never over, and he is the first to refuse to accept the 900 – 1000 of avoidable deaths that occur across the maritime industry each year.
CSMART Academy’s training courses now reach the entire Carnival Corporation fleet, and the concept is spreading to other maritime companies. Therefore, it is impossible to say anything but that Hans Hederström’s efforts have been thorough and impactful. He is humble and extremely thoughtful, and says that the business could not have developed without support from top management, colleagues and role models. When we meet students and colleagues at the roundabout in the center, and especially when you hear about him in the industry, Hans Hederström is highly respected.

Others follow

“We see our approach is being taken throughout the industry, one after the other. Other cruise lines are following suit, and I’ve just heard that Tui will start the training in Hamburg and two of our external consultants have been asked to conduct their training.”
Until 2016, Star Cruises was a CSMART customer and also trained at the facility. Carnival Corporation has decided that CSMART will now focus exclusively on the corporation’s fleet, for several reasons, one being space.
“We did not conduct the courses or take any responsibility for the education of the other cruise lines, but we trained their instructors and we helped them develop their course materials.”

The nautical training environment

– Transas has developed 12 models of Carnival Corporation cruise ships for the simulators. The software includes 60 port
databases where Carnival Corporation operates. The Full Mission Bridge simulators are based on the latest ship built for
Holland America Line, ms Koningsdam.
– The facilities consist of four full mission bridge simulators with separate bridge wings and one debriefing room per simulator,
eight smaller bridge simulators for specific training and seven control stations from which the instructors supervise and control
the exercises.

The technical training environment

– Like on the bridge side, the full mission engine room simulators are built based on a real ship. The diesel electric engine model
has been developed over 20 months and consists of six diesel generators, powering two propellers operated from a replica of
the real engine control room. Course participants can move around in virtual environments through touchscreens.
The environments include authentic audio and communications equipment.
– The facilities are equipped with four full mission engine room simulators, twelve stations with virtual machine environment,
two high-voltage training systems (pictured right), two classrooms with 12 smaller engine room simulators each and four
teaching rooms.

One-man show

According to Hans Hederström, two elements of CSMART’s concept are the cornerstones that contribute to improved maritime safety—CSMART Academy’s role-based BRM and their variant of route planning.

CSMART’s route planning and role-based BRM on the bridge or ERM in the engine room are closely connected. The most important element is to involve the entire team in the operation. This means that everyone has the same information about the route plan and the ongoing operation.
According to the role-based BRM, the Captain must have enough of an overview to manage and engage in leadership. Therefore, the captain is behind the team and is not involved in the direct operation of the ship. Other roles on the bridge have their designated locations; navigator and co-navigator at the front—together with the pilot if onboard. Behind them is the captain, in the role of Operations Director, and the junior officer in the role of administrator.

“As a captain, you have much better options for overseeing the operation when you are not busy with conning the ship yourself. There is nothing that prevents the captain from taking the role of co-navigator to coach an officer in the navigator role, but we usually say that as a Captain, you should avoid being a navigator, because you risk falling into the old system where no one dares to speak up,” says Hans Hederström.

Carnival Corporation is now adapting the ship bridges to the role-based BRM. However, Hans Hederström says that their BRM model can be applied to any ship, regardless of the size of the crew or bridge configuration. But this requires proper training.

Route planning

“I always stress the importance of detailed route planning. Traditionally, there is a course line and some no-go areas marked, but that is completely inadequate,” says Hans Hederström.

Everything is about incorporating the team and building good communication throughout the operation. The voyage plan is the foundation for the navigation control process and it includes track line surrounded by a so-called track corridor, an area around the course line, which can be varied in width depending on circumstances.

Control function

“There should always be an expectation where as a co-navigator, I know that my role is to speak up. Very simple, but clear margins provide a control function that was not available before. If the ship is in the corridor, you do not have to worry, but if you leave it, you will come into something we call the ‘safety margin’, the navigable area between the Track corridor and the no-go areas. Sometimes the ship needs to go into the safety margin area, and in such cases, the officer in the navigator role must say: ‘I’m now going to use the safety margin because we have a potential encounter, and I have to allow a little extra space.’ If the navigator does not say anything, the team should ask ‘what is your intention?’. When there are no such established boundaries or expectations, a young officer will never know when to step in and speak up.”

“The speed is also included in the route plan, but as a range, so that the team knows when it is time to question the speed in the same way as with the track corridor.”

“It is probably the most important thing we do, to maintain the connection with reality onboard.”

The development of new ways of thinking about safety has followed Hans Hederström through his professional life. He was a pilot in Gothenburg for 20 years until 2000, when he started to work for Star Cruises at their Ship Simulator in Malaysia. In 2005, he returned to Gothenburg and started to work at Chalmers University of Technology with the task to build their new large bridge simulator.

Role models

He acknowledges that working 20 years as a pilot provides plenty of personal experience to act as a one man show on a ship’s bridge. But even in the 1980s, he was aware before his colleagues of the importance of a shared mental model, and began presenting the Captain with a detailed route plan before starting his piloting. He proudly shows a tabbed binder with a plan for passage past Vinga lighthouse.

“A few of us used this, including another pilot and good friend, Sven Gyldén.

“We received inspiration from Silja Line’s Captain Kari Larjo, who is my role model, and Benny Pettersson, a Stockholm pilot and also a good friend. They had a great influence on me.

“In the 1970s, Captain Larjo introduced new ways of looking at safety and among other things, this included what CSMART Academy teaches us today—namely that everyone on the bridge knows the same detailed information about the ship’s intended navigation.

“I always thought he was awesome as the Captain. I met him in the early ‘80s and became profoundly impressed by how he navigated and led his team. He stood behind them and never took the conn himself.”

We take a tour of the building and meet Robert Bartels at the coffee machine. He is one of CSMART Academy’s 27 line instructors, an active officer who, for the last four years, switches between three months onboard and three months at CMART, and after that he is on vacation before going onboard again.

The link to the vessels

“A line instructor is the interconnected link between what happens here in-house and the conversion into practice onboard the ship. It removes the old argument that people on land do not know what it’s like onboard, and therefore identifies procedures and solutions that cannot be applied in reality. It is probably the most important thing we do, to maintain the connection with reality onboard,” says Robert Bartels, line instructor at CSMART, who is the first officer of AIDA Cruises and Costa Cruises ships when he is not in Almere, the Netherlands.

Robert Bartels has been a line instructor at CSMART for four years, but will now return to his career at sea. He says that CSMART has made a big difference to his career—in addition to gaining new and in-depth knowledge of leadership and how to get his team to strive together for the same goal, he believes that it has increased his reputation onboard; people assume that he knows what he is talking about because he has worked at CSMART.

Mandatory evaluation

Nautical Instructor David Frassetto has just launched one of the bridge simulators in another part of the building. The screens show the entrance in the port of Hong Kong. David Frassetto has been part of the permanent staff since fall 2014 and is a BRM course instructor. He is preparing for the PTA, Proficiency Training and Assessment, starting later in the day.

It is mandatory for all Carnival Corporation officers who have attended all required courses to annually undergo a one-week PTA at CSMART Academy, as part of the company’s Continuous Professional Development Matrix.

PTA with similar arrangements has been used for a long time in, for example, the aircraft and nuclear power industries. During a PTA week at CSMART, all deck and engine officers are trained and evaluated through layered phases in the classroom and simulator. All of them aim to maintain and develop the skills of the officers and ensure that they live up to the intended standards in their professional practice.

In the large lit area in the middle of the building, Mamun Rahman from the British Maritime & Coastguard Agency is having a coffee. His task is to certify CSMART’s ECDIS course. Hans Hederström asks his opinion so far (and then swears that Rahman has not been paid for his answers).

“Well, nobody’s beating you in quality,” says Mamun Rahman.

“We are spending a lot of time and resources on developing both our courses and instructors. This effort provides us with high-quality courses and dedicated knowledgeable instructors.” says Hans Hederström as we move on.

Senior Nautical Instructor Emiliano Caroletti is conducting the ECDIS course that Mamun Rahman is there to evaluate. Almost all participants in the hall are what Emiliano Caroletti calls “fresh meat”–trainees–and the topic of this phase is the risk of over-relying on the ECDIS. He does not lecture without asking the participants constant questions.

They will immediately go through a case study of a known grounding to test in the simulator if the course participants are able to avoid the same conditions as the actual incident, in which the ECDIS settings were one of the reasons for the grounding.

Getting answers

The training methods used at the CSMART Academy are based on what research shows regarding the learning capacity of an individual. For example, the instructors avoid covering too much information in their lectures.
Additionally, all participants are required to prepare themselves using a Learning Management System (LMS) prior to coming to CSMART. This makes it possible for instructors to interact and ask questions instead of delivering all facts.

“Following an internal rule, we ask one question every minute. This keeps people awake. We let them come up with the answers; we don’t give them the answers. If they cannot answer, we’ll make a little detour and ask someone else. If you figure out the answer yourself, you will remember. If the instructor is providing the answers, participants will not remember,” says Hans Hederström.

In the training center’s Learning Management System, the course material for all courses is available, so that course participants have the opportunity to come to CSMART well-prepared.

More time in the simulator

“You prepare yourself in the weeks before you come here by studying for perhaps four hours. All basic knowledge is there and so we avoid preaching it during classroom time. This means that we have been able to change our structure from four hours in the simulator and four hours for the theory, to five hours in the simulator and three hours for the theory. When people can prepare themselves, there’s a very good effect on the learning outcome,” says Hans Hederström.

Hans Hederström turns 68 in the fall. He quickly answers with a no when he’s asked if he has any plans to stop working. But it turns out that there are other aspects he is now considering.

“My wife has some opinions. I’ve promised her that I will leave this position by the end of 2018. I will be an instructor again and move home to Sweden and work part-time, that’s the plan.”

He thinks there is so much more to be done.

“I think it’s fun to be an instructor. If they want me back at Chalmers, maybe I’ll do something there. But I can work here as an assessor or instructor. I hope I can keep up with it for a while.”

Arison Maritime Center CSMART