BHRM Chapter 7: Human Errors and River Navigation (Bridge Human Resource Management)

Chapter 7 Human Errors and River Navigation

7.1 Human error– One man error – Decision making process

7.2 memory and human element chart

Knowledge - based Errors: Often Dismissed as "Amusing"

On Emotional - Driven Violations and Their Consequences

Case Studies: When Skill Gaps Lead to Catastrophe

7.3 Intuition - Basic Errors and Memory - Based Errors

Case Study: The Tenerife Airport Disaster (1977)

Basic Errors and Their Consequences in Shipping

Case study : Exxon Valdez incident

7.4 Decision Making Process

Working Habits: The Automatic Decision Maker Complacency

One case of application of decision making

forces act on each turning stage

[some points to adhere to in river navigation to avoid the collision and grounding.

What happened in turning

Turning in Four Stages in congested water

How to steady the COG?

7.6 Ultimate river channel safety

Chapter 7 Human Errors Acros

Marine accidents are often framed as inevitable, given the uniquely harsh operational environment of the maritime industry. Challenges such as extreme weather (storms, high waves, strong winds), navigational hazards (shallow waters, blind navigation zones, draft restrictions), and the physical limitations of vessels (massive size, sluggish maneuverability, momentum from ultra-heavy cargo) are collectively described as force majeure—unavoidable natural forces that test both crew and equipment. With so many variables at sea, a zero-accident record is, in theory, unattainable.

Yet these challenges do not render humans powerless. As one LNG-tanker company manager advised his successor, approximately 90% of maritime accidents stem from human factors: about 60% from direct errors (misjudgments or procedural lapses) and 30% from indirect human-element issues (inadequate training or organizational culture). For high-risk vessels like LNG carriers—highlighted by tragedies such as the Sanchi collision—even minor incidents can escalate into catastrophic consequences. While other ship types may tolerate occasional mishaps, incidents rooted in human error pose a universal threat across all maritime sectors.

The Cultural Construction of Error

Notions of error are not intrinsic; they are socially and culturally constructed. Figure 7-01 illustrates six cognitive elements tied to human error—fundamental aspects of brain function such as attention, memory, and decision-making. When any of these falter (for example, due to inattentiveness or flawed risk assessment), errors or violations can occur, often requiring significant resources to rectify.

Cultural norms further shape how errors are perceived and tolerated. In some societies, extended parental support for adult children is viewed as a natural obligation, while in others it may be seen as overindulgence. In extreme cultural or ideological contexts, actions outsiders deem erroneous (for example, high-risk behaviors framed as morally imperative) may be normalized within a group, leading to substantial sacrifices. In maritime settings, seafarers’ ingrained routines or habits—shaped by workplace culture—can obscure risks, making deviations appear unproblematic. Culture functions as a group’s collective memory, legitimizing behaviors that might otherwise be flagged as hazardous.