THE NAVAL ENGINEER

5
weather and the lack of the
Glideslope.
• Following a lengthy absence
from work. The Captain of
Flight 801 hadn’t flown into
Guam for a month.
• When handovers are between
experienced and inexperienced
staff. While the crew on
Flight 801 were experienced,
their cultural background, as
exemplified by their high PDI
score, prevented then from
having a questioning attitude
and an open discussion.
If this still seems entirely
unambiguous and common sense,
then why are the human error rates
so high on Nuclear Propulsion
Operating Standards Quarterly
Report of safety? Complacency
can creep up in any profession.
Nobody can sit back and think they
are safe. The following sections list
many of the tools and techniques
used to improve information flow.
Whilst these lists below might seem
to be lists of the blindingly obvious,
it is amazing how often they are not
given sufficient attention.
Hints for Handovers
Communication can be written
or verbal. An effective handover
or pre-task brief sets the scene
for subsequent actions. The HSE
report “Effective Shift Handovers –
a Literature Review” has some
pertinent things to do. Compare the
rest of Flight 801’s performance
with best practice:
• Logs up to date. Establish
a thorough baseline. Flight
801’s chart was out of date.
• Have a procedure for
handovers/briefs and follow
it. Korean Airlines does have a
standard procedure for descent
briefs but the Captain didn’t
follow it.
• Have accurate carry forward
of written information.
• Involve people working at the
sharp end. The most effective
interventions are those where
operators are involved as they
know the risks and hazards and
can contribute to the debate.
• Give shift handovers and
briefs an effective priority.
The Captain’s brief was too
short.
Improvements – Good
Communications Tools and
Techniques
Below (Table 1) are some more
tools and techniques to encourage
good communications.
When it comes to
communication, engineers
are their own worst
enemy 4
Studies have demonstrated
or observed that the culture
of engineering impedes the
collaborative processes in
team work and hinders good
communications 5 . This seems to
be a truism across a wide variety
of engineering disciplines and from
different cultural backgrounds 6 .
Engineers come in many shapes
and sizes (and WEs) and have
been labelled amongst others as
4. Paul Leonardi, The Mythos of
Engineering Culture.
5. Amongst others Ingram, S. & Parker, A.
(2002) The influence of gender on
collaborative projects in an engineering
classroom. IEEE Transactions on
Professional Communications, 45(1), 7-20.
6. Barley, S.R. (1996) Technicians in the
Workplace: Ethnographic Evidence for
Bringing Work into Organizational Studies
Administrative Science Quarterly 41(3), 404-441.
the creator (an artificer), geeks (Bill
Gates), the maverick (a technology
tinkerer) and the expert (any
engineer)! Engineers are also seen
as macho, with a competitive streak.
Whilst this latter label may seem too
strong, many studies have shown
that engineers thrive in the mastery
of their craft and the fact that they
‘get it’ and grasp new concepts
faster than others. Engineers also
thrive in putting others down and
competitively demonstrating their
mastery to others. If you think this
view is too extreme, think about
the RN push for professional
recognition, encouragement for
master’s level studies, the questions
on our professional boards, the
way we grade ourselves and our
technical back-bar talk.
Unfortunately technology bias
has other consequences. In
demonstrating the mastery of their
art, engineers are likely to assert
their professional opinions 7 . The
more strongly that opinions are
voiced, the less likely it is that
subordinates and peers will to voice
their own opinions, defying one
of the basic ingredients of team
successes – namely openness. On
Flight 801, whilst the Captain wasn’t
an engineer, after he voiced his
strong opinions no-one was likely to
challenge him. Such an impact was
seen during the Fukushima Event,
when it is a matter of record that the
Japanese Prime Minister was giving
technical orders to those working
on minimising the effects of core
meltdown.
The second consequence of
this fixation with the mastery of
the engineering art is that team
members are picked solely on
their technical competence. For
7. La Fasto, F.& Larson, C. (2001) When
Teams Work Best: 6,000 Team Members
and Leaders Tell What it Takes to Succeed.
Thousand Oaks, CA: Sage.
Speak Up Encourage the Team Communicate Openly
Who? Everyone Supervisors Managers
Time out for Safety Safety conversations and training Safety conversations and training
Tool Box Talks Tool Box Talks Site visits
Tools and
Time for Health and Safety Observation and feedback Operators meetings
Techniques
Observations and feedback Staff briefings Staff meetings
Peer reviews
Table 1: Tools and techniques
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