07 Dec Resilience goes hand in hand with systems thinking
This article is about introducing the principles of resilience in simulator training of marine engineers, to enhance their ability to keep all processes running in variable circumstances and situations. Furthermore how thinking in systems contributes in understanding how to apply resilience.
The nurse on the chocolate tin can carries a plate with the same chocolate tin can. On that tin can again a nurse is displayed carrying a plate, and so on. In fact the scene pictures the whole idea of system thinking.
A ship can be approached as a system, performing a function in a higher system on a higher hierarchical level. Zooming in, into the ship as a system, reveals a number of subsystems, like the engine room. Inside the engine room again there are all kinds of sub-sub systems. All systems irrespective of their hierarchical level are somehow connected with one another and serves one another. As a whole they work together to achieve the goal of the main system, in terms of business management the continuity of the company. On the other hand, the failure of one system, even the smallest, can jeopardize the operation of the main system.
Moreover there are various kinds of systems such as management systems, financial systems and technical systems. All systems have one or more processes, also on different levels, just like the systems. Processes have an input and an output and most of them have one or more different control loops to control the desired outcome.
So is the engine room a complex collection of systems and processes, both social and technical, with numerous risks of failure, damage or even loss. This part of a ship is managed by a group of skilled marine engineers, all educated according to STCW [1] and often from various nationalities. They are expected to deal with fluctuations, unexpected events and disturbances, also both in collaborating with each other and in the technical field. They have to change their behaviour and apply their skills to meet all kinds of variations, in an effort to keep things running. In addition, keep it running in an efficient and safe way. Side effects are increased workload, performance pressure, fatigue as well as sometimes lack of sufficient knowledge and understanding.
Efforts to improve the availability and performance of processes and safety as well as to prevent incidents often have been focussed on reactive approach, i.e., implementing new procedures, instructions and other changes. Common practise after an adverse event is that an evaluation or investigation is conducted to reveal the root cause and to define the so called ‘lessons learned’. It is a regressive action. Furthermore proactive actions are taken, such as risk analyses, prior to a risk full job.
Looking back to ‘what should have happened if’ and ‘what could we have done’ to understand what could have prevented the undesired event does not necessarily provide a deeper understanding of underlying factors contributing to the outcome.
The idea of resilience is in line with the proactive approach, but goes much further. It focusses above all more on the question why most of the time things go well instead of why sometimes things goes wrong. In other words, improving the number of things that go right is more effective than reducing the number of things that go wrong, noting that the latter will be a consequence of the former.
[1] International Convention on Training, Certification and Watchkeeping for Seafarers, London: IMO.
The definition of resilience
Hollnagel defines resilience as the intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions[2].
Being resilient in an engine room environment means that personnel is able to have systems recovered rapidly after a major disruption or during a series of successive malfunctions or outages. Moreover, to be ready and respond to unexpected or potential undesired events, avoiding or minimizes loss.
Therefore resilience fits perfectly with other topics of an bridge or engine room resource management training, such as situational awareness, leadership and decision making.
At Simwave people are trained on being resilient by analysing why the same performance leads sometimes to success and sometimes to failure. Furthermore by applying the four cornerstones of resilience engineering: 1) knowing how to respond to undesired events; 2) how to monitor signs that indicates near threats; 3) knowing how to anticipate on those threats; and 4) how to learn from experience, both successes as failures.[3]
In other words, to be adaptive, to anticipate on what possible may happen and monitor on that, as part of the watch keeping, is an important learning objective.
Besides the analyses of undesired events, at Simwave we are developing exercises with scenarios in which these kind of learning objectives systematically can be achieved. Besides other observations , during debriefing in particular things that went well are evaluated.
At Simwave thinking in systems and resilience go hand in hand to increase the things that go right on board ships.