LEARNING FROM INCIDENTS
FACILITATOR GUIDE
FACILITATOR GUIDE: “It will never happen to me!”
Learning from Incident - Navigation
PART A – PREPARATION FOR THE SESSION
INTRODUCTION
SET UP
TIPS
PERSONAL ACTION
HELPDESK
TALKING POINTS
PART B – RUNNING THE SESSION
INTRODUCTION
BACKGROUND ON REFLECTIVE LEARNING
WHAT ARE BARRIERS
USING THE LEARNING TOOL VIDEO
CLOSE
PART A – PREPARATION FOR THE SESSION
INTRODUCTIO The aim of this learning session is not to just watch a video, it is to think and talk about
LEARNING FROM INCIDENTS
FACILITATOR GUIDE
N the incident as a group. We want the audience to reflect on the causes of the incidents
involved in this video. We want them to relate to what has happened (or could happen) in
similar situations at their own site and what they could do differently in the future. Both
individually and as a group they have an opportunity to elaborate on how to prevent a
similar incident from happening at their sites in the future.
PARTICIPANT Ideally 20 participants, maximum 30 participants.
S
MEETING Please prepare carefully, ensure there is sufficient time available for discussion as that is
the most important part.
TIME 70-90 minutes
FACILITATIO Trained and enthusiastic facilitator
N
EQUIPMENT PC/laptop for accessing and projecting the video as appropriate. Note: Be sure to test
both video and audio on the equipment before the meeting
3-5 Flipcharts (depending on size of the group) and markers
Post-its/notepads and pens
Ensure that there is a mix of people in each group (i.e rank, experience, cultures, etc)
ROOM SET UP Chairs for all participants and a few tables. Make sure there is enough space for people to
break into groups of 4-6 people for discussion groups. NB: where possible do not use
break out rooms, you will lose valuable time when people are moving in and out of
meeting rooms.
MATERIALS Printed Action forms for all participants
Downloaded video on laptop or USB stick. Do not rely on internet.
TIPS Review the video and these facilitator notes. Consider similar experiences/ activities
that you are personally familiar with.
Identify and think of ways to manage any questions that might come from the
audience which could distract from the main learning objective.
Think of a personal story preferably related to a navigation incident that you can share
with the audience to make it a personal experience.
Print the handouts and ensure all materials and equipment are available. Note: the
action form should be distributed to participants at the end of the video.
Prepare for a safety briefing at the start of your sessions
familiarise yourself with alarm procedure and emergency numbers and review the
evacuation floor plan for emergency exits and muster points.
Personal Actions: Have the printed Action forms ready (so participants can fill out their
details and actions on paper). Ensure participants find a partner to share their actions
with and agree on a follow date.
For any help with the preparation, execution or follow up of this session, please contact your
HELP DESK managing office
Name & Title:
Telephone:
E-mail:
Preparation Points – Facilitator notes
Video Part 1 – It Will Never Happen to Me! (Setting the Scene)
LEARNING FROM INCIDENTS
FACILITATOR GUIDE
a) Master taking over con – Nav status report prior taking over
b) Call from Charterers – Commercial pressure (Real vs Perceived)
c) Master’s respond to Duty officer highlighting concerns around UKC
d) Bridge manning level reduced during pilot boarding
e) Fatigue elements – Tug Master
f) Pilot giving course orders from gangway
g) Pilot annoyed over lifts not working
h) Master / Pilot information exchange not thorough – Bridge team response to Pilot’s behaviour
i) Pilot complacency having handled similar vessels in the past
j) Look out did not re-enforce the sighting of tug/tow to Duty Officer / Master when Duty officer was
attending to the satellite phone call
k) Vessel started slowing down when approaching the berths
What happens next?
a) Close-quarter situation between tug and tanker – near miss
b) Tanker comes in contact with a buoy or a navigation aid
c) Tanker exits the dredged channel and runs aground
d) Tug collides with the tanker
e) Vessel astern comes close to the tanker leading into a close-quarter situation with tanker / tug
f) Nothing happens
g) Engine failure on tug / tanker
h) Steering failure on tug / tanker
i) Secondary events such as flooding, pollution
j) Secondary events such as personnel injury / loss of life
k) Think of more such eventualities
Video Part 2 – Events leading into the incident
a) Pilot did not communicate intentions to the tug/tow / VTIS after reducing speed despite speaking
to the Tug Master on VHF
b) Tug Master – Loss of situational awareness
c) VTIS did not flag developing situation to either of the vessels in good time
d) Master of tanker was hoping all this while that the Pilot and/or tug will keep clear
e) Ineffective intervention by the Master
f) Developing close-quarter situation was picked up too late by Bridge team, Pilot as well as the Tug
Master
g) Evasive actions taken were ineffective eventually leading in to the collision
h) Use of VHF to avoid collisions
i) Monitoring change in bearing using Visual / Radar monitoring
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FACILITATOR GUIDE
Note: There are several industry reports highlighting failures in bridge team communications, human
factors and behaviors leading to maritime navigational incidents. These can also be referred to while
preparing for the Reflective Learning session.
PART B – RUNNING THE SESSION
Video description
The video consists of 3 parts (the video stops automatically after each part for an engagement activity).
The first part of the video gives a background of incidents related to safety of Navigation and sets the
scene for the incident in the reflective learning video
The second part of the video shows what happens and the incident occurs
The third part explains the causes of the incident, what barriers failed & identifies how we can prevent
such incidents
The last part is the conclusion and allows for commitment to a personal action.
CONTENT & ACTIVITIES
SECTION
INTRO As team members arrive, help to spread out the participants into mixed grouping of 4-6 to facilitate the
- 5 min discussions. This will avoid the need to move people later on.
Welcome
Here are some suggested words:
“Welcome everyone. We’re here today to learn from each other rather than just read about an incident.
We will learn by talking with each other about things that we see, hear and feel about our own safety
and that of our colleagues”.
Safety briefing (depending on site)
Explain Alarm procedure, Emergency numbers, Evacuation signs and Muster Point(s). Check if there
are colleagues present who are qualified to provide First Aid.
Introductions (if applicable)
Check whether all participants are familiar with each other and if not, hold a brief introduction round
where all participants tell their name and function in the organisation.
Agenda
Emphasise that the most important part of this session is learning from each other and hence their
participation is most important to ensuring they can prevent incidents happening on their site.
Explain the flow of the session and that we will be working to takeaway a team action and also a
personal action commitment
Reflective Decide if these supporting slides will be required for your audience and include them as
learning appropriate.
background, The Objective of these slides is to explain what reflective learning is about. They provide information
concept and using the research behind the reflective learning concept and how it caters to the different learning styles
objective – thereby increasing the retention of key safety messages.
10 min Crucially it explains that while we use the process to reflect on an incident by having a structured sharing
conversation around safety using different themes, it makes safety connect personally. It emphasizes that
making a change in our personal behaviours impacts our safety performance.
LEARNING FROM INCIDENTS
FACILITATOR GUIDE
What are Decide if this supporting slide is required for your audience and include it as appropriate.
barriers? The objective of this part is to explain the Swiss cheese model of identifying causes. This will allow
explanation – participants to follow the model when it comes up in the video.
5 min It is called the Swiss cheese model because the barriers with holes look like slices of Swiss cheese.
For this part there is only one animated slide. See notes on the slide pack
Before you start, Ask the group to explain:
- “What is a barrier?” in their own words?
After discussion, run through the animated slide step by step. When finished ask for one or two people to
explain, then ask if they are happy to move to the video.
Run the video using the tool. The video stops automatically after each part. The next button needs to be
VIDEO clicked to move to the next part
PART 1 Use the Menu structure on the screen.
6 min
Part 1: Background of incidents and scene setting for the incident
Introduces why safety of Navigation is important and gives the background of the incident that unfolds.
After the first part the video is paused to allow for open discussion in groups of 4 -6 people about the
BREAK 1 below questions (appears on screen)
10min 1. What different scenarios do you think could have happened next?
2. Which navigational practices have you noticed that could have been executed differently?
You should ask each small group of team members (4-6 people) to take 5 min to discuss these questions.
Each group should write down their thoughts or key talking points on the flipcharts or papers you have
provided for them. After 5 minutes ask for feedback from 1 or 2 of the groups.
Once the feedback and discussion is over, press next to continue the video.
LEARNING FROM INCIDENTS
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VIDEO Part 2: Shows what happened in the incident and the consequence
PART 2 This part shows what happens as the incident progresses and the chain of events that unfold prior the
5 min incident.
Video is paused to narrate a life story before moving on to the next set of questions.
BREAK 2 – This is a good time to share your personal story and create a personal experience for the audience.
10 min Click next to move to the discussion questions
Thereafter discuss in groups of 4 -6 people the next questions (appears on screen)
1. What are the barriers that would prevent this type of incident from happening on your vessel?
2. What could cause these barriers to fail?
3. What could be done to make these barriers more effective?
You should ask each small group of team members (4-6 people) to take 10 min to discuss these
questions and work through them one by one in the given order. Each group should write down their
thoughts or key talking points on the flipcharts or papers you have provided for them. After 10 minutes
ask feedback from 2 or 3 of the groups.
Once the feedback and discussion is over, press next to continue the video.
VIDEO Part 3: Explains the causes that led to the consequences in this incident
PART 3 The video goes through the causes that led to the consequences of this incident using the barriers that
3 min failed. Objective is to raise awareness of preventative barriers and actions. Emphasise that many of the
barriers that caused the incident have a human element to it and that it could happen to the best of
professionals, if the barriers fail.
Acknowledge that we have had some good discussions and that you hope that everyone has learned
BREAK 3 something from the engagement. Describe what needs to be done with the personal action forms and
15 min distribute the personal action forms. Be clear that the participants need to find a partner and share the
action with them including agreeing on a follow up date.
After everyone has exchanged their action forms, thank everyone for participating and encourage them
CLOSE-OUT to follow through on their individual actions and connect with their partners on the agreed date.
2 min
