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IV.D. Using SHEL in Complex Systems
Complex systems often contain many people. The SHEL model can be used to organize information (and guide fact-finding) by considering that people interact with several people, each of them may interact with several more people. Accordingly, in complex systems, the SHEL model can be represented with multiple people:
In this diagram, each person (each member of the bridge crew, or the operator of two
vessels and a VTS operator) should be represented as the "center" of a SHEL diagram, each interacting with the others.
V. USING SHEL TO GUIDE FACT-FINDING
In a practical sense, the number of possible SHEL components affecting each person involved in a marine casualty or pollution incident is very large. If a marine investigator were to describe each possible element of the marine transportation system in detail and then to comprehensively rule out every possible mismatch, the process of conducting fact-finding would be exhausting. Accordingly, the marine investigator should consider the four principal components in the general sense, and should inquire exhaustively into only those areas that are immediately relevant to the incident. Questions about a person's marital status, for instance, are not appropriate when a person's performance is either a) tangential to the incident; or b) not in question (i.e., they did nothing wrong). Generally, information about the other conditions (type of equipment in use, weather and sea state, vessel characteristics, names of people involved and their roles) should be collected first. The section below provides guidance on what order to acquire certain topics.
 
V.A. Order of Topics in the Interview
The temptation during any interview, and particularly during interviews of a cooperative witness, is to presume that the witness is entirely forthcoming and accurate. Marine investigators should remember that extreme care must be used in establishing a rapport with the witness. Part of building this rapport involves gradually easing into discussion of those subjects most uncomfortable for the witness. Witnesses generally feel most comfortable giving factual information (as opposed to opinion information) about matters seemingly external to themselves. Accordingly, marine investigators will begin the interview by obtaining descriptions of the SHEL components involved. Such descriptions might include:
・A list of who was involved in the incident, who was talking with whom, and so on (Liveware to Liveware interactions).
・A list of what equipment was in operation, its condition (Hardware)
・What policies and guidance were in effect, what charts were being used, etc. (Software)
 
Once the outlines of the SHEL model for that person have been established, the marine investigator will proceed "around the diagram" once again, this time focusing on the interactions. Such questions are slightly more uncomfortable, but build on previous discussion. For example, these questions might include:
・A discussion of how well the bridge team got along (Liveware to Liveware Mismatch)
・How well the pilot could see from the starboard radar (Hardware to Liveware Mismatch)
・Whether the Ship's ISM policies were actually read, or just a paperwork drill (Software to Liveware Mismatch)
Finally, the marine investigator will proceed into the most personally uncomfortable aspects of the interview: the factors affecting the witness themselves. Recognizing that people may act to protect their own self-image and/or to hide matters from the investigation, marine investigators should carefully corroborate information provided by a witness pertaining to themselves. Experience indicates that the majority of this information about a person is derived from interviews with other people. For example questions might include:
・"I have to ask: were you using drugs or alcohol?" (Physiological Factors)
・"Did you receive a bonus for reducing the ship's maintenance expenditures?" (Psycho-social Factors)
・"Do you have problems seeing with your glasses off? Were you wearing them?" (Physical Factors)
・"How were you handling all off those radar contacts at the same time?" (Psychological Factors)
Once these topics have been adequately discussed, the marine investigator should then turn his or her attention to the mismatches in their interaction. These mismatches are Latent Unsafe Conditions (LUCs) that will be used in the Causal Analysis.







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