Presentation Esrel 2009
- 1. Accident Reporting Deficiencies related to Human and Organizational Factors in Engine Room Fires on Board Ships Jens- Jens-Uwe Schröder, Michael Baldauf (World Maritime University) Kevin T. Ghirxi (Malta Maritime Administration) jus@wmu.se
- 2. The shipping sector • Introduction – 42,872 ships (300 GT and above, 2007) – 1,009.5 million DWT – More than 90% of world trade involves shipping – International Maritime Organization (IMO) is the UN specialized agency for maritime affairs – World Maritime University (WMU) is IMO’s center for research and education
- 3. Standard cases for organizational factors Scandinavian Star April 1990 Herald of Free Enterprise March 1987
- 4. Why organizational factors? • IMO Res. A 884 (21) • Hybrid model (Reason 1990) – Accidents caused by a combination of factors on different (organizational) levels
- 5. Study of accident reports • Review of 41 investigation reports into machinery space fires and explosions • Majority downloaded from the IMO Global Integrated Shipping Information System (GISIS) • GISIS reports were complemented with additional reports from Australia and Sweden
- 6. Study of accident reports • Consequences of the accidents studied
- 7. How to review the accident reports • The accident investigation reports were analyzed using the Human Factor Analysis and Classification System (HFACS) framework (Wiegmann & Shappell, 2003) • The HFACS framework focuses on four levels (Wiegmann & Shappell, 2001): – Unsafe acts; – Preconditions for unsafe acts; – Unsafe supervision (workplace factors); and – Organizational influences/factors
- 8. HFACS framework as adapted
- 9. Results - overview • 368 3rd Tier contributing factors identified • Most in ‘Unsafe Acts’ and ‘Preconditions of Unsafe Acts’ • All contributing factors coded accordingly and tabulated • Analysis of the tables showed an uneven distribution of all 3rd Tier factors • Highest ranking numbers were found in: – Failed physical barriers; – Faulty equipment; – Machinery space layout; – Poor techniques/seamanship; – Wrong decision making during operation; – Poor engine-room machinery design; and – Channelized attention.
- 10. Results for unsafe acts… • 14 accident investigation reports did not identify unsafe acts; • 47% of unsafe acts where skill-based errors. 5 6 U nsafe acts 4 25 35 0 5 10 15 20 25 30 35 40 No. of contributing factors Skill-based errors Decision and judgement errors Perceptual errors Routine violations Exceptional violations
- 11. Results for preconditions… • Failures related to the technological environment represented 73% of the total conditions; • All accident investigation reports captured preconditions for unsafe acts. Preconditions for unsafe acts 4 11 3 27 152 11 0 20 40 60 80 100 120 140 160 No. of contributing factors Physical environment Technological environment Cognitive factors Physiological state Crew interaction Personal readiness
- 12. Supervision and organisational influences • A different kettle of fish…; • Persistent missing data in accident investigation reports; • Missing link with the immediate lower hierarchal levels of the epidemiological model.
- 13. Illustrative figures… Contributing factors frequency per report 7.00 6.00 5.00 4.00 3.00 2.00 1.00 0.00 AE xxx AV PE xxx PC xxx PP xxx SI xxx SP xxx SF xxx SV xxx OR OP xxx OC FS xxx xxx xxx xxx Contributing factors Very Serious Serious Less Serious
- 14. Examples of accident causes • Primarily technical causes
- 15. Earlier studies Percentage of missing Data category Data sub-category data Fire source 0 Fire detection and Fire detection 0 development Development 12% Initial fire fighting measures 0 Involved crew 100% Accessibility to the fire 18% Measures to fight the fire 12% Fire fighting Further measures to fight the fire 70% Times until commencing with actions 33% Results 6% Fire fighting Fire fighting equipment involved 27% equipment Fire fighting equipment condition 45% Source: Schröder (2004)
- 16. Current data situation Percentage of Data category Data sub-category missing data Manning of the bridge 81% Coordination of the initial measures 40% HE – Beginning of the emergency situation Initial measures 43% and initial measures Organization of emergency response teams 77% Involvement of pilots or VTS centres 93% Manning of the bridge 96% Coordination of emergency response actions 59% HE – Emergency Decision making 93% management Information gathering during the emergency 74% Problems during the emergency response actions 90% Manning of the bridge 96% Coordination of the evacuation 14% HE - Evacuation Decision making 89% Problems during evacuation 81% Source: Schröder (2004)
- 17. Resulting questions • Are organizational factors over-estimated? • Are organizational factors difficult to assess? • Are the models provided not workable in practice?
- 18. Interviews on board • The project involved ergonomic surveys of engine room outlines and interviews with engine staff • 18 engine staff members were interviewed
- 19. Interviews on board • During the past 12 months has the vessel on which you served been subject to (several options possible) Source: Grundewik, 2008
- 20. Interviews on board • Respondent comments: – Two times a month bigger disturbances. Black-out, after ½ hour fully back to normal. Seen as not serious – more routine. – Blown fuse knocked out the machinery, after ½ hour back to normal. Steering out for 10 min. Seen as not serious. – Only less power accessible. Seen as not Source: Grundewik, 2008 serious.
- 21. Investigation of organizational factors • Problems related to the investigation – Legal framework for investigations – Resources – Time available for the investigation – Commercial and liability considerations
- 22. What are the consequences for risk assessments? • Perceived growing frustration about the lack of HF data in the maritime field • Resignation of regulatory bodies and subsequent favoritism of alternative inputs to risk assessment – MarNIS – IALA – IMO PSC study
- 23. Conclusions • This presentation was not about suitable models • Clearer legal mandates and better guidelines for investigators are needed
- 24. THANK YOU FOR YOUR ATTENTION Comments or questions: jus@wmu.se