Human Element & Safety in Shipping

Transcription

1 TRAINMOS II Piraeus Greece, 19/10/2015 Human Element & Safety in Shipping Ernestos Tzannatos

2 The Maritime System.. is a People System. Technology Environment Organization

3 Technology Anthropometry Equipment layout Information display Maintenance Reach, strength, agility Decision-making Safety & performance Human Element Organization People Knowledge Skills Abilities Memory Motivation Alertness Environment Temperature, noise Sea state, vibration Regulations Economics Physical & mental performance Fatigue Risk-taking Fatigue Knowledge & skills Work practices Teamwork Risk-taking Work schedules Crew complement Training Communication Safety culture

4 Causes of Shipping Accidents Shipping Accidents 20% ENVIRONMENT 80% HUMAN 10% 10% 80% DESIGN CONSTRUCTION OPERATION

5 Human Element Human Factor Human Error Cruise Ship Costa Concordia Isola del Giglio - Tuscany - Italy January 13, Human Element: The human (and organizational) influences of marine safety and maritime system performances. Human Factor: Aspects of human capabilities (physical, cognitive, psychological) and performance as applicable to the design of organizations, systems, and devices of all kinds. Human (and Organizational) Error: Unacceptable or undesirable performance on the part of an individual (or a group) that can result in unanticipated or undesirable effects.

6 Human Factors Human Factors concern the relationship between people and technologies, tools, environments and systems. SHELL Model Source: Hawkins, F.H., Human factors of flight. Aldershot. Gower Publishing Co, England. S Software (e.g. procedures) H Hardware (e.g. equipment) E Environment L Liveware (e.g. personnel, crew) Key objectives of Human Factors is to design systems that: people can use increase efficiency and performance minimize the risks of errors

7 Human Error in Shipping Structural Failiure 7% Other 16% Crew Error 15% Mechanical Failure 6% Shore Person Error 7% Equipment Failure 9% Pilot Error 8% Deck Officer Error 30% Engine Officer Error 2% HUMAN ERROR 62% Source: UK P&I Club

8 Human Error in Shipping HOMER embodies several working class stereotypes: he is crude, bald, overweight, incompetent, clumsy, lazy, a heavy drinker, and ignorant. But, he is essentially a decent man!!!

9 Organizational Influences Human Influences in Marine Accidents Unsafe Supervision Source Based on: Reason, J., Human Error. Cambridge University Press, New York. Preconditions for Unsafe Acts Unsafe Acts Failed or Absent Defenses M/V Prestige Coast of Galicia - Spain November 13, 2002.

10 Human Factor Analysis and Classification System(HFACS) Resource Management Organizational Processes Organizational Climate O R G A N I Z A T I O N A L I N F L U E N C E S U N S A F E S U P E R V I S I O N Inadequate Supervision Planning of Inappropriate Operations Failure to Correct Known Problem Supervisory Violations P R E C O N D I T I O N S FOR U N S A F E A C T S Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Crew Resource Management Personal Readiness U N S A F E A C T S Decision Errors Skill-based Errors Percetual Errors Routine Violations Exceptional Violations

11 Human Factor Analysis and Classification System (HFACS) Organizational Influences Resource Management Human Resources Selection Manning Training Budget Resources Excessive cuts Lack of funding Material Resources Poor design Unsuitable equipment Organizational Climate Structure Hierarchy Delegation of authority Communications Accountability Policies Hiring & Firing Promotion Drugs & Alcohol Culture Norms & Rules Values & Beliefs Organizational justice Organizational Process Operations Operational tempo Time pressure Production quotas Incentives Appraisal Schedules Deficient planning Procedures Standards Clear objectives Documentation Instructions Oversight Risk management Safety programs

12 Human Factor Analysis and Classification System (HFACS) Unsafe Supervision Inadequate Supervision Planning of Inappropriate Operations Failure to Correct Problem Supervisory Violations Failed to provide: guidance operational doctrine oversight training Failed to tack: qualifications performance Failed to provide: correct data adequate brief time improper manning Task not acc. rules/reg s Provided inadequate crew rest Failed to: correct error doc identify a crew at risk initiate correction report unsafe tendencies Authorized: unnecessary hazard unqualified crew Failed to enforce rules & reg s

13 Human Factor Analysis and Classification System (HFACS) Preconditions for Unsafe Acts Substandard Conditions of Operators Substandard Practices of Operators Adverse Mental States Adverse Physiological States Tunnel attention Impaired physio state Complacency Medical illness Distraction Physio incapacitation Mental fatigue Physical fatigue Nostos Haste Situational unawareness Misplaced motivation Task saturation Physical/ Mental Limitations Insufficient reaction time Visual limitation Incompatible intelligence/aptitude Incompatible physical capability Crew Resource Management Failed to: back-up communicate/coordinate conduct adequate brief use all available resources Misinterpretation of traffic calls Personal Readiness Excessive physical training Self-medicating Violation of crew rest requirement Violation of bottleto-throttle requirement

14 Human Factor Analysis and Classification System (HFACS) Unsafe Acts Errors Violations Decision Errors Skill-based Errors Perceptual Errors Routine Violations Exceptional Violations Improper procedure Breakdown in visual Misdiagnosed emergency scan Wrong emergency Failed to prioritize response attention Exceeded ability Inappropriate maneuver Poor decision Inadvertent use of nav controls Omitted step in procedure Omitted ckecklist item Poor technique Misjudged distance/speed Spatial disorientation Visual illusion Failed to: adhere to brief use the nav aids properly prepare maneuver Violated training rules Exceeded limits of tools/equipment

15 Human Error The finding of human error should be the starting point of an investigation, not its conclusion.

16 Human Error Skill-based Rule-based Knowledge-based Source Rasmussen, J Information Processing and Human-Machine Interaction: An Approach to Cognitive Engineering. North Holland, New York. Generic error-modeling system (GEMS) Source Reason, J., Human Error. Cambridge University Press, New York.

17 Managing Human Errors

18 Measures for Human Error Skill-based Mainly ergonomics Rule-based Training & Procedures Knowledge-based Training, Safety Management System Violation It depends!!!

19 Some design errors

20 Some routine violations but we have always done it this way!

21 and some exceptional violations (or are they routine?)

22 List of hazards in ship operation: Human-related 1. Personal reduced ability, e.g. reduced vision or hearing. lack of motivation, e.g. lack of performance incentives. lack of ability, e.g. lack of seamanship, unfamiliarity with vessel, inability to communicate. fatigue, e.g. lack of sleep or rest, irregular meals. stress 2. Organization & Leadership inadequate vessel management, e.g. inadequate supervision of work, lack of coordination of work, lack of leadership. inadequate ship owner management, e.g. inadequate routines and procedures, lack of resources for maintenance, lack of resources for safe operation, inadequate follow-up of vessel organization. inadequate manning, e.g. too few crew, untrained crew. inadequate routines, e.g. for navigation, engine room operations, cargo handling, maintenance, emergency preparedness. 3. Task features task complexity and load, i.e. too high to be done comfortably or too long causing boredom. unfamiliarity of task. ambiguity of task objective. different tasks competing for attention. 4. Onboard working conditions physical stress from e.g. noise, vibration, sea motion, climate, temperature, toxic substances, extreme environmental loads, night-watch. ergonomic conditions, e.g. inadequate tools, inadequate illumination, inadequate or ambiguous information, poorly designed HMI. social climate, e.g. inadequate communication, lack of cooperation. background conditions, e.g. restricted visibility, high traffic density, restricted waters.

23 ist of hazards in ship operation: Hazards to crew inhalation of harmful substances, e.g. toxic gases burns from substances, e.g. acids electric shock fall or slip other injuries, etc. List of hazards in ship operation: Hazards to vessel Loss of watertight integrity contact or collision explosion and/or fire flooding grounding or stranding hull structural failure External influences storms lightning underwater obstacle, e.g. submerged object other ships attacks (pirates, terrorists, war)

24 List of hazards in ship operation - Hazardous substances onboard - Accommodation areas: combustible furnishings cleaning materials in stores oil/fat in galley equipment Deck areas: cargo paint, oil, greases etc. in deck stores Machinery spaces: cabling fuel and diesel oil for engines, boilers and incinerators fuel, lube and hydraulic oil in bilges, save ails, etc. residual oils refrigerants thermal heating fluid systems

25 List of hazards in ship operation - Potential sources of ignition - General: electrical arc friction hot surface incendiary spark naked flame radio waves Deck areas: deck lighting exhaust emissions hot work sparking Machinery spaces: air compressors engine exhaust manifold

26 Additional hazards: cargo flammability toxicity weight corrosion Additional hazards: operational pollution static electricity smoking naked lights use of electrical equipment use of tools use of communication equipment spontaneous combustion enclosed spaces etc.

27 Thank you.