Hongtae KIM. 31 October Digital Ship Korea 2012, Busan

Transcription

1 Digital Ship Korea 2012, Busan 31 October 2012 Hongtae KIM KOREA INSTITUTE OF MARITIME & OCEAN ENGINERGING RESEARCH INSTITUTE

2 I. Background II. Human & organizational factors III. Human factors investigation procedure IV. Application to marine accidents V. Conclusions

3 Marine Accidents KOREA INSTITUTE OF

4 Human Error & Marine Accident 84-88% of tanker accidents (Transportation Safety Board of Canada, 1994) 79% of towing vessel groundings (Cormier, 1994) 89-96% of collisions (U.K. P&I Club, 1992) 75% of fires and explosions (Bryant, 1991) 82.9% of marine accidents are caused by operating error (KMST, 2012)

5 Ship System & Human Operator KOREA INSTITUTE OF

6 Marine Accident & Human Element Source : An organizing framework for human factors which contribute to organizational accidents in shipping adapted from Stanton (1996),

7 Design Issues Source : HE Alert!

8 Human Error => Human & Organizational Factors Human Error Organizational Factors Human Element Structural Equipment Other

9 What are Human & Organizational Factors (HOF)? Accident Human Errors Organizational Errors Human and Organizational Factors Underlying cause of human & organizational error "Human and organizational factors are external, internal, and sociological factors, which we are surrounded by. These factors have influence on individuals and teams, and can influence us to make errors (Allen, 1984).

10 HOF in maritime accident investigation Typical catastrophes for human & organizational factors Pier Alpha explosion (1988) Exxon Valdez grounding (1989)

11 HOF in maritime accident investigation Improving Incident Investigation through Inclusion of Human Factors The Maritime System : Effect of Organization on People Source : Anita Rothblum et al., 2002

12 HOF in maritime accident investigation IMO Res. A 884(21) Appendix 2 Guidelines for the investigation of human factors in marine casualties and incidents SHELL & Reason Hybrid Model SHELL & Reason Hybrid Model

13 HOF in maritime accident investigation Human factors areas that need to be improved in order to prevent casualties. Fatigue Inadequate Communications Inadequate General Technical Knowledge Inadequate Knowledge of Own Ship Systems Poor Design of Automation Decisions Based on Inadequate Information Poor Judgement Faulty Standards, Policies, or Practices Poor Maintenance Hazardous Natural Environment U.S. Coast Guard (1995) Prevention Through People: Quality Action Team Report.

14 Human factors analysis techniques and human factors classification systems RSSB(Rail Safety & Standards Board) RAIB(Rail Accident Investigation Branch) HPES(Human Performance Enhancement System) HPIP(Human Performance Investigation Process) HFACS(Human Factors Analysis and Classification System) TRACEr(Technique for Retrospective Analysis of Cognitive Errors) IMO (The code for the investigation of marine casualties and incidents) USCG (United States Coast Guard) CASMET(Casualty Analyses Methodology for Maritime Operations) MAIB(Marine Accident Investigation Branch) HFIT (Human Factors Investigation Tool) TapRooT CREAM (Cognitive Reliability and Error Analysis Method) HFIT (Human Factors Investigation Tool)

15 Human factors analysis techniques and human factors classification systems

16 Human factors analysis techniques and human factors classification systems STEP 1 : Data collection & occurrence sequence determination Collect accident data Determine the sequence of accident SHELL Model, Interview, Simulation.. Cognitive Model STEP 2 : Human factors identification and classification Identify unsafe actions & conditions Classify error or violation type Identify underlying factors Calculate effects levels of human error Generic Error Modeling Systems (GEMS) framework Human error analysis technique (Maritime HFACS) 3. Safety actions development Identify potential safety problem Develop safety actions Causal chains

17 Case ; Collision accident In a head-on situation, the northbound Sand pump Carrier (Vessel A) collided with the southbound Tanker (Vessel B) in a visibility of over 3 miles at night. If both vessels had continued their course and speed, the collision accident would not be happened. However, each vessel failed to stand a vigilant watch and did make unsafe decisions and did act unsafely.

18 STEP 1 : Data collection & occurrence sequence determination Cognitive process model

19 STEP 1 : Data collection & occurrence sequence determination Occurrence sequence sheet

20 STEP 2 : Human factors identification & Classifica. Identify unsafe acts Identified unsafe acts and decisions related to the Vessel A ; - Fail to maintain proper lookout: misunderstood another vessel s intention/situation (2/O A-b) - Keeping watch from static position (2/O A-b) - Small alterations of course (2/O A-b) - Proceeding along the centre of the narrow channel (2/O A-b) - Did not verify the qualification of OOW (Capt. A) - Not qualified OOW on board (2/O A-b) Identified unsafe acts and decisions related to the Vessel B ; - Stuck on the mobile phone (C/O B-b) - Fail to maintain proper lookout (C/O B-b) - Fail to maintain proper lookout (C/O B-b) - Proceeding along the centre of the narrow channel (C/O B-b) - Breach of the minimum safe manning (Capt. B).

21 STEP 2 : Human factors identification & Classifica. Proposed human factors analysis model

22 STEP 2 : Human factors identification & Classifica. Underlying factors

23 STEP 2 : Human factors identification & Classifica. Lists of unsafe acts and underlying factors

24 STEP 3 : Safety actions development Collision accident causal chains focused on human factors

25 STEP 3 : Safety actions development Examples of safety actions

26 Human factors investigation manual KOREA INSTITUTE OF

27 1) The human factors investigation procedures which were developed to provide a guide to determine the occurrence sequence of marine accidents, to identify human error-inducing underlying factors and to develop safety actions 2) In recent years, it is well understood that the study of human factors is a matter which is increasingly important to reduce marine accidents. 3) Thus, it is clear that there is a need to make more research on the human factors investigation of marine accidents and to put more effort into identifying the underlying factors associated with the marine accidents in order to reduce the occurrence and to mitigate the effects of marine accidents.

28 Thank you for your attention! Hongtae KIM, Ph. D., Principal Researcher Maritime Safety Research Division Maritime & Ocean Engineering Research Institute / KIOST hongtae.kim@kiost.ac hongtae.kim@gmail.com URL :