BUILDING BRIDGESSession 3 - Safety and Environment

BERTRANC - Accident InvestigationTasks 21 & 36 - Objectives:

• To facilitate the development of a common maritime accident investigation methodology

• To improve understanding of the human element as related to maritime accidents

BUILDING BRIDGESSession 3 - Safety and Environment

BERTRANC - Accident InvestigationTechnical Secretariat:

• MaTSU (United Kingdom) - Co-Ordinator Technical Secretariat

• TRUTh (Greece)

• RINAVE (Portugal)

BUILDING BRIDGESSession 3 - Safety and Environment

Waterborne Transport Research

• The Human Element

• Safety and Environmental Assessment

• Casualty Investigation and Analysis

BUILDING BRIDGESSession 3 - Safety and Environment

BERTRANC - Accident InvestigationTwo Representatives from:

• Denmark Norway • Finland Portugal• Germany Spain• Greece Sweden• Ireland United Kingdom• Italy• Netherlands

BUILDING BRIDGESSession 3 - Safety and Environment

BERTRANC - Accident InvestigationOrganisation and Meetings:

• July 1995 to June 1999

• 10 x 2 Day Concerted Action Committee Meetings in Brussels, Piraeus, Lisbon, Stockholm, Barcelona

• Plenary and Working Groups

BUILDING BRIDGESSession 3 - Safety and Environment

BERTRANC - Accident InvestigationResults Thus Far:

• State of the art studies of maritime accident investigation methodologies and best practices

• Idealised open flexible learning method for maritime accident investigators

• Framework for a confidential hazardous incident reporting programme for the maritime industry

• Draft agreement on a pan-European maritime accident investigation procedure

• Definition of a database to hold details of the human element of maritime accidents

Current/future research

• Effort are underway to centralize PC based Databases and incorporate CHIRP in most countries

• Maritime Accident Investigator Training Best Practice :– Open Flexible Learning (OFL) Pilot Scheme– Telematically based (Internet, CD-ROM)– Improve competence, especially in Human Factors– Commonality of training within the member states (Mobility)– Preparation of Casualty Manual– Foster and develop a Mentoring system

Proposal for a Database pilot scheme

• Be revealing, which means that it distinguishes between events and the underlying causes, and that the underlying causes or latent conditions are informative because they were not easily identifiable in other ways;

• Be quantitative, so that results can be accumulated across many accidents;

• Be valid, in the sense that the revealed underlying causes are true and have predictive value for future accidents;

• Be reliable, which means that when using the same method, independent analysts should come to the same conclusions;

• Be practical, in the sense that the method is cost effective and no rare specialists need to be employed;

• Be consequential, meaning that it should formulate clear and distinct results of which recommendations for accident prevention can be deducted.

Functional aspect

• Navigation (route planning, track keeping and collision avoidance);

• Propulsion (the responsibility for the integrity of the ships propulsion system and associated auxiliaries);

• Cargo Handling (loading, keeping the cargo (including passengers) in good condition and unloading);

• Platform Maintenance (keeping the ship, its equipment (e.g. the auxiliary equipment) and the crew (the hotel function) in operational condition);

• Ship Management (the allocation of tasks and responsibilities, control and supervision and communication).

Failure of intentional actions (Reason)

• Mistakes : Planning of the action• Lapses : Mental storage of the planned action

into memory• Slips : Execution of the action.

• LEVELS OF CONTROL :– Skill based– Rule based– Knowledge based

Violations• Routine violations. These involve cutting corners, taking the path

of least effort between two points;• Violations 'for kicks'. Here the rules are broken to appear 'macho',

for thrills, or to alleviate boredom;• Necessary violations. Here, people discover that it is impossible

to get the job done by sticking to rules or that they consider as impractical legislation . This can be due to inadequate tools, bad procedures or regulations, or other situational factors outside the control of the people on the spot.

• Exceptional violations. Here, people do risky things in extraordinary situations e.g.when trying to safe the lives of others in acute danger. Exceptional violations mostly involve powerful emotions. For example, someone enters a hold of a ship and is overcome by fumes. The person behind is well aware of the danger, but is driven by the need to help a friend. He too is overcome; and so on.

General failure types or Latent cond.(TRIPOD, Reason & Wagenaar)

1. Hardware defects 2. Design failures 3. Poor maintenance procedures 4. Poor operating procedures 5. Error enforcing conditions 6. Poor housekeeping 7. Incompatible goals 8. Organisational failures 9. Communication failures 10. Inadequate training

11. Inadequate defences

Causation scenario

Latent Psychological Unsafe ActsConditions Precursors (errors, violations Accidents

(GFT's)Defences

GFT's Psychological Unsafe Acts Precursors

* Design * Double-capture slip * Skill-based : slips and lapses* Hardware * Omissions following* Procedures interruptions * Rule-based : mistakes• Error enforcing conditions * Reduced intentionality * Perceptual confusions * Knowledge-based : mistakes* Housekeeping * Interface errors* Training * Omissions * Routine violations ….. etc ……..etc. ……. etc.