marine safety4 casualty
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Marine CasulatiesMarine Casulaties
InvestigationInvestigation
Dr. Trika PitanaDr. Trika PitanaDept. of Marine Engineering
Institut Teknologi Sepuluh Nopember (ITS), Surabaya2010
Outline
Steps of Human Error Investigation
SHEL Model
Reason Model
GEMS Framework
Conclusion
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Human Element Investigation1. Collect occurrence data,
2. Determine occurrence sequence,
3. Identify unsafe acts (decisions) andunsafe conditions; and then for eachunsafe act (decision),
4. Identify the error type and violation,
5. Identify underlying factors,
6. Identify potential safety problems anddevelop safety actions.
Collect Occurrence Data
Investigation any works related to
environment, personnels, task and
equipment
Tool: SHEL (Software-Hardware-Environment-Liveware) Model
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SHEL Model
Focusing human element contribution to
marine casualties.
Liveware
L = human being who is relatedto accident
Interaction of person subject toan accident investigation
Human element is mainlyinfluenced by individual factors: Physical
Physiological
Psychological
Psychosocial
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Hardware
Hardware refers to the
equipment used in the
transportation process. It
refers to ergonomic aspects
of workstations, displays etc.,
too.
Environment
Environment includes the
internal and external climate,
temperature, visibility,
vibration, noise and otherfactors which constitute the
conditions within people are
working.
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Software Software is the non-physical
part of the system includingorganizational policies,procedures, manuals,checklist layout, charts,maps, advisories andcomputer programs.
All this material should bepart of the ISM system.
Interrelation SHEL Component
This field covers human interactions andcommunication breakdown between individuals
by consideration of the following aspects: Oral communications (misinterpretations,
misunderstandings, improper languageusage)
Crew interaction (crew compatibility in terms ofpersonality, knowledge,experience etc.)
Work management factors (Hierarchy, Bridge TeamManagement)
Supervision (Controlling) Regulatory requirements (encourage to bend rules)
Some failures occurred during these interactions areeasy to identify if written procedures, reports, recordsetc. or even tapes are available. Some of them canbe identified through
carefully interviewing only.
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Liveware-Hardware This area refers to human-machine
interaction. Any design limitations andpeculiarities in workstationconfiguration should be considered.Furthermore workspace factors, suchas space, noise, illumination etc. canaffect the performance of the systemand should be investigated therefore.Apart from this correct usage of
available equipment as well as properfunctioning should be inquired.
Software-Liveware
These interactions refer to the informationtransfer between the human and supportingsystems. These factors are usually easy totrace, due to the fact that they can be found inthe written parts of the ISM system. Specialreference is made to checklists, standingorders and manuals. In recent yearscomputerisation was introduced in shipping,too. Therefore the proper usage of computerprogrammes should be investigated, too.Furthermore special consideration is giventowards the proper certification of the system.This means the operators (officers and crew)need to be certified according to their dutiesand the ISM system, equipment, programmesetc. should be type-approved if required in theinternational conventions.
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Liveware-Environment As already mentioned the
environment is divided into three
parts:
Internal climate, personal comfort,
physical working conditions
External weather
Infrastructure or supporting services
contributes to reducing safety orlimited choice of actions (restricted
water depth, limited navigability of
waters etc.)
Determine Occurrence Sequence
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Decision Maker Decision makers set the goals for the system
as a whole according to the input from the
environment (market, political conditions etc.).
They specify on how these goals should be met.
They even allocate the necessary resources for
this purpose to the line managementthis purpose to the line management (money,
equipment, people, time etc.). Special
consideration is given to optimise the use ofresources in order to achieve a maximum
outcome of the production process.
Line Management
Line management refers to specialists in
the different departments that implement
the strategic goals of the decision makers
within their specific spheres of operation.For shipping business this could mean
Head of the operations department,
Supervisors of the fleet, Head of the
crewing area. On board a ship line
management applies to the master.
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Pre Condition Apart from decision makers and line management a
reliable, motivated and knowledgeable workforce andsuitable equipment is necessary to start and to maintaina production process. This includes work schedules,work schedules,maintenancemaintenance programmesprogrammes, as well as environmental, as well as environmentalconditions, such as training, motivation etcconditions, such as training, motivation etc. in orderto permit efficient and safe working. This is a very widespread area on board ships. Apart from technicalaspects of equipment special consideration needs to
given to the crew. Structure, origin (number ofdifferentnationalities) etc. should be considered. Furthermore itshould be observed whether the shipping company or acrewing agency has recruited the crew.
Productive Activities
The productive activities concentrate on
the actual performances of the humans
and the machines. This means for
shipping that all process started fromloading and unloading up to navigation
and maintenance should be included.
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Defences Production can always cause risks. Ships may cause
accidents which could lead to damage of human life, aswell as to environmental disasters. Therefore appropriatemeasures should be taken in advance to reduce this risk.Some of them are required by the internationalconventions (basic standards for equipment,(basic standards for equipment,maintenance, manning of ships, training of crewsmaintenance, manning of ships, training of crewsetc.), some of them have been identified by theetc.), some of them have been identified by theshipping companies themselves, e.g. during ISMshipping companies themselves, e.g. during ISM
implementation etc.implementation etc.A simple example for suchdefences is a lookout during nighttime to assist thewatch officer.
The Human Element accident
Causation
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GEMS
Collecting Evidence
VIDEO
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Assignment
Please find out one of marine accident in
Indonesia.
Analysis the causes of marine accident in
Indonesia by using SHEL Model
Please submit the report within 3 weeks
from October 5 2010 Please make a group (member = 2
persons for each group)
References:
Schroede, J.W(2003), Marine Casualtie InvestigationHand Out
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Conclusion
You have known the principle of human
element investigation