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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
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
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
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
