MORT ANALYSIS | with Example I Gaurav Singh Rajput
1 Technology
1. TECHNOLOGY
1.
Examine the role of technology in preventing
accidents
Getting the most from the equipment you have:
Reducing the individual’s workload
2.
Evaluate the ways technology can improve Accident
Investigation
Importance of continued training for the effective
use of the Technology
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2. Why do we want good technology;
to improve safety, efficiency, reliability, quality of work
and performance (1)
Grounding occurred; the vessel was navigating on BA
charts? (2)
Grounding occurred; the vessel was navigating with
ECDIS? (3)
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3. Can we ensure equipment introduced will improve
safety, efficiency, reliability, quality of work and
performance and then still be cost efficient ?
First we judge if the cost involved reducing the risk
is really beneficial. Equipment errors/flaws and
human error must be reduced to as low as
reasonably particle (ALARP) (4)
But who is really deciding what is an acceptable
ALARP level; all regulatory Authorities (performance
standards)/Flag states, ISM code, Industry and the
Company
A lot of decisions are left for the ship owners to
decide and control (5)
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4. So if the variability of equipment in
some circumstances could be a threat and if design
and regulatory Organizations cannot constrain
variability to prevent human errors, the Company is
obliged to implement preventive and protective
barriers (6)
The way the Company can control human errors
onboard when using the equipment is to have as
many preventive and protective barriers in use so
the risk is reduced to ALARP(7)
Therefore we need to implement/identify the barriers
before the human errors occur; the common practice
we use in Risk Assessments is to identify these
barriers
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5. Minimum list of Risks for equipment to be evaluated on
a Risk Assessment:
1. Equipment error tolerances, capabilities and limitations,
visibility of errors, reliability, redundancy, monitoring,
user friendliness, un-expected side effects, overreliance
and levels of automation (LOA) and related old
equipment integration with the new equipment (8) (10)
2. Resilient equipment/installation: the ability of
equipment/system to adjust its functioning, prior to or
following changes and disturbances, so that it can
sustain operations even after a major mishap or in the
presence of continuous stress (9)
3. Crew training/office staff training sufficient?
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6. 4. Equipment fulfilling at least regulatory requirements IMO,
Flag State, Industry Standards and Company demands
5. Maintenance/implementation in PMS?
6. Supplier support if problems occur / easy access to service?
7. Replacing/upgrading; investigate the previous problems with
the equipment?
8. Larger systems, is Supplier developing upgrades that can
later be implemented?
9. Yearly service costs /service contracts/spare part
availability?
10. The Company procedures must contain barriers for all
above (preventive and protective based on the level of risk)
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7. Human error using a technology is a symptom of trouble with the equipmen
that has not been identified by the Company or regulated by the regulatory
Ny tekst
Organizations.
If an accident occur using the technology:
Investigate how people’s actions made sense at the time given the
circumstances that surrounded them.
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8. Credible data collection from equipment often form
the basis of the Investigators recommendations and
conclusions (11)
Article 8 / Investigative bodies
Article 13 / Preservation of evidence
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9. A lot of equipment onboard have electronic memory (12)
VDR versus ECDIS; ECDIS is a great immediate tool for the
Investigator and include electronic logbook and a playback
function? (13)
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10. TRAINING?
IMO, FLAG STATE, Industry and Company (14)
Article 8 / Investigative bodies
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11. SUM UP:
Grounding occurred; the vessel was navigating with ECDIS.
1. Risk Assessments and related procedures only gets as good as the
knowledge of the persons creating these (risks related to a concrete
situation must be identified)
2. Look into the list with minimum risks that must be evaluated before
implementing equipment (slide 5 + 6 ).
3. Proactive risk identification of any technology/ equipment will
enhance safety a lot, do not wait for regulatory restrictions, if
procedures are implemented and equipment set up correctly then you
will also know what data can be retrieved in case of an accident.
4. Equipment Training for all is essential both for Company employees,
various Inspectors, Investigators and Crew.
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12. QUESTIONS?
Questions?
www.nordictankers.com
kak@nordictankers.com
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Editor's Notes
Larger systems, is Supplier developing upgrades that can later be implemented? Navtex overlay / T/P overlay…..other or will your system soon be outdated. Investigate the market for future demands.
Nordic Helsinkiwasbeforetake over navigatingon BA charts, ondeparture Malta the vesselwasnavigatingonfull ECDIS. The crewwerealredytrainedwithgenetic IMO ECDIS courses, had experiance from otherfleetvesselswith ECDIS and had beforedepartureshipspscific ECDIS training.Crewcanbeshipspecifictrained to know an exact ECDIS system, but the crew still needs to know the Company demands for vital procedures not regulated by anyAuthorities.
11.VDR/SVDR download, in most cases, the assistance of specialist expertise may be required (VDR design insufficient). If backup of the VDR is not done after an accident then you might loose the data as normally this is only stored 24hrs, a backup ensures that the last 12 hrs of data is stored on the VDR. ECDIS electronic logbook, ECDIS play back is easy to access, but data can be lost if this is not done after the occurrence.
12.Assumealmost all newerelectronicequiptmentonboard have some kind of memorythatcanbeviewedwith the crew, otherwise it canberetrieved.Bridge equiptmentwithoutpaper but withmemory; Navtex, Gps, Ecdis, echosounder, fire panles, integrated bridge computers, GMDSS equiptmentDeck equiptment……ODME, gas detection systems, cargo computers withvarious alarm indications. 13.ECDIS electroniclogbooks is givinghardevidence of a lot of information , unfortunately the logbook info canbecontrolled by the operator so some info is not recorded and is thenleft to a standard setting of events logged. A filter for further events mightapply but if not selectedno default is recorded. ECDIS logbooks have memory and information canoftenberetrived long time after the occurance. ECDIS logbooksarenormallyprotected so data alredyrecordedcannotbetampered. ECDIS is nogoodwhenaudio is required. Most ECDIS systems do not show what external layers (Navtex/T&P) that was used during navigation (obscuring or assisting) and data cannot be retrieved. Meaning you do not know when the Navtex, T/P and Radar Overlay was turned on/off. This info can only be found if the ECDIS is connected to the VDR system that records the ECDIS image with video. SVDRs cannot record this normally.SVDRDate and Time,Ship'sPosition,Speed,Heading,BridgeAudio,CommunicationsAudioVDR same as above + RadarData + ECDIS - post-display selection,AIS,EchoSounder,MainAlarms,RudderOrder and Response,EngineOrder and Response,HullOpenings (doors) status,Watertight and fire door status,Accelerations and Hull Stresses,Wind Speed and Direction
The ECDIS can be safe if the features on the equipment had been used/set up correctly then more options for alerts and better system performance – Further workload could also be reduced during navigation (layers T/P + Navtex) . Overview on the bridge not in the back of the BA chart room. Then if a grounding occur the ECDIS electronic logbook and play back can be used immediately by the Investigator.