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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