reflections on investigating marine accidents - with focus on human performance e-nav conference,...
TRANSCRIPT
Reflections on investigating marine accidents- with focus on human performance
E-Nav Conference, Nordic Institute of Navigation
12.Feb 2013
Pål Brennhovd
Inspector of Accidents
Accident Investigation Board Norway
SOLUTIONS
A safety investigation is to answer
• What happened?
• Why?
• What can we learn from it?
SAFETYPROBLEMS
e-Nav, defined by IMO:e-navigation is
the harmonized collection, integration, exchange, presentation and analysis of marine information onboard and ashore
by electronic means
to enhance berth to berth navigation and related services for safety and security at sea and protection of the marine environment
IMO Strategy for e-nav (MSC 85/26)
The MSC document emphasizes the important
human factor, where research indicates that around 60 % of collissions and groundings are caused by direct human error.
It is therefore important that
any integrated navigation or decision-support system
be designed such as to relieve the officer of the watch from some of the burdens of whatchkeeping
while, at the same time,
be sufficient intelligent to filter out some of the less crucial information
and not draw the navigator into a false sense of security by over-reliance on the equipment or the information presented
Safety investigations conducted by AIBN, marine only
Fishing vesselsCargo vesselsPassengerOther
Grounding of container vessel ,Godafoss, Hvaler, 17.Feb 2011, 19:52
• Reduced level of activation: The master
• Insufficient communication and coordination between captain and pilot assumptions
• The pilot disembarked at Løperen• Captain remains alone on the bridge
(narrow waters, dark, national park)
• Pilot boat returned to land
• Misperception of the environment (Situational awareness, level 1)
• The observations confirm captain’s assumptions. Other observations are ignored. (Confirmation bias)
• Decisions and interpretation of the surroundings remained uncorrected Pål Brennhovd, SHT
Grounding of container vessel ,Godafoss, Hvaler, 17.Feb 2011, 19:52
• Safety management systemThe use of dedicated lookout to other tasks – resources
Planning of the voyage
Persisted over time considered as normal and acceptable pratice by the crew (revisions, risk assessments, etc)
• Bridge crew and pilot - BRMNo clarification on how to conduct the outbound voyage
Did not work as a unified team
• Pilot disembarkationNormal pratice to disembark before pilot boarding ground – disregard sea condition
The newly revised instruction allowed this
Previous non-conformity reports and national park made no impact on the instruction
Pål Brennhovd, SHT
Grounding of container vessel ,Godafoss, Hvaler, 17.Feb 2011, 19:52
One qualified and experienced person on the bridge, but ….
Pål Brennhovd, SHT
High-speed vessel touched a rock Lyse Express, Eidssund, 16. Aug 2008 17:45
• Planning of voyage
• Communication between master and engine room attendant
• The master was distracted
• The vessel’s maneuverability
Distance between rock and land: 20 m
High-speed vessel touched a rock Lyse Express, Eidssund, 16. Aug 2008 17:45
• Ship manager’s procedures: Cooperation and communication between master and engine room attendant mainly ignored
• Engine room attendant: Not trained for navigation Had not high-speed qualificationsTraining, checking-out, and exercise program for navigation did not include the attendant
• Regulation concerning qualification: Ambiguous about requirements to crew members for smaller high-speed vessels (other than the master)
Distance between rock and land: 20 m
Distance between rock and land: 20 m
High-speed vessel touched a rock Lyse Express, Eidssund, 16. Aug 2008 17:45
Two persons on the bridge, but …
Distance between rock and land: 20 m
Distance between rock and land: 20 m
Grounding of cement carrier Crete Cement , Nesodden, 19.Nov 2008 06:31
• Narrow watersSmall margins for when changes of course had to be conducted, but the ship’s bridge resources had not been reinforced
• No redundancy for navigationThe officer on watch was required to deal with other tasksLimited communication between the persons on the bridge
• The pilotPreviously heavy work loadStrong sleepines
• Consequences of the groundingThe vessel had not watertight integrity
Ship manager
Recommended to implement measures to ensure the presence of sufficient bridge resources at all times for the vessel’s crew to be able to navigate the vessel safety and monitor the pilot’s navigation
The National Coastal Adm.
Recommended to implement measures to ensure that pilots have sufficient sleep and rest.
Grounding of cement carrier Crete Cement , Nesodden, 19.Nov 2008 06:31
Two qualified and experienced navigators on the bridge (and a lookout), but …
Grounding of cement carrier Crete Cement , Nesodden, 19.Nov 2008 06:31
High-speed vessel collided with a fixed navigation markHelgeland, Lovund island, 13.Dec 2009 21:55
• Narrow waters, high speed
• Reduced situational awareness by the bridge crew
• Supervision of navigationBoth navigators focused on the take-over of the other vesselBoth navigators assumed the other one had control on the ship’s position in the fairway
• PlanningHow to react when the plan has to be changed?
High-speed vessel collided with a fixed navigation markHelgeland, Lovund island, 13.Dec 2009 21:55
The ship manager’s safety management system
To improve• planning of voyages• control of voyages• arrangements for communication and
coordination among members of the bridge team
High-speed vessel collided with a fixed navigation markHelgeland, Lovund island, 13.Dec 2009 21:55
Two qualified and present high-speed navigators, but …
Grounding of bulk carrierFederal Kivalina, Årsundøya, 6.Oct 2008 05:10
Three qualified navigators, lookout,
helmsman,
but …
Ran aground
Within normal practice
If each of the steps 1-4 is viewed independently,
the execution was regarded as normal practice.
The ship ran aground because the ship’s crew and pilot did not identify indications of increasing loss of control over the navigation
Foto: Kystvakten
Ship management
Implement measures that ensure that the bridge crew work together as a well-functioning bridge team when there is a pilot on board
National Coastal Administration
• Training of pilots: Pilots can more efficiently be part of a well-functioning bridge team
• Prerequisites for piloting are fulfilled by the ship’s bridge crew prior to commencement of piloting
• Introduce measures to improve organisation and retrieval of necessary information in order to improve conditions for the pilot and the bridge crew
Grounding of bulk carrierFederal Kivalina, Årsundøya, 6.Oct 2008 05:10
Quay operator
carry out risk management of the quay facility and ships, and establish and evaluate criteria for when it is safe to go alongside the quay
Human Error Human Performance≠
Human error
Is not a conclusion or cause,
but may be
a starting point for further investigation of the system
or
a symptom of a problem in the system
Human PerformanceShifting the focus to
human work within complex socio-technical systems:
Vulnerabilitites in a system – a fallible system
Human-centred work practices
Everyday work environment is inherently imperfect
Enhancing the positive role humans play in fallible systems Owen, Béguin, Wackers, Risky Work Environments, Asgate 2009
e-Nav, defined by IMO:e-navigation is
the harmonized collection, integration, exchange, presentation and analysis of marine information onboard and ashore
by electronic means
to enhance berth to berth navigation and related services for safety and security at sea and protection of the marine environment
