1. Crew-centered Design and Operations of ships and ship systems Incident and Accident Analysis Aditi Kataria World Maritime University, Malmö

2. please insert your company logo on the master slide 2 Please insert your company logo here Goals  Make a case for Crew-centered Design (CCD) –Economic sense –Safe operations –Efficient operations  Explore Human Machine Interface (HMI) in incidents and accidents  Sensitise stakeholders regarding CCD CyClaDes workshop, Bremen, 27 May 2015

3. please insert your company logo on the master slide 3 Please insert your company logo here MaRiSa Database CyClaDes workshop, Bremen, 27 May 2015 Online link to the MaRiSa database: http://marisadb.wmu.se/

4. please insert your company logo on the master slide 4 Please insert your company logo here MaRiSa Database CyClaDes workshop, Bremen, 27 May 2015

5. please insert your company logo on the master slide 5 Please insert your company logo here Database functionality  Query database  Add incidents / accidents  Analyze & create graphs  Filter and download data sets as appropriate CyClaDes workshop, Bremen, 27 May 2015

6. please insert your company logo on the master slide 6 Please insert your company logo here CyClaDes workshop, Bremen, 27 May 2015

7. please insert your company logo on the master slide 7 Please insert your company logo here CyClaDes – incident & accident analysis Incident data: NTUA Accident data: WMU, NTUA & IST Alternate data sources: DNV-GL Benchmark scenarios for typical accident and incident situations: DNV-GL & BV Risk modelling: NTUA & IST Safety culture: SSPA CyClaDes workshop, Bremen, 27 May 2015

8. please insert your company logo on the master slide 8 Please insert your company logo here CyClaDes – incident & accident analysis  Role of Human Machine Interface in maritime incidents and accidents –Incident and near miss investigation (427) –Accident investigations (171) –Questionnaire Seafarers (46) Shipping Companies (9) –Interviews Seafarers (23) Shipping Companies (1) –Subsequently complemented with on-board observations, interviews with seafarers, 5 shipping organizations, 1 pilot organization and 1 training entity CyClaDes workshop, Bremen, 27 May 2015

9. please insert your company logo on the master slide 9 Please insert your company logo here Location of accident Operator User task / equipment used Type of accident Human Machine Interface – Incident & Accident Analysis CyClaDes workshop, Bremen, 27 May 2015

10. please insert your company logo on the master slide 10 Please insert your company logo here TRACEr taxonomy for incident & accident analysis  Developed for ATC domain by Shorrock and Kirwan (2002)  Utilised by CyClaDes in incident and accident analysis –Focuses on Human Machine Interface (HMI) –Adapted to the maritime context CyClaDes workshop, Bremen, 27 May 2015

11. please insert your company logo on the master slide 11 Please insert your company logo here TRACEr adapted to CyClaDes CyClaDes workshop, Bremen, 27 May 2015

12. please insert your company logo on the master slide 12 Please insert your company logo here Incident/near miss analysis –Type of occurrence – machinery, personal accidents and fire –Majority on oil tankers –Majority incidents on deck followed by engine room –Most incidents have taken place during maintenance and cargo work –The user material involved is loading devices emergency response equipment, mooring equipment, stairs and ladders. –The most common operator identified is other engineer, AB and OS CyClaDes workshop, Bremen, 27 May 2015

13. please insert your company logo on the master slide 13 Please insert your company logo here Accident analysis –Accident type: personal followed by collision and grounding in descending order –Most errors were attributed to the bridge, followed by deck and engine room –The most common operator coded was the Captain followed by the Chief Officer –Most of the task errors were coded for supervision, traffic monitoring, navigation and voyage planning –User material involved: radar, paper charts, steering panel, VHF, BNWAS, handbooks, mooring equipment CyClaDes workshop, Bremen, 27 May 2015

14. please insert your company logo on the master slide 14 Please insert your company logo here Seafarers’ questionnaire results Following aspects were considered important -  Usability of equipment  Equipment location, space layout, access  Standardisation of equipment across manufacturers  Availability & configurability of alarms & alerts  Display visibility / customised display options CyClaDes workshop, Bremen, 27 May 2015

15. please insert your company logo on the master slide 15 Please insert your company logo here Company questionnaire results  New build purchase decisions –Price, fuel efficiency, life period, regulatory compliance, usability in that order  Second hand purchase decisions –Price, fuel efficiency, robustness, life period, reliability Usability falls in the rankings for second hand vessels Seafarers suggestions were referred to as “X-Mas wishes” by a respondent CyClaDes workshop, Bremen, 27 May 2015

16. please insert your company logo on the master slide 16 Please insert your company logo here Seafarers’ interview results  AIS, OWS, gangway, pilot ladder, echo sounder, ECDIS, mooring winches, hatch covers, alarms, pipes and manifolds, purifier, ballast water pumps, generators to be made more user friendly  Ballasting, mooring, cargo operations, navigation in restricted waters, bunkering and maintenance work considered important CyClaDes workshop, Bremen, 27 May 2015

17. please insert your company logo on the master slide 17 Please insert your company logo here Company interview results  Ship type drives design considerations –Specialised ship Extensive deign engagement Price no object Opinion of employed seafarers important – retention strategy Design, habitability, safe work environment, reliability, usability, strength/robustness important –Commodity vessel Off the shelf purchase No employee engagement in design Price, operational cost and cost of capital important considerations CyClaDes workshop, Bremen, 27 May 2015

18. please insert your company logo on the master slide 18 Please insert your company logo here Negative consequences of not doing CCD Not engaging with CCD has shown to have consequences for safety, efficiency and even economic repercussions Examples of poor design examples leading to negative outcomes are highlighted next - CyClaDes workshop, Bremen, 27 May 2015

19. please insert your company logo on the master slide 19 Please insert your company logo here (In)accessible for maintenance “Layout of the ballast valves; some are placed in a very ridiculous spot that maintaining it would be next to impossible. There is not enough room to manoeuvre so you’ll have to resort to acrobatics. There was this problem on one ballast valves inside the duck keel. They planned the replacement of the valves and went inside. Upon seeing the location of where the valve is, they put chain blocks, lashings and levers just to move the valve from the tight spot while doing their acrobatics. One seafarer lost his handle on one pipe that supported his balance and suffered multiple hits. His head hit the other pipe, his knee hit the frame and his elbow hit the bulkhead.” CyClaDes workshop, Bremen, 27 May 2015

20. please insert your company logo on the master slide 20 Please insert your company logo here Similar Windlass and Steering motor switches A narrow miss – A new AB went to switch on the windlass. Instead of switching it on, he switched off the steering motor. The vessel suddenly lost power started to move to starboard while approaching a port. There were no alarms on the bridge or engine room. Shortly the power came back and it was learned that the Bosun had told the AB that there was no power and the AB had realised what he had done and switched on the steering motor. CyClaDes workshop, Bremen, 27 May 2015

21. please insert your company logo on the master slide 21 Please insert your company logo here Narrow, unsuitable piping system: oil spill The operator from the port lost patience with the delay in draining the long arm, that he disconnected before all of the oil had been completely drained which resulted in an oil spill on the deck. Design angle: narrow and unsuitable piping system requiring constant switching of pumps. The design issue had been brought to the attention of the company who were delaying fixing it but after the oil spill incident, retrofitted three ships of the same class. CyClaDes workshop, Bremen, 27 May 2015

22. please insert your company logo on the master slide 22 Please insert your company logo here Ballast pump damage During deballasting, sometimes some tanks are empty, and an operator forgot that, the ballast pump was a centrifugal pump and it keeps running so that it actually brings cavitation and breaks the pump. Design angle: There should be an auto-cut off to save the pump in case of low pressure. CyClaDes workshop, Bremen, 27 May 2015

23. please insert your company logo on the master slide 23 Please insert your company logo here Slips, trips and falls A company was sued by an employee who fell carrying equipment on a stairway. “It is expensive when two lawyers talk” Company representative Even though the SOLAS requirement is one handrail, the company installed two to protect themselves from further litigation. CyClaDes workshop, Bremen, 27 May 2015

24. please insert your company logo on the master slide 24 Please insert your company logo here Lifeboat fatality During lowering of a free fall lifeboat, one clamp opened and the other didn’t, leading to a fatality due the impact. Design angle: Either both clamps should open together or none at all. The securing fixtures/straps in the lifeboat should secure personnel properly to protect against impact. Anthropometry a key concern. CyClaDes workshop, Bremen, 27 May 2015

25. please insert your company logo on the master slide 25 Please insert your company logo here Dangerous mooring operations A fatal accident in which mooring operations were ill supported by design - Mooring winch controls located further ahead, so that operator can see over the flair, gun valve and … “The rope parted … like a sword… and then they saw the chief officer standing there without the head…they found his head two holds away.” CyClaDes workshop, Bremen, 27 May 2015

26. please insert your company logo on the master slide 26 Please insert your company logo here Forgetting to put the locking knot – fatal consequences The respondent mentioned he was aware of at least three fatalities that occurred in his company because of the failure to put the locking knot in the purifier and as many as 200 blades rotating at 10,000 rpm cut up the individuals. The design angle:  Purifier should not start without locking knot in place  Purifier should give an alarm CyClaDes workshop, Bremen, 27 May 2015

27. please insert your company logo on the master slide 27 Please insert your company logo here (Un)fit for purpose CyClaDes workshop, Bremen, 27 May 2015 “I have been a pilot for 26 years, so I saw different types of VHF, radar, autopilot etc. 2-3 times per working day. In the past I have kept lists of what was particularly good and particularly bad on bridges, I am sorry that I don’t have these anymore. Examples: radar with 125 buttons, radar with important settings hidden far away in menu structures, VHF automatically switching to 16, VHF needing ‘enter’ without indicating in any way, radars and VHF not near one another. In all kind of equipment cryptic indications (e.g. to find received messages on an AIS you had to open the “send message” menu. What to think of a GPS Receiver where the dimmer button was also the on/off button (short push: dimmer, long push - off…). How many examples are needed to demonstrate that much of the equipment is not fit for purpose at all……?”

28. please insert your company logo on the master slide 28 Please insert your company logo here To conclude “it takes a crew to run a boat” “Experience bears into maintenance and repair” Crew Centred Design “Understanding the needs of the operator; Understanding the goals of the operator; Understanding the context in which the operator fulfils the task; Understanding the language of the operator” CyClaDes workshop, Bremen, 27 May 2015

29. please insert your company logo on the master slide 29 Please insert your company logo here Interactive session CyClaDes e-learning web link – http://elearning.cyclades-project.eu/ CyClaDes workshop, Bremen, 27 May 2015 S.No.User idPassword 1student1Newpass1234! 2student2Newpass1234! 3student3Newpass1234! 4student4Newpass1234! 5student5Newpass1234!

30. please insert your company logo on the master slide 30 Please insert your company logo here Interactive session CyClaDes workshop, Bremen, 27 May 2015 Online link to the MaRiSa database: http://marisadb.wmu.se/ User idPassword wmu13cyclades-admin