1. 1 Human Element in Maritime Safety Capt. Basza Alexzandar Haji Basri Marine Officer Marine Department of Brunei

2. 2 Human Element Complex multi-dimensional issue Complex multi-dimensional issue Involves the entire spectrum of human related activities Involves the entire spectrum of human related activities Seafarers, Shipping Companies, Maritime Administrations, Recognized organization, shipyards, naval architects and others

3. 3 Human Element Studies by NTSB Canada, Cormier, UK P&I Club and Bryant Studies by NTSB Canada, Cormier, UK P&I Club and Bryant 84-88% of tanker accidents84-88% of tanker accidents 79% of towing vessel groundings79% of towing vessel groundings 89-96% of collisions89-96% of collisions 75% of allisions – ship/structure accidents75% of allisions – ship/structure accidents 75% of fires and explosions75% of fires and explosions

4. 4 Human Element Dutch study Dutch study 100 accidents100 accidents causes per accident ranged from 7 to 58causes per accident ranged from 7 to 58 human error was found to contribute to 96 of the 100 accidentshuman error was found to contribute to 96 of the 100 accidents in 93 of the accidents, multiple human errors were madein 93 of the accidents, multiple human errors were made

5. 5 Human Element 80 % Human error 20 % Technical failure

6. 6 Human Element

7. 7 People People KnowledgeKnowledge SkillsSkills AbilitiesAbilities MemoryMemory MotivationMotivation AlertnessAlertness

8. 8 Human Element Technology Technology Anthropometry (body shape and size)Anthropometry (body shape and size) Equipment layoutEquipment layout Information displayInformation display MaintenanceMaintenance Reach, strength, agilityReach, strength, agility Decision-makingDecision-making Safety & performanceSafety & performance

9. 9 Human Element Environment Environment Temperature, noiseTemperature, noise Sea state, vibrationSea state, vibration RegulationsRegulations EconomicsEconomics Physical and mental performancePhysical and mental performance FatigueFatigue Risk-takingRisk-taking

10. 10 Human Element Organization Organization FatigueFatigue Knowledge & skillsKnowledge & skills Work practicesWork practices TeamworkTeamwork Risk-takingRisk-taking Work schedulesWork schedules Crew complementCrew complement TrainingTraining CommunicationCommunication Safety cultureSafety culture

11. 11 Human Error Skill-based Skill-based Rule-based Rule-based Knowledge-based Knowledge-based Rasmussen (1986)

12. 12 Human Error Type GEMS framework (Reason 1990)

13. 13 Skill based Inattention Inattention Omissions following interruptionOmissions following interruption Over attention Over attention RepetitionsRepetitions

14. 14 Rule based Misapplication of a ”good rule” Misapplication of a ”good rule” Application of a ”bad rule” Application of a ”bad rule”

15. 15 Knowledge based Problems with complexity Problems with complexity Problems with causality Problems with causality Overconfidence Overconfidence Confirmation bias Confirmation bias

16. 16 Examples of Human Error Skill based (without intention) Skill based (without intention) Navigation (Position fixing)Navigation (Position fixing) Rule based (with intention) Rule based (with intention) Manoeuvring, Usage of life boatsManoeuvring, Usage of life boats Knowledge based (with intention) Knowledge based (with intention) Underestimate of sea stateUnderestimate of sea state Violation Violation Leaving the port without permissionLeaving the port without permission

17. 17 Measures Different failure types require different measures Different failure types require different measures Skill-based Rule-based Knowledge-based Violation Mostly ergonomics Training, Procedures, Checklists Training, Safety Management System Depending on the cause

18. 18 IMO Measures ISM Code, 1994 ISM Code, 1994 Revised STCW 1995 Revised STCW 1995

19. 19 Challenges Fatigue Fatigue Inadequate Communication Inadequate Communication Inadequate General Technical knowledge Inadequate General Technical knowledge Inadequate knowledge of own ship systems Inadequate knowledge of own ship systems Poor design of automation Poor design of automation

20. 20 Challenges Decision Based on Inadequate Information Decision Based on Inadequate Information Faulty standards, policies, or practices Faulty standards, policies, or practices Poor Maintenance Poor Maintenance Hazardous natural environment Hazardous natural environment

21. 21 Conclusions HE plays a large part in maritime industry HE plays a large part in maritime industry Safety, security, environmental protection and the sustainability of shipping industry dependent on the cultivation of a capable and effective manpower resource Safety, security, environmental protection and the sustainability of shipping industry dependent on the cultivation of a capable and effective manpower resource

22. 22 Conclusions To improve maritime safety requires commitment, dedication, knowledge and skill of a whole range of people in maritime industry To improve maritime safety requires commitment, dedication, knowledge and skill of a whole range of people in maritime industry

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