Kristiansen Svein. Maritime Transportation: Safety Management and Risk Analysis
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irrespective of how they were initiated – by system failure or operator error. The attribute
values are outlined in Table 13.22.
The description of an equipment failure needs certain attributes in order to be
meaningful in a coded format (Table 13.23). The most immediate characteristics
would be the system involved and where it is located. A number of other factors may
also be relevant, but it is limited here to the kind of failure and the immediate
physical cause.
Human error is another dominant accidental event type. In the same manner
as for equipment failure, certain attribut es seemed to be obvious, namely position
and task affected by the error. Secondly, it seemed feasible to characterize the
Table 13.20. Definition of accidental event
Event type Definition/explanation
Hazardous material Critical events are associated with the presence of explosive, flammable
or toxic material. The main sources are cargo and fuel.
Environmental effect Factors like wind, waves and current may have significant effect on
the behaviour of the vessel. These factors may not necessarily show
extreme strength in order to explain the accidental process.
Equipment failure A system module or component does not function as intended due to
some sort of breakdown. Loss of function may also be the result of
operating outside the specified performance (overload, overcapacity).
Human error Operator performs in conflict with intended procedures or in a less than
adequate way. Main forms are omission, commission, wrong timing or
sequence. All kinds of negligence will also fall under this category.
Other agent or vessel Lack of or inadequate support of other vessels, agents or infrastructure.
This group should be applied for phenomena that are not a part of the
investigation or an external influence.
Ta b l e 13 . 21. Attributes for accidental events
Accidental event type Attributes
Hazardous material Material Hazard
Location Failure type
Environmental effect Phenomenon Impact
Equipment failure System involved Failure type
Location Immediate physical cause
Human error Position Performance mode
Task affected Error type
Other agent or vessel Role Performance mode
Task affected Error type
406 CHAPTER 13 AC CID ENT ANALYS IS
kind of behaviour (performance) and error type. The attributes are outlined in
Table 13.24 (p. 409).
Environmental effects, as described in Table 13.25 (p. 409), have two subgroups,
namely physical loading on the vessel and limited visual conditions. The second group
may primarily influence the visual conditions for the bridge watch and to a certa in degree
also the instrument sensors.
The sequence of events for a casualty may be influenced by the intervention of external
parties. This effect may be adequate for ameliorating the consequences but may in some
instances also have a negative effect on the casualty. External agents may either be systems
or assisting vessels or human/organizat ional resources. They may basically fail in the same
way as the vessel itself by equipment failure or human error. The coding will therefore be
similar and so is not described here.
13.13.7 A Case on Event Representation
A casual ty may involve one or a number of events. The idea behind the CASMET model is
that it should handle any number of events and their sequence of appearance. The example
in Figure 13.22 (p. 410) illustrates the interaction between casualty and accidental events.
A broken fuel line sets off an engine room fire that is put out too late due to delayed
mobilization of the firefighting team. This results in loss of propulsion power and, as the
attempt to anchor is also unsuccessful, subsequently leads to drift grounding. Typical
attribute values are indicated for the events.
A simplified summary of the coding structure can be found in Figure 13.23. Note that
it is incomplete and therefore only shows the principles of the coding scheme. The two
upper sections address the events representation. The lower part shows the coding
structure for causal factors, which will be discussed in the next section.
Table13.22. Hazardous material attributes
Attribute Code values
Material Crude oil White spirit Lubricating oil
Diesel oil Gasoline Chemical
Location In the water Engine room Ballast tanks
On land (near vessel) Fuel tanks Void, cofferdam
Bridge Deck stores, paint locker Fore peak
Living spaces, offices
Galley
Deck machinery room
Engine stores
Bow
Open deck
Engine control room Cargo holds Deck house, mast, etc.
Pump room Vehicle deck Aft area, after peak
Cargo tanks
Hazard Empty tank – not gas freed Leak Loaded tank
Vents
Failure type Explosive mixture Reactivity Toxic fumes
Flammable mixture Self-reaction Pollution
13.13 THE CASM ET APPRO A CH 407
13.13.8 Causal Facto rs
The analysis process has so far concentrated on identifying the acciden tal events. The next
step is now to give a diagnosis or answ er as to why the casualty took place. Causal factors
may be seen as conditions or actions not directly associated with the accidental event
sequence and therefore will have taken place or arisen prior to the casualty. In other
words, causal factors are the factors that put the vessel at risk.
Causal factors are related to the following two decision levels:
1. Daily operations on-board.
2. Management and resource-oriented decisions ashore.
The first level focuses on working conditions and organization of work on board. The
main responsibility rests with the Master, department leaders and other supervisors.
Table 13.23. Eq ui pme nt fail ure parameters
Attribute Code values
System involved Ballast, stability Firefighting Hull
Bilge, drain Door Engine
Boiler Hatch Life-saving
Cargo Bulkhead Navigation
Deck machinery Fuel Propulsion
Dry cargo General safety Steering
Electrical Habitation
Location Bridge Fuel tanks Cargo tanks
Living spaces, offices Engine stores Ballast tanks
Galley Deck stores, paint locker Void, cofferdam
Engine control room
Pump room
Deck machinery room
Cargo holds
Fore peak
Bow
Engine room Vehicle deck Open deck
Deck house, mast, etc.
Aft area, after peak
Failure type Bent, buckled Pitted Out of range
Burst Penetrated, holed Outdated
Fractured Torn Unclean
Loose, parted Not appropriate Worn
Missing Insufficient Inaccessible
Immediate
physical cause
Not installed Incorrect loading
Not in operation Normal wear
Accident damage Overload
Corrosion Fatigue
Erosion Flooded
Material defect
408 CHAPTER 13 AC CID ENT ANALYS IS
Ta b l e 13 . 2 4 . Human error parameters
Attribute Code values
Position Master Engineer Travel repairman
Mate Electrician Steward department
Bosun Engine crew Longshoreman
Deck crew Pilot Passenger
Visitor
Task affected Anchoring Lubrication Lookout
Towing operation Main engine operation Monitor radar, ARPA
Mooring Aux. engine operation Assess collision risk
Cargo handling Engine maintenance Monitor instruments
Cargo pumping Deck maintenance Set speed, r.p.m.
Load plan Cargo space maintenance Set heading, rudder
Stability control Vessel command Ship handling
Close door Trip planning Give navigation order
Secure hatch Position fixing Communicate
Ballasting Monitor wind, current Radio communication
Bunkering Give signal
Performance
mode
Detection Analysis Manual control
Identification Decision-making Communication
Perception Activation Ordering
Error type Attempted Inadequate Omission
By-passed Exceeded, excessive Ignored
Commission Improper Overestimated
Delayed Imprudent Underestimated
Disregarded, ignored Ineffective Wrong timing
Table 13.25. En v i ronmental effect att ri butes
Attribute Code values
Phenomenon Wind Channel effect Fog, haze, smoke
Wave Hydrostatic head Rain, snow, hail
Current Light Icing
Shallow water Whiteout Debris
Impact Drift, set Reduced steering ability Reduced visibility
Impact
Roll, heave, etc.
Unstable course
Green/white water
Inadequate light
Inflow, flooding
Squat List Outflow
13.13 THE CASM ET APPRO A CH 409
The second level reflects the fact that safety critical decisions are also taken by the owning
and managing company. They are responsible for setting up the organization and the
management system and also for taking key decisions relating to the hiring of personnel
and the acquisition of vessels.
Causal factors grouping related to conditions on board is outlined in Table 13.26
(p. 412). The causal factors associated with the supporting shore organization are sum-
marized in the same manner in Table 13.27 (p. 413).
13.13.9 A Case on Causal Factors Representation
The analysis of casua lty and accidental events was illustrated by a case example in
Figure 13.22. We will develop this further here by showing how causal factors might
be related to the accidental events (see Figure 13.24, p. 414). Let us take the first event,
namely ‘broken fuel line’. The analys is revealed that the failure could be traced back to
‘lack of repair skills’ and ‘lack of instruction’ of the crew member who did the repair task.
It was further assessed that the faulty repair job was not detected due to an ‘insufficient
inspection programme’. The latter cause was traced back to an inadequate mainte-
nance policy in the company. Similarly we found causal factors for the other two
accidental events.
13.14 CASE-ORIENTED ANALYSIS
The focus on coding and statistical analysis of accident findings has been subject
to criticism. Johnson (2000) argues that the learning process might be improved by
focusing more on the individual report and emphasizing more the logic in the causal
Figure13.22. Modell ing of accidental and casualty events.
410 CHAPTER 13 AC CID ENT ANALYS IS
analysis. He argues that each causal factor should be supported in a structured manner as
follows:
. Conclusi on: statement of the causal explanation.
. Analysis: analysis of factors and lines of argument that support the conclusion.
. Evidence: facts and observations that support the analysis.
Figur e 13.23. Codi n g tax onomy (rou g h out line) .
13.14 C A SE - ORI E N T E D A N A LYS I S 411
Table 13.26. Basic causal factor s, daily operation
Causal group Causal factors
Social environment Labour–management relations Person-to-person conflict/animosity
LTA communication Safety awareness, cutting corners
Language problem Cowboy attitudes, horseplay
Social and cultural barriers and
conflicts
Resistance to change
Supervision Lack of co-ordination of tasks Expectations of supervisor is unclear
Inadequate work preparation Inadequate work method
Inadequate briefing, instruction Conflicting orders, cross-pressure
Lack of resources Inappropriate peer pressure
Supervisors not in touch Improper supervisory example
Manning Long working periods, much
overtime
Idleness, waiting
Low job satisfaction, monotony
Frequent change of watch schedule Lack of responsibility for own job
Wrong person assigned Inadequate manning
Too high/too low work load
Personnel Lack of motivation
Lack of skill
LTA physical/physiological
capability
Lack of knowledge LTA mental and psychological state
Sea sickness
Workplace
conditions
Anthropometric factors/dimensions
Lack of information, inadequately
presented information
Display design, controls
Inadequate illumination
Hazardous/messy workplace
Physical stress Noise, vibration Toxic substance, other health hazards
Sea motion, acceleration Lack of oxygen
Climate, temperature
Inadequate tools
and equipment
Right tools and equipment
unavailable
Inadequate standards or
specifications
LTA assessment of needs and risks Use of wrong equipment
Inadequate tool or aid
Maintenance Failure not detected during IMR
Lack of maintenance
Improper performance of
maintenance/repair
Inadequate maintenance System out of operation
Environmental
conditions
Too low visibility for observation
Traffic density hinders vessel control
Hindrances in the seaway
Restricted fairway
Emergency
preparedness
Contingency plans not updated
Training ignored
Inadequate control of life-saving
equipment
Lacks initiative to deal with
emergencies
Lack of leadership
Lack of information to passengers
412 CHAPTER 13 AC CID ENT ANALYS IS
Ta b l e 13 . 2 7. Causal factors related to management and resources
Causal group Causal factors
Business climate Economic conditions
Market change
Bad relations with other
organization
Extreme competition
Organization and
general management
Policy, ethical values Support from land organization
Focus on liability and
punishment
Too wide control span
Authoritarian command style
Communicate policy Unclear roles and responsibility
Set standard by example
Company loyalty and
commitment
Response to feedback from
employees
Cross-pressure from schedule
and economy
Lack of communication and
coordination
Vessel undermanned
Operations
management
Pressure to keep schedule
and costs
No review of critical
tasks/operations
Inadequate procedures and
checklists
Management training
SE management Critical system and cargo
documentation
Concern for quality improvement
Inadequate promotion of safety
Inspection LTA safety plan and program
Follow-up of non-conformities
Incident reporting, analysis,
improvement
LTA formal safety assessment,
risk analysis
Work instruction
Occupational health
management
Information about health risks Substandard hygiene onboard
Personal protective equipment LTA medical services provided
Health control of personnel Follow-up of programmes and plans
Workplace inspections No off-the-job safety policy
Personnel management Hiring and selection policy Control by use of overtime
Inadequate training programme Opportunity for advancement
Selection/training of officers High turnover, lack of continuity
System acquisition Substandard components
Substandard contractors
Verification of contract
requirements
Control of contractors Inadequate testing
Design Deviation from standards/
specifications
LTA design verification
LTA system review and evaluation
Inappropriate regulations LTA change management
Design error
Maintenance policy Lack of priority to IMR LTA planning
Lack of competent repair
personnel
Lack of follow-up and
compliance
Emergency
preparedness
Emergency plans
Emergency procedures
Inadequate fire-fighting equipment
Emergency training programme
Management training Life-saving equipment
Crisis handling Lack of decision support
Maintenance of life-saving
equipment
Lack of warning systems
13.14 C A SE - ORI E N T E D A N A LYS I S 413
In order to visualize the a nalysis, Johnson (2000) propose a so-called CAE diagram
format. Figure 13.25 shows an example of a machi ne room engine fire. The cause of the
fire was a result of technical failures and lax maintenance procedure (C2). This assessment
was based on four lines of argument:
A6: Diesel oil sprayed from a shut-off cock.
A7: The spindle bonnet of the shut-off cock had vibrated loose.
A8: The handle of the shut-off cock had been released and resulted in removal of the
locking function.
A9: Despite having spare assemblies the missing handles had not been replaced.
Each of these analysis elements is supported by evidence documented in the right-hand
diagram blocks. Apart from bringing an overview of the analysis in the accident report,
the CAE diagram is also a useful medium for integrating supplem entary or contradictory
evidence from other sources. Figure 13.26 shows how findings from the Chief Engineer’s
workbook indicate that fuel links had been detected earlier but not dealt with.
13.15 INCIDENT REPORTING
13.15.1 Motivation
There is a growing understanding that accidents represent a limited source for learning by
the fact that they happen fairly infrequently. This raises the question of the potential of
incidents and other non-conformities. A second argument for the study and analysis of less
serious events is the very fact that the ISM Code states that all kinds of incidents and
non-conformities should be used in the learning process.
Figure 13.24. Causal factors related to accidental events.
41 4 CHAPTER 13 A CCI DENT ANALY SIS
Figure 13.25. CAE diagram of the causes of the fire. (Source: Johnson, 2000.)
13 .15 INC I D ENT REPORTING 415