Kristiansen Svein. Maritime Transportation: Safety Management and Risk Analysis
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Ferguson et a l. (1999) lists the following alternative sources of information:
. Near-accident (near-miss) occurrences
. Hazardous situations/events
. Human or organizational relationship problems
. Lesso ns learned on safety
. Perce ived safety problems or issues
Figure 13.26. Representing secondary findings and contradictory evidence in an accident report.
(Source: Johnson, 2000 .)
416 CHAPTER 13 AC CID ENT ANALYS IS
There are different opinions about the frequency of incidents relative to accidents.
Heinrich (1950) postulated that there are 300 no-inju ry accidents for every major accident
(Figure 13.27). Ferguson et al. (1999) proposes that there are 100 incidents and 1000 safety
situations for every accident. The figures in themselves are not critical as there will be
different conditions in the different sectors of industry and transport, and there are also
different definitions of incidents and situations.
A fundamental assumption is that incidents are basically an identical phenomenon to
accidents. The only difference is that the sequence of even ts is interrupted before it leads to
damage for incidents. This opinion has been challenged because the very difference is that
incidents do not end as accidents. Incidents are in other word different phenomena and
therefore have limited learning potential.
Incident report ing may be organized in two different forms:
. Open reporting within the shipping organization
. Confidential reporting by an external and independent organization (CHIRP)
13.15.2 Open Reporting
There is obvious potential for safety improvement in operating an incident reporting
programme within the company. The main challenge is to motivate the crew to report
every relevant incident or situati on in a candid manner. This requires that the company
Figur e 13.27. Iceberg theory (according to Heinrich, 1950) .
13 .15 INC I D ENT REPORTING 417
arrange for the following:
. Top management have to promote the philosophy.
. Assure the employees that reporting is not negative to their career and does not lead to
sanctions or reprisals.
. Demonstrate how the experience will be used in the safety programme.
. Incidents reported will lead to concrete action.
. Ensure that the reporters are given feedback from the analysis of the incident.
It is presently a fact that companies have trouble in establishing a culture of reporting.
Indications from even quality-oriented shipping companies show that reporting is
infrequent and much lower than the iceberg model indicates (Figure 13.27). In order to
function adequately, the report should go directly from the person who experienced the
incident to the safety coordinator or review committee. This means that the reporting form
should be simple and not based on complicated coding schemes. We will return to this
matter in the following section.
13.15. 3 CHIRP
The Confidential Hazardous Incident Report ing Program (CHIRP) has been practised in
the aviation industry for many years. As the name indicates, the identity of the reporter is
kept confidential from the public. It represents a vast information source by the very fact
that it has also involved international exchange of data. The UK CHIRP has been
operated since 1982 and is organized as an independent charitable company (CHIRP,
2003). The system receives reports from pilots, air traffic controllers, licensed engineers
and approved maintenance organizations. The findings are reported in the newsletter
Feedback which has a circulation of 30,000.
The Marine Reporting Scheme (MARS) was set up in 1992 and has been operated by
Captain R. Beedel. It is a voluntary and non-official system and has primarily engaged the
maritime community in the UK. Reports are published in Seaways, the journal of the
Nautical Institute. The main lessons learned are (Beedel, 1999):
. Inadequate bridge watchkeeping
. Did not know Collision Regulations
. Over-reliance on instruments
. Lack of cooperation between Master and pilot
. Poor bridge and control room design
13.15.4 Reporting Form
The example on page 419 indicates how an incident might be reported by means of a
form. Notice that coding is kept to a minimum and that the description of the incident is
given primarily in plain text. The layout of the form proposed by a US initiative is given
by Ferguson et al. (1999).
418 CHAPTER 13 AC CID ENT ANALYS IS
Incident Report
1. This report is about (cross out):
q Near accident
q Dangerous co ndition, potential hazard
q Observation, proposal for improvement
2. My position on-board:
q Master q Deck crew
q Chief mate q Combined posit ion
q Engine officer
q Engine crew q Other position
3. The incident might have resulted in:
q Allision q Engine breakdown
q Collision q Pollution
q Grounding, stranding q Fat ality, injury
q Fire, explosion q Other
q Founder
4. When did it occur: Time and day
5. What kind of vessel:
6. Where did it take place (fairway category, place on-board)?
7. What kind of activity was going on (vessel phase, activity on-board)?
8. Describe incident or potential hazard:
(What initiated the incident and what happened next? Indicate failures and
errors made with reference to persons (role/position) and systems involved)
9. Describe particular physical circumstances:
(Influenced by external conditions, visibility, sea state, traffic. Conditions
on-board: Noise, vibration, climate)
10. What caused the accident?
(Technical failure, lack of equipment. Human factors: Did not see, detect, wrong
assessment of situation, a nd wrong action, and miscommunication. State or
skills of individuals: Lack of moti vation, fatigue, and competence. Organization:
Watch system, supervision, work load, social and cultural factors, etc.)
11. What went right?
(How was the potential accident avoided: Critical action or system function)
12. How can similar accidents be avoided?
(Indicate technical, personnel-related or organizational measures. Who should
address these measures?)
Processing of report
Information on where to send the report and its confidential treatment.
How to contact the reporter for supplementary information.
13 .15 INC I D ENT REPORTING 419
13.15. 5 Org aniz ation
A number of countries are presently in the process of organizing national systems for
maritime CHIRP (Kristiansen et al., 2003; Ferguson et al., 1999). Table 13.28 gives a
summary of the characteristics of some of the systems that are in the planning phase.
We will mention only a few factors that are vital for its success:
. Existence of general positive attitude to CHIRP within the industry: shipowners,
managers, shipyards, authorities and crew organizations.
. Secure independence of the industry itself.
. The CHIRP organization has the necessary resources to make the system known and
operate efficiently.
. Guarantee confidentiality and legal protection against criminal prosecution as a result
of a report.
. Personnel acknowledge the fact that information about incidents may contribute to the
prevention of serious accidents.
. Personnel have the motivation to take the time to report.
. Individuals are in a position to report.
. Being aware of the existence of the CHIRP system.
. Professional processing and analys is of reports.
. Relevant feedback in the form of reports, newsletter and statistics.
Table 13.28. Com parison of the planned marit i me CH I R Ps
Activity US UK Norway Finland
Planning of
the system
Industry-based
working group
under SNAME
MAIB MARINTEK VTT
Funding Industry and
government
Government
first 5 years
Industry
Government Government
Management Maritime
administration
Independent
organization
Independent
organization
Permanent staff 7 employees 3 employees
Reporting Paper form Paper form Paper form Paper form
Analyses Trend analyses Trend analyses
Narrative text
Classification
of incidents
Possible causes
Possible consequences
Possible frequencies
Narrative text
Classification
of incidents
Trend analyses
Status Pending Starting 2003 Pending Pending
Source: Kristiansen et al. (2003).
420 CHAPTER 13 AC CIDENT ANALY SIS
Figure 13.28 shows how it is envisaged that the Finnish maritime CHIRP organization
will process the reports. The operation will be monitored by a board. The staff will be
supported by experts in various fields due to the fact that it has to address a broad set of
incidents and related phenomena.
Figure 13.28. A schematic picture of the propo sed organization for the Finnish confidential incident
reporting system. (Source: Kristiansen et al., 2003.)
13 .15 INC I D ENT REPORTING 421
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REFERENCES 423
14
EMERGENCY PREPAREDNESS
Hell is the place where everything test perfectly and nothing works
(‘‘Campbell’s Maxim’’)
14 .1 INTRODUCTION
A substantial part of this book has so far focused on how to improve the safety of
maritime activities, primarily through the implementation of risk-reducing measures. If
the safety work is effective the numb er of accidents will be reduced, but the chance of an
accident occurring will always exist as no activity or system is 100% reliable and safe,
mainly because of human involvement. The role of emergency preparedness, also known
as contingency planning, is that of being ready to take the necessary and correct actions
in the undesirable event that an unforeseen accident occurs. Emergency preparedness
also includes being ready to initiate proper mitigating actions in the event that incidents
threaten to escalate into a major accident with serious consequences for people, property
and the environment. One thing is definitely certain: many accidents could have had
less serious consequences if the right actions had been made at the right time and in the
right place. Emergency preparedness requires that one makes the necessary planning and
training proactive ly, i.e. before something undesirable happens.
The lack of emergency preparedness was, for instance, devastatingly evident in the
grounding of the oil tanker Exxon Valdez in Prince William Sound (Alaska) in 1989.
The accident took place in protected water and under favourable weather conditions,
and the catastrophi c environmental and economic consequences of the accident were
largely the result of an inadequate handling of the situation. The mobilization of necessary
resources for the clean-up operation was seriously delayed, and in addition the
co-ordination of the containment and clean-up operation was poor. The result is now a
tragic chapter in maritime history: what was initially only a moderate-sized spill resulted in
one of the worst man-made environmental disasters of modern times.
This chapter will examine some key aspects related to emergency preparedness. After
a brief presentation of a few maritime accidents in which improved and appropriate
emergency preparedness could have reduced the consequences, the focus will be on the
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