ISSN 2083-6473
ISSN 2083-6481 (electronic version)




Associate Editor
Prof. Tomasz Neumann

Published by
TransNav, Faculty of Navigation
Gdynia Maritime University
3, John Paul II Avenue
81-345 Gdynia, POLAND
www http://www.transnav.eu
e-mail transnav@umg.edu.pl
Effective Learning from Safety Events Reporting Takes Two: Getting to the Root & Just Culture
ABSTRACT: SAFEMODE is an EU-funded project under the Horizon 2020 programme. The project brings together experience from the whole safety value chain including manufacturers, service providers, regulators, academia, and small-medium enterprises. This paper focuses on two core aspects the project is addressing: 1) the systematic collection, analysis, and categorization of Human Factors (HF) data from maritime and aviation safety events, and 2) the development of a Just Culture framework for maritime to encourage reporting of safety events and learning from them, and at which respondents feel they are treated in a fair and just manner when reporting. Learning from safety events is only possible if root causes of accidents and incidents are properly and systematically identified, analysed, and categorized, and reporters know that reporting is a “safe” and beneficial practice. The implementation of these two outcomes as part of the institutionalization strategy of the project includes recommendations to industry guidance and practice and proposals to the International Maritime Organization (IMO).
Apostol-Mates, R., Barbu, A.: Human error-the main factor in marine accidents. Naval Academy Scientific Bulletin. 19, 2, 451–454 (2016).
Baumler, R., Bhatia, B.S., Kitada, M.: Ship first: Seafarers’ adjustment of records on work and rest hours. Marine Policy. 104186 (2020). https://doi.org/10.1016/j.marpol.2020.104186.
Bhattacharya, S.: Sociological factors influencing the practice of incident reporting: the case of the shipping industry. Employee Relations. 34, 1, 4–21 (2012). https://doi.org/10.1108/01425451211183237.
Conchie, S.M., Donald, I.J., Taylor, P.J.: Trust: Missing Piece(s) in the Safety Puzzle. Risk Analysis. 26, 5, 1097–1104 (2006). https://doi.org/10.1111/j.1539-6924.2006.00818.x.
Dekker, S.: The Field Guide to Understanding Human Error. Ashgate Publishing Company (2006).
Ek, Å., Runefors, M., Borell, J.: Relationships between safety culture aspects – A work process to enable interpretation. Marine Policy. 44, 179–186 (2014). https://doi.org/10.1016/j.marpol.2013.08.024.
EuroControl: Establishment of ‘Just Culture’ principles in ATM safety data reporting and assessment, https://www.skybrary.aero/bookshelf/books/235.pdf, last accessed 2021/03/01.
Hanzu-Pazara, R., Barsan, E., Arsenie, P., Chiotoroiu, L., Raicu, G.: Reducing of maritime accidents caused by human factors using simulators in training process. JMR. 5, 1, 3–18 (2008).
International Maritime Organisation: Casualty investigation Code (MSC.255(84)). Adoption of the code of the international standards and recommended practices for a safety investigation into a marine casualty or marine incident (Casualty Investigation Code). , London, UK.
International Maritime Organisation: Guidance on Near-miss reporting. , London, UK (2008).
International Maritime Organisation: Human and Organizational Factors – the Critical Role of “Just Culture”. Submitted by the United Kingdom. , London, UK (2011).
International Maritime Organisation: Just Culture – Essential for Safety. Submitted by the United Kingdom. , London, UK (2010).
Knudsen, F.: Paperwork at the service of safety? Workers’ reluctance against written procedures exemplified by the concept of ‘seamanship.’ Safety Science. 47, 2, 295–303 (2009). https://doi.org/10.1016/j.ssci.2008.04.004.
Leveson, N., Dekker, S.: Get To The Root Of Accidents. Chemical Processing. 16, 2, (2014).
Lützhöft, M.: “The technology is great when it works” Maritime Technology and Human Integration on the Ship’s Bridge. University of Linköping (2004).
Marine Accident Investigation Branch (MAIB): Accident Investigation Report 18/2020. Report on the investigation of the fatal crush accident on the general cargo vessel Karina C at Seville, Spain. (2019).
NTSB: Safer Seas Digest 2019 Lessons Learned from Marine Accident Investigations, https://www.ntsb.gov/investigations/AccidentReports/Pages/SPC2004.aspx, last accessed 2021/03/01.
Oltedal, H.A., McArthur, D.P.: Reporting practices in merchant shipping, and the identification of influencing factors. Safety Science. 49, 2, 331–338 (2011). https://doi.org/10.1016/j.ssci.2010.09.011.
Parker, S.: Just Culture Safety Reporting Programme Lead. Civil Aviation Authority. 1–13 (2021).
Reason, J.: Managing the Risks of Organizational Accidents. Ashgate (1997).
Regulation (EU) No 376/2014: of the European Parliament and of the Council of 3 April 2014 on the reporting, analysis and follow-up of occurrences in civil aviation, amending Regulation (EU) No 996/2010 of the European Parliament and of the Council and repealing Directive 2003/42/EC of the European Parliament and of the Council and Commission Regulations (EC) No 1321/2007 and (EC) No 1330/2007 Text with EEA relevance.
Sampson, H., Turgo, N., Acejo, I., Ellis, N., Tang, L.: ‘Between a Rock and a Hard Place’: The Implications of Lost Autonomy and Trust for Professionals at Sea. Work, Employment and Society. 33, 4, 648–665 (2019). https://doi.org/10.1177/0950017018821284.
Schröder-Hinrichs, J.U., Baldauf, M., Ghirxi, K.T.: Accident investigation reporting deficiencies related to organizational factors in machinery space fires and explosions. Accid Anal Prev. 43, 3, 1187–1196 (2011). https://doi.org/10.1016/j.aap.2010.12.033.
Shappell, S.A., Wiegmann, D.A.: U.S. naval aviation mishaps, 1977-92: differences between single- and dual-piloted aircraft. Aviat Space Environ Med. 67, 1, 65–69 (1996).
Swift, A.J.: Bridge team Management. Nautical Institute, London, UK (2004).
Turan, O., Kurt, R.E., Arslan, V., Silvagni, S., Ducci, M., Liston, P., Schraagen, J.M., Fang, I., Papadakis, G.: Can We Learn from Aviation: Safety Enhancements in Transport by Achieving Human Orientated Resilient Shipping Environment. Transportation Research Procedia. 14, 1669–1678 (2016). https://doi.org/10.1016/j.trpro.2016.05.132.
World Maritime University: A culture of adjustment, evaluating the implementation of the current maritime regulatory framework on rest and work hours (EVREST). Reports. (2020). https://doi.org/10.21677/wmu20201108.
Citation note:
Carrera Arce M., Baumler R.: Effective Learning from Safety Events Reporting Takes Two: Getting to the Root & Just Culture. TransNav, the International Journal on Marine Navigation and Safety of Sea Transportation, Vol. 15, No. 2, doi:10.12716/1001.15.02.08, pp. 331-336, 2021

Other publications of authors:

M. Baldauf, R. Baumler, A. Ölçer, T. Nakazawa, K. Benedict, S. Fischer, M. Schaub

File downloaded 28 times

Important: TransNav.eu cookie usage
The TransNav.eu website uses certain cookies. A cookie is a text-only string of information that the TransNav.EU website transfers to the cookie file of the browser on your computer. Cookies allow the TransNav.eu website to perform properly and remember your browsing history. Cookies also help a website to arrange content to match your preferred interests more quickly. Cookies alone cannot be used to identify you.
Akceptuję pliki cookies z tej strony