International Journal
on Marine Navigation
and Safety of Sea Transportation
Volume 1
Number 3
September 2007
Identifying the Potential Roles of Design-based
Failures on Human Errors in Shipboard
M. Celik & I.D. Er
Istanbul Technical University, Istanbul, Turkey
ABSTRACT: Despite the various developments in maritime society, human errors have been continued to be
one of the primarily causes of marine accidents. The outcomes of detailed investigations on the root causes of
human errors can provide valuable support on execution process of required precautions on board merchant
ships. This paper examines the potential role of the design-based failures in shipboard systems on human
errors during operational process. After completing the statistical research on maritime accidents, the paper
concentrates on the Human Factors Analysis and Classification System (HFACS) and the model is supported
with the illustrative cases related to the influences of design-based failures on human errors. Consequently,
this study originally proposes integrated unit into the HFACS systematic to manage to identify design-based
human errors in maritime casualties. The model is eagerly expected to provide additional contributions on
identifying the influences of poor design and constructional failures on human errors.
As the collective results of technological
developments and motivations of the international
authorities, it is succeeded in sustaining of
decreasing trends in maritime accidents. However,
the number of casualties are not still managed to
reach the desired level. The impact of the damages,
caused from maritime accidents, have been varying
such as loss, death, injury, environmental
catastrophe, and disasters (Hansen et al. 2002);
hence, major parts of the maritime society such as
environmental organizations, insurers, classification
societies, port state authorities also concentrate on
this issue. The changes in the rate of accident
statistics and objective evidences of claim analyses
have been utilized to make a detailed investigations
and to monitor the existing situation regarding with
the problem. The scopes of statistical researches are
determined to investigate data in both worldwide
and regional.
Collisions and groundings were outlined as
common incidents according to the outcomes of the
statistical research of the United States Coast Guard
(USCG, 2004) and the financial impacts were
underlined. Another organization, the UK Marine
Accident Investigation Branch (MAIB), was
emphasized human error as dominant factor in the
majority of maritime accidents (MAIB, 2000). As a
regional study, Maritime Safety Authority of New
Zealand is published the results of statistical data on
accidents in the time interval of 1995-1996
(Maritime Safety Authority of New Zealand, 1995-
1996). According to the outcomes of synthesis, 49%
of shipping incidents are regarding with human
factors, while only 35% cite technical factors, and
16% of them regarding with environmental factors.
As a very recent investigation, statistics were
released by The Transportation Safety Board (TSB,
2006) of Canada. Reports illustrate that shipping
accidents, which comprised 90% of marine
accidents, reached 419 in 2006, down from 444 in
2005 and from the five-year average of 455. In 2006,
marine fatalities totaled 18, down from both the
2005 total of 20 and the 2001-2005 average of 25.
On the other hand, analysis and discussions on the
statistical reports have been performed within
various studies (Esbensen et all 1985; Wagenaar &
Groeneweg 1987; UK P&I, 1997; Rothblum, 2000,
O'Neil, 2003, Darbra & Casal 2004) in literature.
Existing analyses on statistical data are clearly
indicates that human error is still continue to be the
most critical factor in maritime accidents. In
addition, the investigations on reducing the human
error in maritime accidents have been continued
eagerly both in industrial base and academic field.
Parallel to the distribution of the main causes of
maritime accidents, it can be recognized as an
effective approach to investigate the root-causes of
the human error in maritime accidents.
The urgent needs on solving of human-related
errors in ship operations are outlined to increase the
motivation on this research. The remains of the
paper are organized as follows: Section 2 reviews
the taxonomies on the root causes of maritime
casualties; in addition, human error evaluation
models are introduced. The Human Factors Analysis
and Classification System (HFACS) are determined
to structure an evaluation model and the evaluation
stages are originally interlinked with the illustrative
examples on human errors and maritime casualties
in Section 3. Additional unit are integrated into the
existing evaluation model based on HFACS to be
able to investigate the influences of design and
installation of system on human error. This paper is
concluded with discussing of the originality and
expected contributions of the integrated model on
examining human errors and expressing the
significance and methodology of managing of group
consensus between investigators as further research.
Human error has been cited as a cause or
contributing factor in maritime accidents in many of
the studies in literature (Hetherington et al. 2006).
For identifying the potential role of the human error
in casualties, the syntheses on the statistical data and
the relevant casualty reports, have been performed in
existing studies, are reviewed. As a result of their
analysis, Esbensen et al. (1985) argue that the actual
figure of incidents involving human error may be as
high as 80%. Wagenaar and Groeneweg (1987)
analyzed 100 accidents heard by the Dutch Shipping
Council between 1982 and 1985, and determined
to only 4 of them occurred with no human error
causes. Examining the data of Major Hazard
Incident Data Service (MHIDAS), human factors
were cited in 16% of all in port accidents by Darbra
& Casal (2004). Based on Baker & McCafferty
(2005), human error was primarily responsible
for approximately 46% of maritime accidents.
Engineering failures, weather related failures, and
material failures, with the percentage of 41%, 11%,
and 2% in a correspondence manner, are recognized
as other top level failures by considering United
States Coast Guard (USCG) database over the period
1991 to 2001. The outcomes of the various
evaluations on the maritime accident reports are
reviewed in this section. As a general tendency of
the researchers, human error continues to be a
dominant factor in approximately 80 to 85% of
maritime accidents.
Much more effort on investigating the causes of
human error is required to clearly identify the
preventive actions and urgent precautions. For
investigating the root causes of shipboard accidents,
the complexity of the issue increases due to the
complicated systems, components, and various user
interfaces. The operational requirements of technical
system and social environment of crewmembers
onboard ships should be considered as significant
points of the human error analysis. The scope and
complexity of the problem is addressed utilizing of
systematic evaluation methodology to manage the
effective analysis and applicable outcomes on
reducing human error in maritime accidents. As
understanding the main causes of the human errors
in accidents, a number of human error models and
frameworks have been developed and cited by
various authors (Edwards 1972; Rasmussen 1982;
Wickens & Flach’s 1988; Reason 1990; Moray
2000; O’Hare 2000; Wiegmann & Shapell 2001a).
Table 1 illustrates the results of bibliographic survey
on human error analysis model.
Table 1. Human error evaluation models
Model Author(s)
SHEL model Edwards, (1972)
Skills rules- knowledge
Rasmussen (1982)
Four-stage information
processing model
Wickens & Flach (1988)
Generic Error Modeling
System (GEMS)
Reason (1990)
Socio-technical model Moray (2000)
Wheel of Misfortune O’Hare (2000)
HFACS Wiegmann & Shapell (2001)
After introducing the existing model, it is
determined to refer in this paper to The Human
Factors Analysis and Classification System
(HFACS), based on Reason’s (1990a, b) model of
latent and active failures, for designing an evaluation
system on maritime accidents and related causes.
HFACS is a general human error framework
originally developed as a tool for investigating and
analyzing the human causes of aviation accidents
(Shappell & Wiegmann 2001; Wiegmann & Shapell
2001b; Wiegmann and Shappell, 2003). HFACS
model utilizes to describe human error at each of
four levels of failure: unsafe acts of operators,
preconditions for unsafe acts, unsafe supervision,
and organizational influences. Recently, successful
applications of HFACS approach have been
performed in U.S. Navy, Marine Corps, Army, Air
Force, and Coast Guard for use in aviation accident
investigation and analysis.
Table 2 illustrates the major components of the
HFACS by categorizing the each elements of the
model. For managing the implementation of the
HFACS on special cases, additional definitions are
required to clearly state the scope of the model. The
outputs of the statistical researches, widely discussed
in previous sections, can be utilized to perform the
model on maritime casualties. Data of the statistical
researches are distributed on the related factors and
priority weights of them are computed to identify the
primarily causes of human errors.
Table 2. General framework of the HFACS
HFACS - Major Components
Unsafe Acts
Skill-based errors
Decision errors
Perception errors
Routine violations
Exceptional violations
Pre-conditions for unsafe acts
Substandard conditions of operators
Physical/Mental limitations
Adverse physiological states
Adverse mental states
Substandard practices of operators
Crew resource mismanagement
Personnel readiness factors
Unsafe Supervision
Inadequate supervision
Planned inappropriate supervision
Failed to correct problem
Supervisory violations
Organizational influences
Inadequate resources management
Organizational climate
Organizational process
3.1 General Overview on Application Requirements
For implementing the HFACS structure on
identifying the human error, it is required to define
the causal categories in the level base such as unsafe
acts of operators, preconditions for unsafe acts,
unsafe supervision, and organizational influences.
The investigators, who are examining the accident
scenarios, are considering the classification scheme
on supporting their judgments on the case.
The evaluation items on unsafe acts is generally
concentrates on the nature errors of the human
beings. The crewmembers on board are the potential
candidates to cause unexpected casualties onboard.
Hence, in the initial stage of the evaluation, the
investigator should decide that the origin of the
situation based on error or violence. Improper
checking of barometer device as a skill based error,
wrong response on emergence fire alarms as a
decision error, and misjudged on distances during
voyage as a perceptual errors can be expressed as
sub-categories of skill-based errors. Furthermore,
failing to adhere to safety maneuvering procedure as
a routine violence, and unauthorized anchoring
during voyage as an exceptional violence are
illustrated as sample cases on violations.
Preconditions for unsafe acts are another category
for identifying the roles of human errors in
accidents. The investigators mainly concentrate on
the question that why the unsafe acts took place.
Mental and physiological fatigue, medical illness,
failed to coordinate hierarchy on board can be
illustrated as a couple of example for this unit.
Unsafe supervision is much more related
to coordination and executive activities within the
operational process. Failed to provide training,
improper manning on board ships, failed to
managing corrective action strategy, assigning
unqualified personnel on board, scheduling personnel
rest hours inadequately can be illustrated as sample
cases regarding with the unsafe supervision.
Finally, organizational influences are investigated
and the role of the organizations on poor supervisory
facilities is expected to be outlined. Conditions of
the equipments, availability of communication
opportunities, satisfaction of policies and
procedures, risk management and safety related
programs, are determined as the focusing themes
during accident analyses.
3.2 Integrated Unit Proposals on Structuring
Despite it is relatively considered within the level of
organizational influences as equipment and facility
resources, there are also additional needs on
expressing influences of operational requirements
and system characteristics on human error.
Therefore, specifications and complexity of the
technical system are required to examine the related
operational constraints such as maintainability,
ergonomics, safety, technology, and automation on
board ships as well. Enhancing the shipboard
working environment such as managing user
interfaces, motivating on working conditions such as
noise, vibration, ventilation, lighting, temperature,
and air quality are addressed as primarily issues
regarding with improvement of shipboard systems in
manner of ergonomics and human factor. On the
other hand, repairing and maintenance facilities,
performed onboard ships, are the significant
activities. The impacts of technological
improvements and automation in system level on
human error in maritime casualties should also be
considered as another critical factor.
Additional unit can be integrated into the model
to clearly identify the human errors that are caused
by hardware in terms of ship’s systems and
components. Table 3 illustrates the relevant items
that are required to be able check the influences of
system and operating conditions on human error in
maritime accidents.
Table 3. Integrated unit into HFACS structure
HFACS - Integrated Unit
Design and installation
Working environment
User interfaces
Human fatigue
Maintenance facilities
Maintenance procedures
System maintainability
Workspace conditions
Technology and Automation
Training needs
Technical support
Application requirements of the HFACS, systematic
approach for investigating human errors, on
investigating influences of system related failures on
human error in maritime accidents are outlined in
this paper. The human errors are cited in previous
studies in literature as the most focusing factor in
maritime accident; therefore, the model is expected
to provide original contributions on investigating the
potentials of human factors in marine casualties
successfully. In addition, the paper proposed
integrating unit, including the evaluations on
ergonomic requirements, maintenance facilities, and
technology and automation levels of the system, into
the HFACS to be able to manage to identify design-
based human error in maritime accidents. The
influences of lacking of ergonomics requirements,
maintainability, and integration of technology and
automation into systems onboard ships can be
examined deeply by utilizing integrated model unit.
Therefore, the roles of poor system design and
constructional failures on human error can be clearly
identified in detail in applications on real cases
regarding with onboard ships. The various systems
in different levels of complexity, sub-systems, and
components in ship machinery systems, user
interfaces in both engine room and bridge can be
recognized as the hardware elements of the ships.
Hence, the scope of the investigations on human
errors in maritime accidents can be extended in
system level by utilizing the proposed methodology
as well.
As practical application, the original model can
be performed on a set of data and accident reports to
be able to obtain illustrative results. The outcomes of
the HFACS based analysis with the additional
integrating unit on maritime accidents provide to
identify the potential roles of the system based
failures on human errors quantitatively. In advance,
integrating of the group decision methodology on
determining judgements with more than one
investigator in a group consensus can be assigned as
a further research proposal to increase the
consistency of the HFACS mechanism.
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