journal article·2023-06-02Open access

The Analysis of Social and Situational Systems as Components of Human Errors Resulting in Navigational Accidents

Lech Kasyk, Anna Eliza Wolnowska, Krzysztof Pleskacz, Tomasz Kapuściński

Applied Sciences· Volume 13· Issue 11

Abstract

As in any industry exposed to risk, human and organizational factors are the main stakes of maritime safety. Understanding the causes and risks of maritime accidents is integral to the sustainability of shipping. The investigation of marine accidents is a crucial tool for their identification in areas related to operations and ships, including social and situational systems, their design, and technical systems. The authors conducted a cause–effect analysis of marine incidents. For this purpose, case-by-case analysis and an Ishikawa diagram were used, which is a tool that helps identify actual or potential causes of accidents. The study showed that by far the most significant cross-section of causes of accidents were elements of social and situational systems that affect the safety of the ship, crew, and environment. The least significant contribution came from the machinery area. Through the detailed descriptions, a picture emerges not so much of a lack of knowledge of the regulations as of a failure to comply with existing procedures or best practices. In the authors’ opinion, more emphasis is needed on preventive measures, including safety culture, training, competence assessment, and increased awareness of the need for sustainability.
Source: crossref · Quality: baseline

Research context

OpenAlex topics: Maritime Navigation and Safety · Risk and Safety Analysis · Occupational Health and Safety Research

SciVX discovery tags are terminology-based. OpenAlex topics are source-provided classifications.

Affiliations

Institute of Mathematics, Physics, and Chemistry, Maritime University of Szczecin, Wały Chrobrego 1-2, 70-500 Szczecin, Poland

Faculty of Engineering and Economic of Transport, Maritime University of Szczecin, H. Pobożnego St. 11, 70-507 Szczecin, Poland

Faculty of Navigation, Maritime University of Szczecin, Wały Chrobrego 1-2, 70-500 Szczecin, Poland

Funding

Maritime University of Szczecin

References (100+)

Show source-provided references
1. Swift, A.J., and Bailey, T.J. (2004). Bridge Team Management—A Practical Guide, The Nautical Institute.
2. (2022). Bridge Procedures Guide, International Chamber of Shipping. [6th ed.].
3. International Atomic Energy Agency (1991). Safety Culture, A Report by the International Nuclear Safety Advisory Group, IAEA.
4. Assessing artefacts of maritime safety culture—current state and prerequisites for improvement10.1007/s13437-018-0160-5 ↗
5. Anderson, P. (2003). Cracking the Code. The Relevance of the ISM Code and Its Impact on Shipping Practices, Nautical Institute.
6. Rothblum, A. (2000, January 13–14). Human error and marine safety. Proceedings of the Maritime, Human Factors Conference, Linthicum, MD, USA.
7. International Maritime Organization (2023, February 20). Human Element Vision, Principles and Goals for the Organization, Resolution A.850(20). Available online: https://wwwcdn.imo.org/localresources/en/KnowledgeCentre/IndexofIMOResolutions/AssemblyDocuments/A.850(20).pdf.
8. International Maritime Organization (2023, February 20). Human Element Vision, Principles and Goals for the Organization, Resolution a.947(23). Available online: https://wwwcdn.imo.org/localresources/en/KnowledgeCentre/IndexofIMOResolutions/AssemblyDocuments/A.947(23).pdf.
9. IMO Website on Legal Affairs (2022, August 03). IMO/ILO Work on Seafarer Issues. Available online: https://www.imo.org/en/OurWork/Legal/Pages/JointIMOILOWorkingGroupsOnSeafarerIssues.aspx.
10. (2022, September 10). International Labour Conference, Maritime Labour Convention, 2006, Consolidated Text Established by the International Labour Office, Including the Amendments of 2014 and 2016 to the Code of the Convention. Available online: https://www.ilo.org/wcmsp5/groups/public/---ed_norm/---normes/documents/normativeinstrument/wcms_554767.pdf.
11. Out-of-the-loop performance problems and the use of intermediate levels of automation for improved control system functioning and safety10.1002/prs.680160304 ↗
12. Reporting practices in merchant shipping, and the identification of influencing factors10.1016/j.ssci.2010.09.011 ↗
13. Why do they violate the procedures?—An exploratory study within the maritime transportation industry10.1016/j.ssci.2019.104538 ↗
14. How deregulation can become overregulation: An empirical study into the growth of internal bureaucracy when governments take a step back10.1016/j.ssci.2020.104772 ↗
15. Attitudes of experienced seafarers as predictor of ISM code10.7307/ptt.v31i5.3118 ↗
16. Administrative burdens and over-exertion in Swedish short sea shipping10.1080/03088839.2016.1154994 ↗
17. Risk perception and safety management systems in the global maritime industry10.1080/14774003.2006.11667682 ↗
18. Safety clutter: The accumulation and persistence of ‘safety’ work that does not contribute to operational safety10.1080/14773996.2018.1491147 ↗
19. Bieder, C., and Bourrier, M. (2013). Trapping Safety into Rules: How Desirable or Avoidable Is Proceduralization?, Ashgate. [1st ed.].
20. Dekker, S. (2015). Safety Differently: Human Factors for a New Era, Taylor & Francis. [2nd ed.].
21. One size fits all? Safety management regulation of ship accidents and personal injuries10.1080/13669877.2016.1147487 ↗
22. (1993). Working Paper on Tankers Involved in Shipping Accidents 1975–1992, Transportation Safety Board of Canada.
23. Cormier, P.J. (1994). Towing Vessel Safety: Analysis of Congressional and Coast Guard Investigative Response to Operator Involvement in Casualties Where a Presumption of Negligence Exists. [Master’s Thesis, University of Rhode Island].
24. Bryant, D.T. (1991). The Human Element in Shipping Casualties, Department of Transport, Marine Directorate. Report.
25. (2022, September 09). Annual Overview of Marine Casualties and Incidents 2021. Available online: www.emsa.europa.eu/.
26. Review of techniques and challenges of human and organizational factors analysis in maritime transportation10.1016/j.ress.2021.108249 ↗
27. Classification of human errors in grounding and collision accidents using the TRACEr taxonomy10.1016/j.ssci.2016.02.026 ↗
28. Human error in European air traffic management: The HERA project10.1016/S0951-8320(01)00099-0 ↗
29. Evaluation of human error contribution to oil tanker collision using fault tree analysis and modified fuzzy Bayesian Network based CREAM10.1016/j.oceaneng.2019.03.031 ↗
30. A Human and Organisational Factors (HOFS) Analysis Method for Marine Casualties Using HFACS-Maritime Accidents (HFACS-MA)10.1016/j.ssci.2013.06.009 ↗
31. Modified human factor analysis and classification system for passenger vessel accidents (HFACS-PV)10.1016/j.oceaneng.2018.04.086 ↗
32. Use of HFACS–FCM in Fire Prevention Modelling on Board Ships10.1016/j.ssci.2015.03.007 ↗
33. Human and organisational factors in maritime accidents: Analysis of collisions at sea using the HFACS10.1016/j.aap.2013.05.006 ↗
34. Analytical HFACS for investigating human errors in shipping accidents10.1016/j.aap.2008.09.004 ↗
35. A marine accident analysing model to evaluate potential operational causes in cargo ships10.1016/j.ssci.2016.09.010 ↗
36. Assessment of collisions and grounding accidents with human factors analysis and classification system (HFACS) and statistical methods10.1016/j.ssci.2017.09.022 ↗
37. Use of HFACS and fault tree model for collision risk factors analysis of icebreaker assistance in ice-covered waters10.1016/j.ssci.2018.07.002 ↗
38. A methodology to evaluate human factors contributed to maritime accident by mapping fuzzy FT into ANN based on HFACS10.1016/j.oceaneng.2019.106892 ↗
39. The human factor and maritime safety10.1016/j.trpro.2019.07.183 ↗
40. Haugen, S., Barros, A., Gulijk, C.V., Kongsvik, T., and Vinnem, J. (2018). Safety and Reliability—Safe Societies in a Changing World, CRC Press.10.1201/9781351174664 ↗
41. Toward a theory of situation awareness in dynamic systems10.1518/001872095779049543 ↗
42. Hollnagel, E. (2014). Safety-I and Safety-II: The Past and Future of Safety Management, Ashgate.
43. Patraiko, D. (2022, September 21). Into the Future, the Technology of Tomorrow, The Navigator, Issue 24. The Nautical Institute. Available online: https://www.nautinst.org/resources-page/into-the-future-the-technology-of-tomorrow.html.
44. Acejo, I., Sampson, H., Turgo, N., Ellis, N., and Tang, L. (2018). The Causes of Maritime Accidents in the Period 2002–2016, Seafarers International Research Centre (SIRC), Cardiff University.
45. Global Claims Review 2022, Available online: www.agcs.allianz.com/.
46. Accidents at sea: Multiple causes and impossible consequences10.1016/S0020-7373(87)80017-2 ↗
47. Parker, A.W., Huhinger, L.M., Sargent, L., and Boyd, R. (2002). Health Stress and Fatigue in Shipping, Australian Maritime Safety Agency.
48. Maekay, M. (2000). Safer Transport in Europe: Tools for Decision-Making, The European Transport Safety Council. European Transport Safety Council Lecture.
49. Safety in shipping: The human element10.1016/j.jsr.2006.04.007 ↗
50. On your watch automation on the bridge10.1017/S0373463301001588 ↗
51. Brun, W., Johnsen, B., Iabertg, J.C., Ekomas, B., and Kobbeltvedt, T. (2004). How Professionals Make Decisions, CRC Press.
52. Does crew resource management training work? An update, an extension, and some critical needs10.1518/001872006777724444 ↗
53. Risk analysis and human factor in prevention of CRG casualties
54. Czynnik ludzki w lotnictwie
55. Human factor in air and sea traffic management
56. (2021, October 12). Encyklopedia Zarządzania. Available online: www.mfiles.pl.
57. Risk, human error, and system resilience: Fundamental ideas10.1518/001872008X250773 ↗
58. ‘Only work and sleep’: Seafarers’ perceptions of job demands of short sea cargo shipping lines and their effects on work and life on board10.1080/03088839.2017.1371347 ↗
59. Stres jako źródło wypalenia zawodowego
60. Profil zawodowy oficera floty handlowej—udział cech osobowości w radzeniu sobie ze stresem. Humanizacja Pracy
61. Safety and ergonomics on board
62. Temperature as an important factor in the work environment—selected aspects
63. (2021, July 11). Przewidywanie Stresu. Available online: www.szybkanauka.net.
64. Lubaś, P. (2010). Diagnoza Ergonomicznych Czynników Ryzyka, Okręgowy Inspektorat Pracy w Szczecinie.
65. Wróblewska, M. (2004). Ergonomia, Wydaw, Politechniki Opolskiej.
66. (2022, September 15). Państwowa Komisja Badania Wypadków Morskich, EXPRESS 1 & BALTIC CONDOR, Summary Report on Collision, 10 May 2019, Available online: https://pkbwm.gov.pl/wp-content/uploads/images/Reports/enFinal-marine-accident-report---EXPRESS-1-og-BALTIC-CONDOR---Collision-on-10-May-2019.pdf.
67. (2023, March 11). CSL Virginia. Available online: https://wwz.cedre.fr/Ressources/Accidentologie/Accidents/CSL-Virginia.
68. Walker, J. (2022, October 23). Cruise Law News. Everything Cruise Lines Don’t Want You to Know. Available online: www.cruiselawnews.com/2019/.
69. Nautilus International (2023, January 10). IMO Raises Concern over Euroferry Olympia Ferry Fire, 24 February 2022. Available online: https://www.nautilusint.org/en/news-insight/news/imo-raises-concern-over-euroferry-olympia-ferry-fire/.
70. (2023, January 10). Seiner Fishing Boat Accidents and Injuries. Available online: www.maritimeinjurycenter.com/accidents-and-injuries/seiner-fishing-boat/.
71. Marine Accident Investigation Branch (2023, January 10). Accident Report, Capsize of Tug Domingue while Assisting CMA CGM Simba Resulting in Two Fatalities, July 2017, Available online: https://assets.publishing.service.gov.uk/media/596dd157e5274a0a690001ba/MAIBInvReport16_2017.pdf.
72. (2023, January 10). UN Environment Programme, X-Press Pearl Maritime Disaster Sri Lanka—Report of the UN Environmental Advisory Mission, 6 August 2021. Available online: https://www.unep.org/resources/report/x-press-pearl-maritime-disaster-sri-lanka-report-un-environmental-advisory-mission.
73. (2022, September 01). WION Web Team, Ship Owner Says Suez Canal was at Fault over Ever Given Grouding, Wionews.com, 23 May 2021. Available online: https://www.wionews.com/world/ship-owner-says-suez-canal-was-at-fault-over-ever-given-grounding-lawyer-386811.
74. Accident Report (2023, February 20). Marine Accident Investigation Branch. 2018, 11, Available online: https://assets.publishing.service.gov.uk/media/5b30b379ed915d587f69eee6/MAIBInvReport11_2018.pdf.
75. (2022, December 01). Cargo and Crane Accidents in the Maritime Industry. Available online: www.maritimeinjurycenter.com/accidents-and-injuries/cargo-and-crane/.
76. (2022, December 12). Examining Fatal Shipyard Accidents. Volume 2, Available online: www.osha.gov/video/shipyard-accidents/transcripts#v2_4.
77. (2022, December 01). Fatal Incident Onboard a Dive Support Vessel. IMCA Safety Flash, 2009, 18. Available online: www.imca-int.com/safety-events/fatal-incident-onboard-a-dive-support-vessel/.
78. (2023, February 20). Barge Accidents. Available online: www.simmonsandfletcher.com/maritime-law/offshore-accident/barge-injury/.
79. Human error in maritime operations: Analyses of accident reports using the Leximancer tool10.1177/154193120204601906 ↗
80. Zainal, Z. (2017). Case Study as a Research Method. J. Kemanus., 5, Available online: https://jurnalkemanusiaan.utm.my/index.php/kemanusiaan/article/view/165.
81. (2022, December 12). Arnold and Itkin. Available online: www.offshoreinjuryfirm.com/.
82. (2021, October 15). Department of Merchant Shipping, Ministry of Communications and Works, Republic of Cyprus, MARINE ACCIDENT REPORT Collision between “CORVUS J” and “BALTIC ACE” in the North Sea on 5 December 2012, Available online: https://pkbwm.gov.pl/wp-content/uploads/images/uchwaly_raporty/raporty/raporty_obce/Final_report_Corvus_J_WIM_07_12_DMS_Cyprus.pdf.
83. Swift, J.A., Ross, J.E., and Omachonu, V.K. (1998). Principles of Total Quality, St. Lucie Press. [2nd ed.].
84. Rios, N., Spínola, R.O., Mendonça, M., and Seaman, C. (2019, January 26–26). Supporting Analysis of Technical Debt Causes and Effects with Cross-Company Probabilistic Cause-Effect Diagram. Proceedings of the 2019 IEEE/ACM International Conference on Technical Debt (TechDebt), Montreal, QC, Canada.10.1109/TechDebt.2019.00009 ↗
85. Wong, K.C., Woo, K.Z., and Woo, K.H. (2016). Ishikawa Diagram in Quality Improvement in Behavioral Health, Springer.10.1007/978-3-319-26209-3_9 ↗
86. Ishikawa, K., and Loftus, J.H. (1990). Introduction to Quality Control, 3A Corporation. [3rd ed.].
87. Root Cause Analysis: A Framework for Tool Selection10.1080/10686967.2005.11919269 ↗
88. Use of the Ishikawa diagram in a case-control analysis to assess the causes of a diffuse lamellar keratitis outbreak10.5935/0004-2749.20170069 ↗
89. Koncepcja ważonego wykresu Ishikawy
90. Jasiak-Kujawska, Cause and Effect Analysis of Hospital Infections with the Use of Weighted Ishikawa Diagram
91. Leśniak, A., Górka, M., and Skrzypczak, I. (2021). Barriers to BIM Implementation in Architecture, Construction and Engineering Projects—The Polish Study. Energies, 14.10.3390/en14082090 ↗
92. Risk assessment methodology in quality assurance of logistic systems
93. Zastosowanie koncepcji ważonego wykresu Ishikawy do analizy wad odlewów
94. Steenbergen, R.D.J.M., va Gelder, P.H.A.J.M., Miraglia, S., and Vrouwenvelder, A.C.W.M. (2014). Safety, Reliability and Risk Analysis: Beyond the Horizon, Taylor and Francis Group.10.1201/b15938 ↗
95. Nowakoski, T., Mlyńczak, M., Jodejko-Pietrucuzuk, A., and Werbińska-Wojciechowska, S. (2015). Safety and Reliability, Taylor & Francis.
96. Schröder-Hinrichs, J.U., Praetorius, G., Graziano, A., Kataria, A., and Baldauf, M. (2015, January 22–25). Introducing the Concept of Resilience into Maritime Safety. Proceedings of the 6th Symposium on Resilience Engineering, Lisbon, Portugal. Available online: http://www.resilience-engineering-association.org/wp-content/uploads/2016/11/Proceedings-REA6SYM-2016–230916-1.pdf.
97. Steenbergen, R.D.J.M., van Gelder, P.H.A.J.M., Miraglia, S., and Vrouwenvelder, A.C.V.M. (2014). Safety, Reliability and Risk Analysis: Beyond the Horizon, Taylor & Francis.10.1201/b15938 ↗
98. The effectiveness of the ISM Code: A qualitative enquiry10.1016/j.marpol.2011.09.004 ↗
99. Bris, R., Soares, C.G., and Martorell, S. (2010). Reliability, Risk, and Safety: Theory and Applications, Taylor & Francis.10.1201/9780203859759 ↗
100. The legitimacy of safety management systems in the minds of norwegian seafarers