Based on the 2012-2016 statistics, about 75% incidents attributed to human error. An explanation that is being used more often, especially from the Clubs, is crew negligence; however, this reason is no longer acceptable. Beyond crew negligence there is always another reason which has its roots to the cause of incident. That is coming very crucial to analyze what affects the human factor, human performance, and see more seriously the training, before we always count as a part of our SMS checklist the training purpose.
Systems or processes that depend on perfect human performance are inherently flawed. They have to communicate, make decisions at the same time, they are very valuable to make mistakes and they have to take risks all the time. All these associated factors, make the risk quite high. They count a lot of technology developments, new equipment but no one assesses at first glance, how people use this new equipment, how we are exposed on the risk and how we treat human factors and human errors.
I don’t feel very confident that we address proper actions for each of the human factors and errors we identify following an incident. I can see that the third parties now have also changed a lot the way they see the investigation and the way they track the corrective actions, to really identify if you have done whatever you need to eliminate re-occurrence.
For instance, if you have a rule based error that means that someone has consecutively made the same mistake all over the vessel; either he comes from previous company or the next. Either you adopt new technologies, or you implement your BMSA with your operators in diligence requirement. If you don’t go back to address your rule-based error and do some training that must be dedicated then you have repeated failures, because the same person has learned all over the years to treat an operation the same way, possibly with different equipment and different procedures, will do the same.
So, he will bring the same mistake. As you said, an incident that has just happened is no longer acceptable. Because I don’t think when we take the plane, the same thing applies on aviation. No one takes the plane because an incident can happen. The same thing will go in the near future in shipping as well.
Why repeated failures?
Through historical records, we might find that we had one crew that was participating on the same incident six times. All over the years we have been together 25 years. So, there are so many repeated failures; also, if you don’t have the technology track, you miss the point. Again, investigation has been submitted on the claims with crew negligence, but this can’t be a stand-alone reason.
Definitely safety culture, which is something that we try to develop through the forums as well. From our company data we also have a percentage to human error attributed from shore staff. Again, I’m coming back to the well-known resilience of Shell.
Concerning the safety culture, lately we discuss weak signals. If you don’t have the knowledge or monitoring, technology comes again with monitoring so you have the data all the times; you don’t get any weak signal; if someone has psychological problems, you don’t get his problems. One feels uncomfortable onboard, possibly he will make a mistake in the future, but you don’t have the tools to see that.
As TMSA says so, we all do a psychometric test, but I don’t know if it’s bad or good that they have used the psychometric assessment. Because we have samples that someone has bad crisis management and obviously it means that when it is an emergency, possibly he cannot take control, so, you do what? You sent someone onboard with him, that he has a psychometric assessment dealing with an emergency.
Safety culture I think is the most important, as it is our primary responsibility to develop. It has to do with a series of actions and there’s also the negligence error. Although we’re all aware of the safety culture process, no one takes the process till the end.
Following the analysis of Costa Concordia, ICS is giving a 75% of human error, which is extremely high. Yet, they don’t analyze the human error in what perspective, whether it is a crew onboard, shore staff or any other aspect involve. It’s dramatic that although we still run on new technology, we have almost the 100% of incidents attributed to operators.
Where does the problem stand nowadays? The investigations revealed that most of incidents attributed to human error.
Has in depth analysis been carried out to further analyze what is the root cause? After so many statistical data we did this year and found so many crucial results to address.
What is the underlying cause for crew negligence? We have to go back. It is easy to take the claim from the insurance but we have to give them reason, because it is lack of training, lack of supervision, lack of monitoring. Something is wrong behind the negligence, because I think it’s not that people are born negligent.
What is the approach of a proper analysis to identify the error and eliminate the re occurrence?
Human fails for a reason connected with his culture, state of mind and mental health, knowledge and training adherence. For instance, for Costa Concordia, they said the captain’s part of failure was because of mental health issues. If I were onboard and saw my vessel sink, possibly my mental health would not be so good. But that is something before the event taking place.
External factors may and will affect the nature of the incident and the subsequent side effects. However, by dealing only with these factors do we eliminate the possibility of errors alignment which may result to an incident? Is this adequate?
Has human being given the proper attention to this analysis? Has training being developed as such to deal mostly with the human?
Can you predict human error?
We can eliminate and address mental health. Don’t focus only to the crew. Most of the errors occur in the office. We don’t get weak signals, we don’t support the group only at a time of an incident and when we do the investigation we try to be a little bit more loyal. We can do an investigation, by the way. We have to identify the route cause because, eventually we know what is wrong.
Concluding, what we can gain out of this investment to human:
- Eliminate uncontrolled behavior;
- Reduce risk of incident;
- Manage to a cost effective way on long-term basis;
- Maintain sustainability.
Above article is an edited version of Mrs. Panagiota Chrysanthi’s presentation during the 2019 Hellenic American Maritime Forum.
You may view her presentation here.
The views presented hereabove are only those of the author and not necessarily those of SAFETY4SEA and are for information sharing and discussion purposes only.
About Panagiota Chrysanthi
Panagiota Chrysanthi has a master degree in Maritime Operations and Management and currently holds the position of the DDPA/EMR in Andriaki Shipping. She is also responsible for the development and monitoring of implementation of fleet ship energy environmental plan. She is member of INTERTANKO Environmental Committee, LR Environmental Sub-Committee, HELMEPA Training Committee, Hellenic Maritime HSCQ Forum, WISTA and MTS.