Identified Challenges and proposed solutions

Guidance for accident investigation

At a flag state level, guidance and structure for the completion of maritime investigation is provided through international organizations (e.g., IMO, EMSA). Nevertheless, at an operator level (e.g., shipping company or port authority) the guidance is less descriptive and no enforcement to follow a clear structure is in place. This leads to different interpretations and applications by operators which in turn lead to a variety of investigation types. Not employing the same standards and taxonomies makes it complicated to compare safety occurrences and identify trends.

To fill this gap the OALC-M case study aims to develop a Human Factors and Risk-based Investigation Suite for maritime end-users that utilizes the existing guidance and structure from international organisations (e.g. IMO, EMSA). Additionally, the adoption of SAFEMODE tools and techniques (e.g. SHIELD Taxonomy, HF Fact Sheets and Best Practice, Risk Models) at an operational level will be encouraged.

Lack of Proactive Safety interventions

The traditional approach adopted by the marine industry has been focused on accidents, developing reactive regulations to prevent the recurrence of such accidents. Indeed, maritime safety regulations have often been introduced as a response to an accident (see Figure: Regulations implemented after Accidents).

More often than not, safety critical occurrences do not result in accidents due to safety barriers and interventions. These near misses and positive interventions provide a great source for learning and identifying risks before they result in an accident. Therefore, the second identified need is addressed by creating a proactive investigation process, encouraging its adoption and by providing harmonised tools to successfully collect data during safe interventions and near misses.

Knowledge about Human Factors Techniques/Methods

A multitude of HF techniques and methods exist but it was found that this knowledge is not widely spread within the maritime domain and therefore only a small number of operators are specialized in their use. This situation prevents organizations from applying HF techniques for accident investigation. The issue is addressed by providing guidance on how to apply HF techniques and providing recommendations on which techniques are suitable for which scenarios. This is done by utilizing the Human Factors Toolkit which has been developed within SAFEMODE.

Benefits from the Case Study

• Support and accelerate the uptake and adoption of the SAFEMODE HF taxonomy enabling enhanced identification of performance influencing factors across multiple levels in an organisation.
• Support and accelerate the implementation of Human Reliability Assessments in maritime end users to enhance the analysis and understanding of human contribution to risk.
• Support and accelerate the implementation of the SAFEMODE Risk model in maritime end users to enhance the ability to improve the assessment and management of future risks through the concept of barrier management.
• Encourage the adoption of a Just Culture framework which aids organisations in their cultures of high anticipation, open reporting, intervention and learning.
• Harmonised investigation backbone and output report facilitating cross functional (XFN) and cross organisational (XO) learning.

Main Scenario and Pilot Exercises

The OALC-M case study is composed of a higher level scenario, which consist of the development of a bi-directional HF and risk-based investigation process, which harnesses the learnings and deliverables from SAFEMODE that not only can be used reactively for accident investigation but also to analyse proactively safety assessments to investigate near misses and safety interventions.

Three exercises complement this higher level scenario.

Pilot exercise 1: Utilisation and Validation of SAFEMODE Domain Specific Taxonomy

This first exercise has the aim to benchmark various techniques and compare them to the Human Factors taxonomy created within SAFEMODE for SHIELD. For the exercise a set of HFs Interview Techniques and Questions for accident investigators is developed that assist in identifying HF elements. Further, during the exercise the SAFEMODE HF taxonomy and its use is explained at the operational level.

For this exercise a set of workshops is planned and the first of the series has already been conducted. In this first workshop a near miss report available within CalMac Ferries was selected and analysed using different HF techniques/models. Among others, SAFEMODE HF taxonomy for SHIELD and European Marine Casualty Information Platform (EMCIP) were employed.

First results indicate that EMCIP does not include definitions of the different factors which led to the identification of different HF elements for the same analysis conducted by different operators. Further, employing the SAFEMODE HF taxonomy seemed to capture additional HF elements that did not have a match in the other methods. As these outcomes were obtained from the first workshop they can only be seen as a first indication which has to be verified and assessed through further workshops.

Pilot exercise 2: Utilisation and Validation of SAFEMODE HFs and HRAs.

Within in SAFEMODE different Human Factors techniques, models and processes have been identified and collected in the Human Factors Toolkit. In this exercise it is planned to apply the most suitable methods to past investigation reports, aiming to make the approach understandable at an operator level. Further, based on this exercise recommendations will be created on how and when to apply selected HF techniques depending on the case under analysis.

Pilot exercise 3: Utilisation and Validation of SAFEMODE Risk Models.

Within SAFEMODE risk models are created, these will be utilized to analyse the following scenarios:

• Collision in Open Sea Risk Model
• Collision in Congested Waters Risk Model
• Collision in Narrow Waters Risk Model
• Grounding when approaching the berth Risk Model
• Grounding in Coastal/Shallow water Risk Model