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Procedures for Investigating and Reporting Human Factors and Fatigue Contributions to Marine Casualties.
Abstract
This project was aimed at identifying strategies for improving current U. S. Coast Guard (USCG) procedures for investigating, reporting, and analyzing fatigue contributions to marine casualties. The focus was on evaluating the contribution of fatigue in vessel and personnel injury casualties. A total of 397 casualties were investigated. Fatigue contributed to 16 percent of the critical vessel casualties and 33 percent of the personnel injury casualties. These estimates were substantially greater than the ones currently available from the USCG Marine Investigations Module (MINMOD) database. Analyses identified three potential indicators of fatigue: (1) the number of fatigue symptoms reported by mariners, (2) the number of hours worked in the 24 hours prior to a casualty; and (3) the number of hours slept in those 24 hours. This study demonstrated the feasibility of using simple procedures to obtain meaningful data on the contribution of fatigue in transportation accidents.
... The negative impact and consequences of fatigue have surfaced in high-profile maritime disasters such as the Herald of Free Enterprise's capsizing and the Exxon Valdez's grounding [17], [18]. Studies suggest that fatigue contributes to maritime accidents within the 10-16% range, aligning with the consensus among 26 renowned fatigue scientists who posit its role in 16-20% of accidents across various transportation modes [19]- [23]. ...
... Consequently, this paper involves a survey of fishermen in Korea-a country where accidents on fishing boats often result in fatalities-to identify the conditions under which human error is most likely to occur. In particular, the main cause of human casualties is human error [9]. Human errors that occur during maritime operations can directly lead to accidents, implying that there are many risks involved in the various tasks required in the fishing industry. ...
In this paper, we introduce a model designed to predict human error probability (HEP) in the context of fishing boat operations utilizing the cognitive reliability and error analysis method (CREAM). We conducted an analysis of potential accidents on fishing boats and calculated the cognitive failure probability (CFP) for each identified accident. The common performance conditions (CPCs) from the original CREAM were adapted to better reflect the conditions on fishing boats, with the adapted CPCs’ validity confirmed through expert consultations. To apply CREAM, data were gathered via a survey of fishermen, with the uncertainty in the collected data addressed through the application of fuzzy set theory (FST). We then established a Bayesian network (BN) model to elucidate the relationship between the fuzzy data and HEP, utilizing a weighted sum algorithm to determine conditional probabilities within the BN. Both basic and extended versions of CREAM were applied to analyze the most common accidents among fishermen, calculating the CFP for each type of accident. According to our analysis, the poorer the dynamic CPC, the higher the probability that a fall accident will occur inside the boat due to human error, necessitating a countermeasure. The paper proposes safety enhancements for small fishing boats and illustrates the increased precision of human reliability analysis (HRA) models in forecasting human error by incorporating quantitative methods. It calls for further data collection and refinement of the model for more accurate operational risk assessments.
... Fatigue remains a critical safety concern in the transport industry, responsible for 12%-20% (Marcus & Rosekind, 2017;NTSB, 2020;Parenteau et al., 2022;TSB, 2022). In shipping, 7 fatigue can be attributed to 10%-16% of accidents, including high-profile disasters, such as 8 the capsizing of the Herald of Free Enterprise and the grounding of the Exxon Valdez (Acejo 9 et al., 2018;Department of Transport, 1987;MAIB, 2004;Mccallum & Raby, 1996;NTSB, 10 1990; Rajapakse & Emad, 2023). Although the role of fatigue in accidents varies, twenty-six 11 fatigue and sleep scientists have acknowledged that it contributes to 15%-20% of accidents 12 across transportation modes (Akerstedt, 2000). ...
... A study conducted by the US Coast Guard Research and Development Centre showed that fatigue is the primary cause of 16% of ship casualties and 33% of board injuries [4]. Onethird of ship groundings is due to fatigue in OOWs and performing night duties solitarily at the bridge, according to a study by the UK Department for Transport involving 1,647 collisions, groundings, and other accidents between 1994 and 2003 [5]. ...
Ninety percent of the world’s cargo is transported by sea, and the fatigue of ship officers of the watch (OOWs) contributes significantly to maritime accidents. The fatigue detection of ship OOWs is more difficult than that of vehicles drivers owing to an increase in the automation degree. In this study, research progress pertaining to fatigue detection in OOWs is comprehensively analysed based on a comparison with that in vehicle drivers. Fatigue detection techniques for OOWs are organised based on input sources, which include the physiological/behavioural features of OOWs, vehicle/ship features, and their comprehensive features. Prerequisites for detecting fatigue in OOWs are summarised. Subsequently, various input features applicable and existing applications to the fatigue detection of OOWs are proposed, and their limitations are analysed. The results show that the reliability of the acquired feature data is insufficient for detecting fatigue in OOWs, as well as a non-negligible invasive effect on OOWs. Hence, low-invasive physiological information pertaining to the OOWs, behaviour videos, and multisource feature data of ship characteristics should be used as inputs in future studies to realise quantitative, accurate, and real-time fatigue detections in OOWs on actual ships.
... Excessive fatigue has subsequently the potential to reduce vigilance and other aspects of cognitive performance (Goel et al. 2009). Fatigue is also a major factor in maritime safety because excessive fatigue is estimated to be associated with 25% of maritime accidents (Raby and McCallum 1997). ...
The operation of naval vessels involves watchkeeping 24 h per day, which is globally carried out by a variety of different watch systems. In this study, the rotating 4:4 and fixed 4:4/6:6 two-section watch systems were compared in terms of sleepiness, fatigue, and stress responses. The data collection took place on a Finnish Defence Forces' (FDF) Navy missile patrol boat with 15 crew members serving as study participants. The data collection periods lasted two separate weeks (7 days, 6 nights) with the different watch systems. The subjective sleepiness of the participants was assessed before and after every watch using the Karolinska Sleepiness Scale (KSS). Stress responses were assessed daily by the recorded levels of salivary alpha-amylase (sAA), cortisol (sCor), immunoglobulin A (sIgA), and dehydroepiandrosterone (sDHEA). The participants' sustained attention, inhibitory control, and working memory were assessed daily by cognitive tests (SART, N-Back). The heart rate variability (HRV) during an orthostatic test was used as an additional daily marker to assess the amount of psychological stress of the participants. In this study, the difference regarding sleepiness and fatigue between the study weeks was most visible in the subjective KSS, which clearly favored the 4:4/6:6 system. The results of sAA and sIgA also suggested that the subjects were psychologically less stressed during the study week with the 4:4/6:6 watch system. Cognitive test results (SART, N-Back) indicated that there were overall no significant differences in the subjects' sustained attention, inhibitory control, or working memory during the study weeks or between the study weeks. The results of the HRV data during the daily orthostatic tests were inconclusive but there was some indication that the subjects were less stressed during the study week with the 4:4/6:6 watch system. In conclusion, the present study indicates that in navy surface operations: working with the fixed 4:4/6:6 watch system causes less sleepiness, fatigue, and psychological stress than working with the rotating 4:4 watch system. The study result is well in line with previous research regarding watch systems.
... A 1996 report co-authored by Anita Rothblum [61] (O) prior to her famous paper [26] gives another interesting insight. It discloses that a human factor can be found directly contributing to some 50% of critical vessel casualties, but as much as 91% of personnel injuries. ...
There is a strong belief among researchers that humans contribute to some 80% of industrial accidents, including those occurring in shipping. However, few sources give actual evidence and hard data to support this statement, and even fewer sources provide a detailed analysis of what where the actual human factors or errors causing the accidents. Therefore, a literature review has been performed to verify the common belief and identify its source. A total of 292 documents has been reviewed. Results indicate that although original research generally agrees that a human error constitutes a significant contribution to the maritime accident occurrence, the widely accepted 80% rate itself in unsubstantiated.
In recent years, despite the technological advances, and increasing security measures in the maritime industry, it is observed that the effect of the human factor in the marine accidents has not changed. Most of the accidents occur in narrow canals, straits, rivers and entering port areas, resulting in environmental pollution, economical casualties and injury/loss of life. Pilotage is set compulsory in order to maintain safe passage at such confined waters. The purpose of this study is to investigate the effect of critical human factors on the potential ship accidents under pilotage operations. To explore the identified human factors, depth interviews and a questionnaire study were conducted with masters and pilots. The obtained data was analysed using DEMATEL (Decision Making Trial and Evaluation Laboratory) method to identify the most important and influential factors. The DEMATEL method is used to investigate interaction among human factors and to visualize them with help of causal-effect relation diagram. The results show that master experience, pilot experience and crew training are significant factors compared to other human risk factors. As a result of the findings of this research, it is also thought that improving the collaboration and communication between the master and the pilot will be effective in preventing the accidents. Moreover, understanding casual relations among human factors is important to prevent marine accidents. Furthermore, sensitivity analysis was performed for testing reliability of the experts’ evaluation and being clear certainty of the main results/findings in the DEMATEL method. It is found that expert considerations to the casual relationship between human factors are objective and sufficient. The findings of this article provide a critical overview of the research literature on the development of preventive measures for policy makers, shipping companies and port authorities.
The three volumes of this report detail a standard investigation process for use by US Nuclear Regulatory Commission (NRC) personnel when investigating human performance related events at nuclear power plants. The process, called the Human Performance Investigation Process (HPIP), was developed to meet the special needs of NRC personnel, especially NRC resident and regional inspectors. HPIP is a systematic investigation process combining current procedures and field practices, expert experience, NRC human performance research, and applicable investigation techniques. The process is easy to learn and helps NRC personnel perform better field investigations of the root causes of human performance problems. The human performance data gathered through such investigations provides a better understanding of the human performance issues that cause events at nuclear power plants. This document, Volume I is a concise description of the need for the human performance investigation process, the process` components, the methods used to develop the process, the methods proposed to test the process, and conclusions on the process` usefulness.
Normal Accidents analyzes the social side of technological risk. Charles Perrow argues that the conventional engineering approach to ensuring safety--building in more warnings and safeguards--fails because systems complexity makes failures inevitable. He asserts that typical precautions, by adding to complexity, may help create new categories of accidents. (At Chernobyl, tests of a new safety system helped produce the meltdown and subsequent fire.) By recognizing two dimensions of risk--complex versus linear interactions, and tight versus loose coupling--this book provides a powerful framework for analyzing risks and the organizations that insist we run them. The first edition fulfilled one reviewer's prediction that it "may mark the beginning of accident research." In the new afterword to this edition Perrow reviews the extensive work on the major accidents of the last fifteen years, including Bhopal, Chernobyl, and the Challenger disaster. The new postscript probes what the author considers to be the "quintessential 'Normal Accident'" of our time: the Y2K computer problem.
The three volumes of this report detail a standard investigation process for use by US Nuclear Regulatory Commission (NRC) personnel when investigating human performance related events at nuclear power plants. The process, called the Human Performance Investigation Process (HPIP), was developed to meet the special needs of NRC personnel, especially NRC resident and regional inspectors. HPIP is a systematic investigation process combining current procedures and field practices, expert experience, NRC human performance research, and applicable investigation techniques. The process is easy to learn and helps NRC personnel perform better field investigations of the root causes of human performance problems. The human performance data gathered through such investigations provides a better understanding of the human performance issues that cause events at nuclear power plants. This document, Volume III, is a detailed documentation of the development effort and the pilot training program.
As part of its mission to prevent and mitigate marine accidents, the U. S. Coast Guard (USCG) investigates the causes of marine casualties and analyzes investigation data in an effort to identify measures that will improve marine safety. It is estimated that 60-80% of marine casualties have human-related causes; therefore, it is important to record and analyze human errors in order to identify measures that will reduce these errors. In 1992 the USCG introduced a new casualty database, the Marine Investigations Module (MINMOD), which provided taxonomies for reporting human factors causes. The purpose of this project was to study the USCG casualty investigation process particularly with reference to the identification and reporting of human factors causes, analyze the data entry process, and make recommendations for improvements to the current computer system and the casualty investigation process. Six Marine Safety Offices (MSOs) were visited. Twenty-four Investigating Officers (lOs) and nine Senior Investigating Officers (S lOs) were interviewed. The data analysis revealed a number of problems with the collection and entry of marine casualty data in general, and human factors data in particular. The problems were discussed in terms of the requirements for an accurate and reliable database, and suggestions were made for addressing these problems.
Human Factors in Casualty Investigations: Evaluation of the Accuracy of
- A M Rothblum
Rothblum, A.M. Human Factors in Casualty Investigations: Evaluation of the Accuracy of Human
Factors Data. Letter Report (unpublished), April 5, 1993 (Enclosure for Letter 733302 from CO
USCG R&DC to Commandant (G-MMI), dated April 9, 1993).
An Integrated Process for Occurrence Investigation, (draft document)
- Nottrodt J.
Prevention Through People Quality Action Team Report
- U S Coast Guard