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Investigating the Impact of Bridge Resource Management on Navigational Safety by Root Cause Analysis
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This study aims to analyze the causes of delays in decision-making within the company. Managers can identify several constraints in decision-making by using analytical tools. In this study, the device used to analyze the problem is root cause analysis. Root cause analysis is used to determine the initial cause of the issues. The method used in the root cause analysis is a fishbone diagram where the fishbone diagram can identify some of the problems that underlie the constraints in decision making. This study uses a qualitative descriptive method by taking data from interviews and documentation. The results of this study can be seen in decision making four problems underlie the inhibition of decision making. The problem is the first decision-maker; namely, the company's management is not wholly a determinant in making decisions. The second problem is that the information presented as a guide for decision-making is inaccurate, not timely, and irrelevant. The third problem is the absence of software that processes data into information needed by company management. The last problem is the lack of integration between divisions, so the resulting information is out of sync. Root cause analysis and fishbone diagrams, that was possible to analyze in detail the causes of delays in decision making. In the end, management can find solutions to each of these problems. Management will search each problem for the root cause, and the answer that they will give will be right on target so that the hope to minimize the obstacles to decision making will be implemented.
This paper analyses the marine accident reports published by the USA National Transportation Safety Board (NTSB) between June 1975 and September 2017, in order to ascertain the exact influence of the crew and/or other people involved (pilots, company, etc.) on the cause of the incident and to find out the types of errors made by them. Additionally, the mistakes and those involved are analysed together to verify the correct implementation of international regulations concerning seafarers. The results suggest that crew error is relatively uncommon in cargo and passenger fleets. This points to the effectiveness of the International Convention on Standards of Training, Certification and Watchkeeping (STCW convention). However, taking into consideration the high percentage of human error due to failure in communication and misjudgements during navigation in pilot waters, it may be deduced that the coordination among those on the bridge may be improved. On the other hand, crew error on board tugs exceeds 50%. This increase seems to be due to the difficulties of navigation in narrow waterways.
Academic research in the laboratory is often considered as the work with lower risks compared with other process industries. Whereas, it is revealed that there are still many accidents happening in the laboratory, causing deaths, injuries, and economic losses. In order to identify the main causes and improve the safety management, an explosion accident in a laboratory of a university is thoroughly investigated based on the 24Model and 5Whys method. The results indicate that inadequate safety knowledge and insufficient safety awareness of the experimenters serve as main contributors of the accident. In order to effectively prevent such accidents, it is necessary to strengthen the safety training of the experimenters and associated technical managers, so as to create a good safety culture atmosphere in the university. Moreover, a smart safety management system based on internet of things (IoT) is established for the laboratory, which contains equipment management subsystem, experiment consumables management subsystem, personnel management, training and assessment subsystem, environmental monitoring subsystem, and accident diagnosis subsystem. With the help of the system, daily safety of the laboratory can be greatly improved.
Introduction: This systematic review examines and reports on peer reviewed studies that have applied systems thinking accident analysis methods to better understand the cause of accidents in a diverse range of sociotechnical systems contexts.
Methods: Four databases (PubMed, ScienceDirect, Scopus, Web of Science) were searched for published articles during the dates 01 January 1990 to 31 July 2018, inclusive, for original peer reviewed journal articles. Eligible studies applied AcciMap, the Human Factors Analysis and Classification System (HFACS), the Systems Theoretic Accident Model and Processes (STAMP) method, including Causal Analysis based on STAMP (CAST), and the Functional Resonance Analysis Method (FRAM). Outcomes included accidents ranging from major events to minor incidents.
Results: A total of 73 articles were included. There were 20, 43, six, and four studies in the AcciMap, HFACS, STAMP-CAST, and FRAM methods categories, respectively. The most common accident contexts were aviation, maritime, rail, public health, and mining. A greater number of contributory factors were found at the lower end of the sociotechnical systems analysed, including the equipment/technology, human/staff, and operating processes levels. A majority of studies used supplementary approaches to enhance the analytical capacity of base applications.
Conclusions: Systems thinking accident analysis methods have been popular for close to two decades and have been applied in a diverse range of sociotechnical systems contexts. A number of research-based recommendations are proposed, including the need to upgrade incident reporting systems and further explore opportunities around the development of novel accident analysis approaches.
When confronted with a problem, have you ever stopped and asked “why” five times? The Five Whys technique is a simple but powerful way to troubleshoot problems by exploring cause-and-effect relationships.
Attempts to learn from high-risk industries such as aviation and nuclear power have been a prominent feature of the patient safety movement since the late 1990s. One noteworthy practice adopted from such industries, endorsed by healthcare systems worldwide for the investigation of serious incidents, (1-3) is root cause analysis (RCA). Broadly understood as a method of structured risk identification and management in the aftermath of adverse events, (1) RCA is not a single technique. Rather, it describes a range of approaches and tools drawn from fields including human factors and safety science (4,5) that are used to establish how and why an incident occurred in an attempt to identify how it, and similar problems, might be prevented from happening again.(6) In this article, we propose that RCA does have potential value in healthcare, but it has been widely applied without sufficient attention paid to what makes it work in its contexts of origin, and without adequate customisation for the specifics of healthcare. (7,8) As a result, its potential has remained under-realised (7) and the phenomenon of organisational forgetting (9) remains widespread (Box 1). Here, we identify eight challenges facing the utilisation of RCA in healthcare and offer some proposals on how to improve learning from incidents.
Bridge resource management (BRM) is the maritime equivalent of crew resource management (CRM), and has been used in the civilian maritime industry for over a decade. An evaluation of the effectiveness of the U.S. Navy's BRM training was carried out by assessing the attitudes toward, and knowledge of, the human factors that contribute to accidents in high-risk organizations. A comparison was made between surface warfare officers (SWOs) who had and had not attended BRM training. The responses of the SWOs were also compared to CRM-trained U.S. Naval aviators. It was found that BRM training did not have a significant effect on the attitudes and knowledge of SWOs. Further, naval aviators were significantly more knowledgeable, and generally held attitudes toward the human factors that are causal to accidents in high-risk organizations than did SWOs. It was concluded that the Navy's BRM training is not having the impact on knowledge and attitudes that is typical of the CRM training reported in the literature. It is proposed that the main reason for the lack of effectiveness of the BRM program is that the content of the training was not based on a needs assessment carried out within the surface warfare community.
İstanbul Boğazı, kıvrımlı jeomorfolojisi ve yoğun deniz trafiğiyle seyir emniyeti açısından oldukça zorlu bir suyoludur. Gelişen gemi inşa teknolojisi bugün geçmişe kıyasla daha büyük boyut/kapasitedeki gemileri deniz ticaretine kazandırmıştır. Bu durum, kazaların karakteristiğini de değiştirmekte; Boğaz’ın deniz trafiği dinamiklerine paralel olarak seyir emniyetini güçlendirici tedbirler geliştirmeyi gerekli kılmaktadır. 07 Nisan 2018 tarihinde meydana gelen M/V VITASPIRIT kazası bu ihtiyacın altını çizen en önemli ayrımlardan biri olmuştur. Makine arızasının köprüüstüne haber verilmesi ile kazanın yaşanması arasında sadece 7 dakika olması, kaptan/kılavuz kaptana karar verme açısından fazla bir zaman bırakmamıştır. Bu noktada, karar verme konseptinin önemi ortaya çıkmakta ve karar verici durumunda olan kaptan/kılavuz kaptanın duygu, düşünce ve davranışlarının kaza dinamikleriyle birlikte incelenmesi önem taşımaktadır. Literatürde, denizcilik alanına ilk kez uygulanan Altı Şapkalı Düşünme Tekniği ile insan faktörü, M/V VITASPIRIT vaka analizi üzerinden denizci psikolojisi perspektifiyle araştırmaya dahil edilmiştir. Bu doğrultuda, siyah şapka ile kazaya dair risk değerlendirmesi yapılmış, sarı şapka ile kazadan çıkarılacak dersler araştırılmış, kırmızı şapka ile personel duygu, düşünce ve davranışları değerlendirilmiş ve yeşil şapka ile benzer kazaların yaşanmaması için geliştirilen çözüm önerileri sunulmuştur. Çalışma kapsamında elde edilen bulgular, en az 17 yıllık mesleki tecrübesi bulunan 6 uzakyol kaptanı ve 2 uzakyol başmühendisin katılımıyla gerçekleştirilen anket yöntemi ile elde edilmiştir.
A novel methodology to model disruption propagation for resilient maritime transportation systems-a case study of the Arctic maritime transportation system, Reliability Engineering and System Safety (2023), Abstract Disruption cognition is critical for the development of resilient maritime transportation systems to withstand uncertain risks and achieve sustainable development. Aiming at improving the resilience of maritime transportation systems, a comprehensive methodology is proposed in the present study to model the propagation process of disruptions. First, a conceptual framework of disruption propagation within resilience theory is developed for the maritime transportation system, based on which a directed weighted complex network of disruption propagation is established, and data-driven Bayesian inference is applied to extend the complex network using a probability-based method. The propagation process and mechanisms can then be analysed quantitatively through critical node identification for each propagation stage and the determination of the shortest propagative paths by the combination of bidirectional Bayesian inference, sensitivity analysis, and uncertainty analysis. Then, the proposed methodology is applied to the Arctic maritime transportation system to improve resilience by controlling the key disruptions in each propagation stage and cutting off the critical disruption propagation paths. The findings suggest that greater effort should be devoted to strengthening the resilience aspects related to environmental forecast and route planning systems, monitoring and functional maintenance mechanisms, emergency responses pertaining to repair and damage control, emergency escape and evacuation, and coastal SAR services to reduce the escalated impact of disruption propagation.
Accidents caused by steering gear malfunctions, especially during port berthing maneuvers, the strait, and canal crossings, can lead to hazardous consequences on the environment and human life. This study aims to provide the risk evaluation and investigation of the root causes of the steering gear failures on board using Fuzzy Bayesian Networks. To determine the effects of root causes on steering gear failures, the Bayesian Network was built in the NETICA software. Running several scenarios on the network are ensured the investigation of how the root reasons affect the problem. Prior and conditional probabilities obtained from meetings and interviews with six different experts were used to apply Bayesian inference. Sensitivity analysis, forward propagation analysis by applying the best- and worst-case scenarios, and validation of the network were conducted. Results depicted that the functionality of the electrical and mechanical line components is essential to preventing the breakdown of the steering gear system. The most significant contributor to component-related electrical failures is loose or corroded wiring and connections, whereas hydraulic oil-sourced errors have a significant impact on equipment wear and malfunction. The probability of a steering gear accident is assessed to be 13.7% under the best-case scenario and 79.1% in the worst-case scenario.
The melting of Arctic Sea ice has significantly facilitated Arctic shipping. However, such increased shipping has brought about higher maritime accidents in Arctic waters, especially for grounding and fire/explosion accidents. The paper presents a framework for quantitative analysis of the causation of grounding accidents in Arctic shipping by developing an accident map (AcciMap) - Bayesian network (BN) model. First, the potential risk factors for grounding accidents in the Arctic shipping were identified according to 322 maritime accident investigation reports (MAIRs) - 299 global MAIRs of grounding accidents (including 5 in Arctic waters) and 23 MAIRs (except grounding accidents) in Arctic waters and related literature. Consequently, an AcciMap model is developed for describing the evolution of grounding accident scenarios and reflecting the interdependency of the identified risk factors. Then, a probabilistic model is proposed to evaluate the probability and severity of the grounding accident for presenting a convincing justification for risk control options (RCOs). The framework is applied for the quantitative analysis of a cruise ship grounding accident in Arctic waters. Results demonstrate (1) improved understanding of cruise ship grounding risk factors related to government supervision, shipping company management, technical and operational management, unsafe incidents and behaviors, and environmental conditions; (2) quantitative analysis of the evolution of grounding accident and better identification of the critical risk factors; (3) determination of RCOs for risk management in Arctic shipping.
Our research study indicates that, over the past few decades, the expected decrease in the number of maritime accidents has not occurred. The statistics show the collision and contact types of marine accidents have always been the most frequent. Primary causes that contribute to ship collisions were collected from 513 collision accidents reported since 1977, which is the date the Convention on the International Regulations for Preventing Collisions at Sea, 1972 (COLREGs) came into effect. The root causes of ship-to-ship collisions were determined statistically. Qualitative and quantitative analyses were carried out using the Fault Tree Analysis (FTA). This provided the probability and importance of the primary causes contributing to the ship collision accidents and defined minimal cut sets. Results show that the violation of the COLREG Rules is the most important and effective factor for collision accidents. Therefore, further analysis was conducted and the results showed which type of COLREG Rules mostly violated statistically. The primary causes were also examined by Multiple Correspondence Analysis, and it was determined that maneuvering and perception errors were the most effective factors in collision accidents. The results represent the cause statistics of the ship-to-ship collision accidents that occurred in the last 43 years. Considering the collision accident reports data, our results show %94,7 of collision accidents are related to human error.
The objective of this work was to assess whether the implementation of a bridge resource management (BRM) unit into the simulator-based nautical training of the German Navy is effective in improving non-technical skills and navigation performance. To this end, questionnaire data, observations of behaviour and performance outcomes were compared between a control group and an experimental group. Data of 24 bridge teams (126 sailors) were used for the analyses. Ten teams received BRM training and 14 teams served as the control group with unchanged simulator training. Reactions to simulator training were positive in both groups but more favourable in the control group. In the BRM group, significantly more positive attitudes towards open communication and coordination, more frequent sharing of information and fewer collisions were found than in the control group. Effect sizes were rather small. This may be due to the limited scale of the BRM unit, which consisted of only one instruction-training-feedback cycle. The extension of BRM-related feedback to all simulator runs of the nautical training can be expected to produce larger effects on attitudes, behaviour and performance.
With the diminishing extents of Arctic sea ice, Arctic shipping becomes increasingly attractive for the shipping industry. Voyages along Arctic sea routes have seen a significant increase in recent years. Given the harsh environment, shipping operations in the Arctic constitute a hazardous activity for people onboard vessels, while vessels pose risks to vulnerable ecosystems and traditional socio-cultural environments. Given this emerging trend, this paper presents a bibliometric analysis of the broad academic literature related to risk management of Arctic shipping, published in the period from 2000 to 2019. Based on 221 articles, the bibliometric analyses provide insights in publication patterns concerning the year of publication, keywords, journals, and countries/regions from which the work originates. Furthermore, through a qualitative systematic review, this article presents a synthesis of risk influencing factors (RIFs) of navigational accidents in the Arctic, based on published quantitative risk models containing accident scenarios in Arctic shipping. To this effect, ten papers are investigated in detail, focusing on the scenario, methods, data sources, and RIFs. Identifying major thematic clusters in the RIFs, a model is proposed for synthesizing and illustrating the relationships among environmental and ship-related RIFs, and accident scenarios in Arctic shipping. A discussion is made concerning challenges in the research domain and future research directions, focusing on the strength of evidence in the risk models, the use of linear versus complex, systemic accident theories, and on the alignment of academic work with focus issues in regulatory contexts.
Collision accident accounts for the largest proportion among all types of maritime accidents, emergency decision-making is essential to reduce the consequence of such accidents. This paper proposes a novel Bayesian Network based emergency decision-making model for consequence reduction of individual ship-ship collision in the Yangtze River. The kernel of this method is to propose a three-layer decision-making framework, to develop the graphical structure for describing the accident process and to establish the conditional probability tables for the quantitative relationships. The merits of the proposed method include the intuitive representation of accident development, easy to implement, ability to deal with incomplete information and updated information. This proposed method is applied to a typical collision accident in the Yangtze River. Consequently, this paper provides a practical and novel decision-making method for collision accidents.
Analyzing maritime accidents plays a key role in improving maritime safety and raising environmental awareness. “The Functional Resonance Analysis Model (FRAM)” describes a structure to provide a system for achieving the aims of accident analysis. This paper considers the application of FRAM for qualitative risk analysis of shipping operations. The Prestige Oil Spill, an environmental catastrophe that caused a great amount of oil spill, is analyzed by using the aforementioned method. Through the results of the analysis, the variabilities of events underlying the accident are tried to be determined, and suggestions to examine them are provided. The essence of having a consistent opinion on the operation of the system and the fact that FRAM is an integral part for enhancing the risk analysis of the ship accidents were found out based on the results of the study.
Extreme weather conditions of the Arctic and its icy waters pose high-risk potential for a range of marine accidents in the region. Ship-ice collision is the focus of this paper. A large number of vessels operating in the Arctic waters are at risk of ice damage due to ship-ice collisions. The damage may vary from a minor hull deformation to ruptures that could put the lives, assets, and environment at risk. To minimize the risk of ship-ice collision in Arctic waters, a simple yet robust model to make routine safety-driven operational decisions could help. The present study proposes a Dynamic Bayesian Network (DBN) model to fill this gap. The model assesses the operational risk of ship-ice collision in an ice prone region using the hypothetical form of observations. Low temperatures, Weather, Ice, Fog, Darkness, Blowing snow, Poor visibility, Ice strength, Ice drift, Types of ice, Ice concentration and Speed of the vessel are considered as the primary risk factors in the region. The estimated collision risk would provide an easy to use indicator for decisions concerning safe operations in ice such as maneuvering, route selection, and safe speed. A case study of an oil tanker navigating across the Barents Sea is presented to explain the proposed model.
Naval maritime operations entail a permanent concern for safety, ensuring that all crew members receive the necessary information on time. This implies the existence of specific training for improving non-technical skills (NTS). This paper proposes that bridge resource management (BRM) may be determinant for the success of naval maritime operations. Through a literature review on NTS, maritime team training and BRM, the paper presents insights about the way the level of NTS, inherent to BRM, may be determinant for naval officers to operate in safety. We propose that human error may be minimised and safety maximised in military teams operating in the maritime environment through the implementation of an NTS training programme. The paper offers an insight into the importance of safety during maritime operations, focusing on recent international orientations about training requirements, proposing that implementing BRM will be pivotal for the future of the military navy context.
Human error is a significant factor triggering oil tanker collisions. Drawbacks jeopardizing the effectiveness of human error analysis from traditional studies are spotted. This study proposes a risk assessment of human error contribution to oil tanker collision. The research evaluates the collision probability of oil tanker using a Fault Tree Analysis (FTA) structure under which a modified Fuzzy Bayesian Network based Cognitive Reliability Error Analysis Method (CREAM) is developed to conduct human error assessment. 39 specialists with substantial seagoing experience are invited to provide expert judgement for oil tanker navigation particularly in vicinity of the Taiwanese waters. Different from traditional studies, the proposed methodology provides a higher degree of result distinguishability meanwhile contemplating the weights and quantitative effects caused by the ambient elements without the loss of information from the experts. It is concluded that lack of Bridge Resource Management Communication, lack of Communication between Ships, Fatigue and Collision Regulation Violations are the elements with higher occurrence rates and would also have great potential contributing to oil tanker collision once the likelihoods deteriorated. In addition, Number of Simultaneous Goals in the bridge is the Common Performance Condition (CPC) that significantly causes the occurrence of all the human error basic events.
With the global warming and a large amount of sea ice melting, the available Arctic Sea Route has greatly enhanced the value of Arctic shipping. Ship operations under icebreaker assistance have become an essential way to facilitate the safe navigation of merchant vessels sailing through the Arctic Sea Route in ice-covered waters, but they can also put the crew and the ship in danger caused by a possible collision between the assisted ship and the icebreaker. In this paper, a dedicated Human and Organizational Factors (HoFs) model of ship collision accidents between an assisted ship and an icebreaker is developed and analyzed with the aim to identify and classify collision risk factors. First, a modified model of the Human Factors Analysis and Classification System (HFACS) for collision accidents between a ship and an icebreaker in ice-covered waters is proposed, which helps to analyze ship collision reports. Then, a Fault Tree Analysis (FTA) model is utilized to analyze the fundamental collision risk factors according to the statistical analysis of accident reports and expert judgments based on the HFACS-SIBCI model. Finally, qualitative analysis is carried out to analyze collision risk factors under icebreaker assistance, where Risk Control Options (RCOs) are formulated. An important guidance for the risk control of ship collisions during icebreaker assistance in ice-covered waters is provided for lawmakers and shipping companies.
This book is open access under a CC BY-NC 3.0 IGO license.
This book comprehensively covers topics in knowledge management and competence in strategy development, management techniques, collaboration mechanisms, knowledge sharing and learning, as well as knowledge capture and storage. Presented in accessible “chunks,” it includes more than 120 topics that are essential to high-performance organizations. The extensive use of quotes by respected experts juxtaposed with relevant research to counterpoint or lend weight to key concepts; “cheat sheets” that simplify access and reference to individual articles; as well as the grouping of many of these topics under recurrent themes make this book unique. In addition, it provides scalable tried-and-tested tools, method and approaches for improved organizational effectiveness. The research included is particularly useful to knowledge workers engaged in executive leadership; research, analysis and advice; and corporate management and administration. It is a valuable resource for those working in the public, private and third sectors, both in industrialized and developing countries.
Constituting the key backbone of global trade, maritime transport essentially entails in itself a number of hazards both during the navigation and during the time spent on the port due to the different structure of work environment. This complex structure of ship operations makes the occurrence of ship accidents inevitable, which might in effect critically damage the environment, the human life and the commodity. To prevent the occurrence of such results or to minimize their impacts, it matters greatly to investigate hazardous incidents having occurred for the aim of taking appropriate measures. The key reason in investigating ship accidents is to comprehend the root causes that lead to accidents and to apply the required arrangements via detecting applicable risk- minimizing strategies. Because of the unique quality of ship operations, application of current methods in root analysis may not be sufficient in some cases. In this study a root cause analysis technique SHARE (SHip Accident Root cause Evaluation) exclusive to ship accidents has been developed to assist in a global scale all related departments of maritime companies to envisage lead causes of accidents and to implement appropriate corrective actions. In this particular technique in which it is feasible to obtain numeric data, to identify stakeholders responsible in implementing corrective actions and to forge risk-minimizing strategies, a standard terminology exclusive for ship accidents has been used. Being developed on the basis of Fuzzy SWOT AHP Method, this unique technique has been validated upon applying onto an actual case of a ship accident.
A survey of the safety culture and hazard risk perception has been carried out involving 77 maritime pilots around Australia and New Zealand, representing more than the 20% of the maritime pilots in each country, in proportional geographic distribution. In 82% of the cases, interviews were carried out face-to-face, based on a questionnaire designed to be completed in less than 1Â hour. Questions on 4 different aspects were asked, relating to each pilot's professional background, safety culture and perception of risks, navigation and pilotage hazards and their perception of the pilot's role. The responses indicated that there are issues with regulator identification, commercial pressures on pilots in some locations, incident reporting mechanisms and feedback, training opportunities and improved bridge resource management. In addition to reviewing comments made by pilots, the paper also presents recommendations for consideration in improving operational performance and safety of navigation in ports and regulated waterways. These recommendations can be used by regulators to improve their performance concerning pilotage matters and understand pilots' concerns.
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