Marine Casulaties

Investigation
Dr. Trika Pitana
Dept. of Marine Engineering
Institut Teknologi Sepuluh Nopember (ITS), Surabaya
2010

Outline

Steps of Human Error Investigation

SHEL Model
Reason Model
GEMS Framework
Conclusion

Human Element Investigation

1. Collect occurrence data,
2. Determine occurrence sequence,
3. Identify unsafe acts (decisions) and
unsafe conditions; and then for each
unsafe act (decision),
4. Identify the error type and violation,
5. Identify underlying factors,
6. Identify potential safety problems and
develop safety actions.

Collect Occurrence Data

Investigation any works related to
environment, personnels, task and
equipment
Tool: SHEL (Software-HardwareEnvironment-Liveware) Model

SHEL Model
Focusing human element contribution to
marine casualties.

Liveware
L = human being who is related
to accident
Interaction of person subject to
an accident investigation
Human element is mainly
influenced by individual factors:

Physical
Physiological
Psychological
Psychosocial

Hardware
Hardware refers to the
equipment used in the
transportation process. It
refers to ergonomic aspects
of workstations, displays etc.,
too.

Environment
Environment includes the
internal and external climate,
temperature, visibility,
vibration, noise and other
factors which constitute the
conditions within people are
working.

Software
Software is the non-physical
part of the system including
organizational policies,
procedures, manuals,
checklist layout, charts,
maps, advisories and
computer programs.
All this material should be
part of the ISM system.

Interrelation SHEL Component

This field covers human interactions and

communication breakdown between individuals
by consideration of the following aspects:
Oral communications (misinterpretations,
misunderstandings, improper languageusage)
Crew interaction (crew compatibility in terms of
personality, knowledge,experience etc.)
Work management factors (Hierarchy, Bridge Team
Management)
Supervision (Controlling)
Regulatory requirements (encourage to bend rules)
Some failures occurred during these interactions are
easy to identify if written procedures, reports, records
etc. or even tapes are available. Some of them can
be identified through
carefully interviewing only.

Liveware-Hardware
This area refers to human-machine
interaction. Any design limitations and
peculiarities in workstation
configuration should be considered.
Furthermore workspace factors, such
as space, noise, illumination etc. can
affect the performance of the system
and should be investigated therefore.
Apart from this correct usage of
available equipment as well as proper
functioning should be inquired.

Software-Liveware

These interactions refer to the information

transfer between the human and supporting
systems. These factors are usually easy to
trace, due to the fact that they can be found in
the written parts of the ISM system. Special
reference is made to checklists, standing
orders and manuals. In recent years
computerisation was introduced in shipping,
too. Therefore the proper usage of computer
programmes should be investigated, too.
Furthermore special consideration is given
towards the proper certification of the system.
This means the operators (officers and crew)
need to be certified according to their duties
and the ISM system, equipment, programmes
etc. should be type-approved if required in the
international conventions.

Liveware-Environment
As already mentioned the
environment is divided into three
parts:
Internal climate, personal comfort,
physical working conditions
External weather
Infrastructure or supporting services
contributes to reducing safety or
limited choice of actions (restricted
water depth, limited navigability of
waters etc.)

Determine Occurrence Sequence

Decision Maker
Decision makers set the goals for the system
as a whole according to the input from the
environment (market, political conditions etc.).
They specify on how these goals should be met.
They even allocate the necessary resources for
this purpose to the line management (money,
equipment, people, time etc.). Special
consideration is given to optimise the use of
resources in order to achieve a maximum
outcome of the production process.

Line Management
Line management refers to specialists in
the different departments that implement
the strategic goals of the decision makers
within their specific spheres of operation.
For shipping business this could mean
Head of the operations department,
Supervisors of the fleet, Head of the
crewing area. On board a ship line
management applies to the master.

Pre Condition
Apart from decision makers and line management a
reliable, motivated and knowledgeable workforce and
suitable equipment is necessary to start and to maintain
a production process. This includes work schedules,
maintenance programmes,
programmes, as well as environmental
conditions, such as training, motivation etc.
etc in order
to permit efficient and safe working. This is a very wide
spread area on board ships. Apart from technical
aspects of equipment special consideration needs to
given to the crew. Structure, origin (number ofdifferent
nationalities) etc. should be considered. Furthermore it
should be observed whether the shipping company or a
crewing agency has recruited the crew.

Productive Activities
The productive activities concentrate on
the actual performances of the humans
and the machines. This means for
shipping that all process started from
loading and unloading up to navigation
and maintenance should be included.

Defences
Production can always cause risks. Ships may cause
accidents which could lead to damage of human life, as
well as to environmental disasters. Therefore appropriate
measures should be taken in advance to reduce this risk.
Some of them are required by the international
conventions (basic standards for equipment,
maintenance, manning of ships, training of crews
etc.), some of them have been identified by the
shipping companies themselves, e.g. during ISM
implementation etc. A simple example for such
defences is a lookout during nighttime to assist the
watch officer.

The Human Element accident

Causation

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GEMS

Collecting Evidence

VIDEO

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Assignment
Please find out one of marine accident in
Indonesia.
Analysis the causes of marine accident in
Indonesia by using SHEL Model
Please submit the report within 3 weeks
from October 5 2010
Please make a group (member = 2
persons for each group)

References:
Schroede, J.W(2003), Marine Casualtie Investigation
Hand Out

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Conclusion
You have known the principle of human
element investigation

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