Contemporary issues in marine casualty

ESSP
investigation

Contemporary issues in maritime

World Maritime University

casualty investigation

Dr. Jens-Uwe Schröder

Assistant Professor

World Maritime University, Malmö,

Sweden

Dr.-Ing. Jens-Uwe Schröder

n Master Mariner
n Transportation
Engineering (MSc)
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n Safety Science (PhD)

World Maritime University - Dr. Jens-Uwe Schröder 1

 Contemporary issues in marine casualty
ESSP
investigation

Example BÖHLEN

n Grounding
1976
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Deviation of 30 nm

Torrey Canon
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World Maritime University - Dr. Jens-Uwe Schröder 2

 Contemporary issues in marine casualty
ESSP
investigation

Accidents – a need to
investigate?

1 Major accident
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30 Minor accident

300 Near accident

3000 Unsafe acts and conditions

H.W. Heinrichs scheme concerning the relations of serious accidents and unsafe conditions)

Accidents – a need to
investigate?

2000
Total losses (in 1000 gt)
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1500

1000

500

0
1994 1995 1996 1997 1998 1999
Year

Total losses of ships of more than 500 GT between 1994 and 1999 (Source: ISL)

World Maritime University - Dr. Jens-Uwe Schröder 3

 Contemporary issues in marine casualty
ESSP
investigation

Accidents – a need to
investigate?

1
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0.75
1.000.000 US Dollar

0.5
Damage

0.25

0
1987 1988 1989 1990 1991 1992 1993 1994 1995 1996
Year

Development of the average damage amount for major accidents in the UK P&I club Source: UK P&I club

Marine casualties and the

human element (HE)

Technical
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Failure
20%

Human error
80%

World Maritime University - Dr. Jens-Uwe Schröder 4

 Contemporary issues in marine casualty
ESSP
investigation

Human error vs.

Technical failure
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EXPRESS SAMIA – 26. September 2000 Structural damage

Image of seafaring
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World Maritime University - Dr. Jens-Uwe Schröder 5

 Contemporary issues in marine casualty
ESSP
investigation

Short-term needs vs.

long-term interests
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Proactive vs. reactive

approach to maritime risk
assessment
n Titanic (1912)
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World Maritime University - Dr. Jens-Uwe Schröder 6

 Contemporary issues in marine casualty
ESSP
investigation

Maritime casualties
and their impact
Year Ships name Measures adopted In force

n Intervention Convention (1969) 1975

Torrey
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1967 n MARPOL (1973) 1983

Canyon
n Civil Liability Convention (1969) 1975

Argo
1976 n MARPOL (1973) – Protocol of 1978 1983
Merchant

n ISM Code (1994) 1998

Herald of n SOLAS 1988 amendments 1989
1987 Free
n SOLAS 1988 (October amendments 1990
Enterprise
– SOLAS 90 stability standards)
n OPRC (1990) 1995
n MARPOL 1992 amendments 1995
1989 Exxon Valdez
(double hull)
n Oil Pollution Act (OPA 90) 1990

Proactive ? YES !!!!

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World Maritime University - Dr. Jens-Uwe Schröder 7

 Contemporary issues in marine casualty
ESSP
investigation

Are the root causes

identified?
n Exxon Valdez (1989)
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Photo: EVOS Trustee Council

Double-hull tankers
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World Maritime University - Dr. Jens-Uwe Schröder 8

 Contemporary issues in marine casualty
ESSP
investigation

Baltic Carrier vs. Tern

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29. March 2001

Baltic Carrier vs. Tern

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 Contemporary issues in marine casualty
ESSP
investigation

Functions of marine
casualty investigation

Scientific
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Legal

Educational

Practical

Tasks of flag State

administrations
n Conduct accident evaluation
n Assessment of overall trends
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n Assessment of existing safety

regulations
n Creation of new safety
regulations
n Support the safety related
research

World Maritime University - Dr. Jens-Uwe Schröder 10

 Contemporary issues in marine casualty
ESSP
investigation

Current status of HE
detection in casualties
n Missing data
n Overemphasis of technical
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aspects
n Missing agreed definitions,
procedures etc. in marine
casualty investigation
n Lacking concentrated efforts

Shortcomings in the current

marine casualty investigation

n Framework for
marine casualty
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investigation
n Data situation
n Accident
process

World Maritime University - Dr. Jens-Uwe Schröder 11

 Contemporary issues in marine casualty
ESSP
investigation

Framework for casualty

investigation
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Method

Focus of Investigating
Analysis Taxonomy Model
investigation body

Conclusion

IMO

n Code for the

investigation of
marine casualties
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and incidents

World Maritime University - Dr. Jens-Uwe Schröder 12

 Contemporary issues in marine casualty
ESSP
investigation

IMO code

n James Reason
– Generic Error Modelling
system
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n Skill-based
n Rule-based

n Knowledge-based

– Accident causation
model
n Hierarchy oriented

Current data situation

Percentage of
Data category Data sub-category
missing data
Fire source 0

Fire detection 0
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Fire detection and

development Development 12%

Initial fire fighting measures 0

Involved crew 100%

Accessibility to the fire 18%

Measures to fight the fire 12%

Fire fighting
Further measures to fight the fire 70%

Times until commencing with actions 33%

Results 6%

Fire fighting equipment involved 27%

Fire fighting
equipment Fire fighting equipment condition 45%

World Maritime University - Dr. Jens-Uwe Schröder 13

 Contemporary issues in marine casualty
ESSP
investigation

Current data situation

Percentage of
Data category Data sub-category
missing data
Manning of the bridge 81%
HE – Beginning of Coordination of the initial measures 40%
the emergency
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Initial measures 43%

situation and
initial measures Organization of emergency response teams 77%
Involvement of pilots or VTS centres 93%
Manning of the bridge 96%
Coordination of emergency response actions 59%
HE – Emergency Decision making 93%
management
Information gathering during the emergency 74%
Problems during the emergency response
90%
actions
Manning of the bridge 96%
Coordination of the evacuation 14%
HE - Evacuation
Decision making 89%
Problems during evacuation 81%

Human Element -
Introduction

Performance
demands
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Monitored Process

ACTIONS AND ERRORS

Resources and Organisational

constraints context

The socio technical approach according Hollnagel (1998)

World Maritime University - Dr. Jens-Uwe Schröder 14

 Contemporary issues in marine casualty
ESSP
investigation

Problem Performance
shaping factors

Number
of goa the day
ls Time of
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Fatigue, stress
Available time

ation
Crew cooper Working conditi
ons

isation Sufficient
Organ training

Errors always occur in Common Performance Conditions

a contents. Performance Shaping Factors

Why to investigate
Human error ?
Number the day
of goa ls Time of

Fatigue, stress
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Available time

? Crew cooper
ation

isation
Working conditi
ons ?
Organ Sufficient
training

To find the links between events and their underlying

factors and to prevent these links from happen

World Maritime University - Dr. Jens-Uwe Schröder 15

 Contemporary issues in marine casualty
ESSP
investigation

Accident process

Technical Return
failure to normal
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yes

Human
Dangerous Adequate Near
operator
situation Defences ? miss
failure

yes
no
Adequate
Organisational Developing
(human)
failure incident
recovery ?

no

Accident
Source: van der Schaaf et al. (1996)

Model of the maritime

accident process
Dangerous situation
Safe shipboard operational status
Technical
failure

Stop
Human Dangerous
Near miss

evacuation
failure situation
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Release extern.
Accident support
Organisational
failure
Monitoring
Preparation of system recovery
evacuation
yes yes
System
System Calling for
recovery
assessment external support
possible System
yes
recovered
no Emergency
yes yes yes response actions no
Failure Situation Initial System Further
detection assessmt. response recovered? no data
input
no no no

Evacuation
Total loss

Beginning accident External

support
Emergency
delay

Abandon ship

World Maritime University - Dr. Jens-Uwe Schröder 16

 Contemporary issues in marine casualty
ESSP
investigation

Potential support through

casualty investigation
n Assessment of
existing safety
regulations
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n Decision support
systems
n Maritime
education and
training

Maritime education
and training
n Training
n Simulation
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World Maritime University - Dr. Jens-Uwe Schröder 17

 Contemporary issues in marine casualty
ESSP
investigation

Conclusions

n New quality in
casualty
investigation
World Maritime University

n HE has to be
treated more
systematic

World Maritime University - Dr. Jens-Uwe Schröder 18