Human Error Assessment and Reduction Technique

Applied Mechanics and Materials ISSN: 1662-7482, Vol. 874, pp 199-206 doi:10.4028/www.scientific.net/AMM.874.199 © 2018 Trans Tech Publications, Switzerland

Submitted: 2017-01-27 Accepted: 2017-05-26 Online: 2018-01-10

Human Error Assessment and Reduction Technique for Reducing the Number of Marine Accidents in Indonesia Ludfi Pratiwi BOWO1,a*, Masao FURUSHO1,b 1

Graduate School of Maritime Science, Kobe University, Japan a

[email protected], [email protected] *corresponding author

Keywords: Error-producing conditions (EPC); HEART method; human factors; marine accidents.

Abstract. Human factors is playing an important role in every accident, particularly marine accidents. Hence, a lot of researches were conducted to analyze the human factors involvement in the accidents. Since the development of marine industry shows progressively increasing nowadays, especially in Indonesia, as Indonesia vision to be a global maritime axis of the world for marine industry, the awareness of safety life at sea has to be increase as well. Human reliability analysis (HRA) consist of many methodologies to analyze the accidents, the basic steps of HRA is qualitative method and quantitative method, one of the HRA methodology is Human Error Assessment and Reduction Technique (HEART) methodology which has been established in 1982 to assess nuclear power plant. HEART methodology is applied in this study to analyze the cause of marine accidents by human factors. The aims of this study are to know the main cause of accidents by human factors, to increase the awareness of safety at sea especially, and furthermore to improve the quality of ergonomics at sea. There are 93 EPC which discovered in this study for analyzing marine accidents in Indonesia. Introduction Nowadays a lot of researches are conducted to assess the human factors contribution in many types of industries, particularly marine industry. In vessel grounding cases, human error has contributed about 79% of the accidents causes, resulted in the spilling of 100.000 tons of crude oil [1]. Human reliability analysis (HRA) is concerned with the qualitative and quantitative assessment of human error and the reduction technique to reduce the probability of future accidents [2]. In many types of industries such as nuclear power plant [3], aerospace industries [4], railway sectors [5], the analysis of accidents occurred based in human factors had been developed well. Some of the HRA were developed because of the accidents where occurred in those industries, as well as in marine accidents. The marine industry has contributed to the progress of nations in the development of modern transportation system worldwide and economic globalization [6]. Because the number of cargo demand has increase in the worldwide, the number of ship sailing is progressing quickly. Therefore, the safety behavior while sailing the ship has to be concerned, especially among the seafarers. The objectives of this study are to know the main cause of accidents by human factors, to increase the awareness of safety at sea especially, and furthermore to improve the quality of ergonomics at sea. This paper will be divided by several sections, the second section will be explained about Indonesia shipping conditions and the marine accidents, the third sections consist of the explanation of the casualty factors in marine accidents. The methodology of this study will be explained in the next section. The fifth section will be consisting of Indonesian accidents analysis. The consideration and discussion will be explained in the sixth section. Then the last one of this paper is conclusion.

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Marine Systems and Technologies

Indonesian Shipping As an archipelago country, Indonesia has a lot of islands which separated by the sea, therefore sea transportation is very important to connect each islands. As Indonesia’s vision, that Indonesia is going to be a global maritime axis [7], it is a positive signal for developing Indonesia maritime industry. However, the quality of safety at sea has to be improved as well. Based on Indonesia National Transportation Safety Committee the types of accidents consist by two types: • Very serious casualty is an accident which causes total loss for both ship and her cargo, fatalities, and heavy damage pollution for environment. • Serious casualty is accidents such as fire, explosion, grounding, contact, hull cracking, and so on, which doesn’t cause the ship nor the cargo sink (total loss), no fatality. The number of accidents in Indonesia based on the data from National Transportation Safety Committee from 2007 – 2010 [8], as follows:

Number of Accidents

Indonesia Marine Accidents Data 2007-2010 70 60 50 40 30 20 10 0

63

2007

54

2008

2009

2010

41 41 27

sink

22

26

fire

15

20

15 16

21

collision

23

29 17 19

capsized

26

29

22 22

etc

Accident Types Source: National Transportation Safety Committee Figure 1. Indonesia marine accidents data. According to the chart above, the most common accidents occurred in Indonesia for 2007-2010 is Sink. Sink is including in very serious casualty, because causing the total loss and fatalities. Hence, it is important to analyze the cause of sink accidents in Indonesia. In the other hand, fire and explosion has placed in the second positions of the most occurring accidents in Indonesia. In order to obtain the right recommendation to reduce the number of fire and explosion in the future, it is necessary to assess the cause of fire and explosion as well. Marine Accidents Error-Producing Conditions Understanding and preventing the marine accidents is still main focus of maritime interest and importance [9]. There are a lot of research were conducted to analyze the factors which led to marine accidents. The dangerous conditions which did by the seafarer related with other factors which can lead to the accidents, is called error-producing conditions. For many decades, human error has been reported as a major reason behind accidents in complex system. Based on the causes of marine accidents, here are some conclusions that were drawn by T.Porathe and G. Shaw [10]:  Human error becomes a dominant factor in marine accidents approximately 85%.  Failures of situation awareness and situation assessment overwhelmingly predominate, being a causal factor in the majority of those accidents attributed to human error.  Human fatigue and task omission closely related to failures of situation awareness.

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Based on the IMO (International Maritime Organization) there are differences between human elements and human factors. Human element is a complex multidimensional issue that play an important role in the operation of industries, in enhancing maritime safety, security, and marine environment protection. Furthermore, the human element remains a basic component for all its strengths and weaknesses that can either cause a disaster or prevent it. In the other hand, human factors is an interactive process between humans, the tasks and their working environment [6]. The International Maritime Organization (IMO), through its Resolution A.947(23) – Human Element Vision, Principles and Goals for the Organization – recognizes “the need for increased focus on human-related activities in the safe operation of ships, and the need to achieve and maintain high standards of safety, security and environmental protection for the purpose of significantly reducing maritime casualties” In the maritime industry, it needs good, qualified and motivated shore and staff to operate effectively. In the term of seafarer, the basic human needs of the mind, the body and the spirit is needed. This table below shows the basic human needs [11]: Table 1. The basic human needs. Mind Competence Attitude Motivation

Body Spirit Happy and healthy lifestyle Self-actualization Safe and secure working Moral values environment

These basic human needs are important to have and apply in the working environment, in order to create a safe and secure working environment. Based on the annual report of European Maritime Safety Agency (EMSA) in 2014, human factors are the highest factors which caused accidents in marine industry. For about 67% of accidents were caused by human error [12]. This condition is as same as in Indonesia, based on the record of Indonesia Marine Court Decision (IMCD) from 2007 to 2011, human factors is the main cause of marine accidents. Then followed by the mechanical failure. Therefore, it is necessary to concern about the causes of accidents based on human errors. Human Error Assessment and Reduction Technique (HEART) Methodology In 1986, HEART methodology had been developed by William, to solve the Nuclear Power Plant accident [13]. Furthermore, the HEART methodology has been developed to analyze the accidents in other industry, particularly marine industry. Maritime Human Reliability Analysis (MAHRA) has been developed by [14], the aim of this method is to analyze the human factors in shipboard operation by determining the suitable Error-producing Conditions (EPCs). This method has been applied to analyze various shipboard operation cases, such as bunkering operations, emergency drills. Generally, HEART methodology consist of two steps, the first step is qualitative method and then quantitative step. The qualitative method is started by classifying the generic task based on the accidents data report. There are eight generic tasks which discovered by William, and each of generic task has their own number of nominal human unreliability as follows;

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Table 2. Generic tasks. Generic Task

1. Totally unfamiliar 2. Shift or restore system to a new or original state without supervision. 3. Complex task requiring high level of comprehension and skill. 4. Fairly simple task performed rapidly or given scant attention. 5. Routine, highly-practiced, rapid task involving relatively low level of skill. 6. Restore or shift a system to original or new state following procedures, with some checking. 7. Completely familiar, but without the benefit of significant job aids. 8. Respond correctly to system command. Since the tasks are not typically the same as the Table 1, then the researcher had to be decided how to define the task, and classify it accordingly [15]. The applicability of proposed nominal human unreliability is based on the assessor experiences, but Williams obtain the mean number to use if the assessor cannot determine the exact number of proposed nominal human unreliability to analyze the task. The nominal human unreliability which is used in this research, is the mean of the nominal human unreliability. After classifying the generic tasks of each data reports, the next qualitative method is assigning the Error Producing Conditions (EPC) for each data report of accidents. It breaks down to be more detail when assigning the EPC. There are 38 types of EPC which are used in this research. Every EPC has multiplier number which will be used to calculate assessed impact value. This EPC was arranged by the most dangerous behavior which has the most probability number of accident occurrence.

Nominal Human Unreliability 1

PROBABILITY

0,1

0,97 0,55 0,35

0,01

0,42 0,26 0,14

0,28

0,13

0,16 0,12

0,09

0,045

0,06

0,02

0,007

0,007

0,003

0,001

0,0008

0,0001 Min. Limit

0,00001 0,000001

0,009 0,0009 0,0004

Average 0,00008 0,00002

Max. Limit

0,000006 GT.1

GT.2

GT.3

GT.4

GT.5

GT.6

GT.7

GT.8

Figure 2. Nominal Human Reliability Diagram. The next method is quantitative methods, to calculate the assessed impact value (AIV) of each EPC on the nominal HEP and overall probability of failure. Multiplier is gotten by the EPCs table. Then the assessed proportion of effect (APE) is highly judgmental, and no guidance is given in the current HEART documentation [15]. It is based on an assessment of the conditions and circumstances which may lead the EPC being applicable for the task being considered. This is one of the difficulties to apply this methodology, because the obtaining of the value of assessed proportion effect is based on the researcher or assessor experience. The formula to calculate the assessed impact value of each EPC is as follows: 𝐴𝐴𝐴𝐴𝐴𝐴 = �(𝐸𝐸𝐸𝐸𝐸𝐸 𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖 − 1) × 𝐴𝐴𝐴𝐴𝐴𝐴� + 1

(1)


203

The result of this calculation will be used to calculate Human Error Probability to determine the overall probability of failure for each case. The formula is as follows: (2)

𝐻𝐻𝐻𝐻𝐻𝐻 = 𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁 𝐻𝐻𝐻𝐻𝑚𝑚𝑚𝑚𝑚𝑚 𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈 × 𝐴𝐴𝐴𝐴𝐴𝐴1 × 𝐴𝐴𝐴𝐴𝐴𝐴2 × ⋯ × 𝐴𝐴𝐴𝐴𝐴𝐴𝑛𝑛

Nominal Human Unreliability is based on the generic task unreliability which has been chosen before. In this research, the nominal human unreliability number which used, is the average number of nominal human unreliability. In fact, the nominal human unreliability can be chosen between the range of every nominal human unreliability. Because each of the 8 of generic task has the Nominal Human Unreliability percentage, based on the characteristic of each task in the scenario. As a total probability of failure can never exceed 1.00, if the multiplication of factors takes the value above 1.00, the probability of failure has to be assumed to be 1.00 and no more [3]. Indonesia Accidents Analysis In this research there are two types of accidents in Indonesia which analyzed using HEART methodology, sink and fire and explosion. There are several data which already obtained, the generic task, EPC and Human error probability. Table 3. Marine Accidents Generic Tasks. Generic Task Routine, highly-practiced, rapid task involving relatively low level of skill. Fairly simple task performed rapidly or given scant attention. Complex task requiring high level of comprehension and skill. Totally unfamiliar Shift or restore system to a new or original state without supervision. Total

% 38% 29% 14% 10% 10% 100%

In the sink accidents the highest number of generic tasks which discovered is fairly simple task performed rapidly or given scant attention. This generic task means that the marine accidents which had been occurred were caused by the seafarers didn’t give attention and didn’t focus when doing the task. In sink accidents, the role of weather was very important, it is necessary to check the weather condition in the day of voyage. Furthermore, for fire and explosion accidents were mostly occurred in the condition routine, highly-practiced, rapid task involving relatively low level of skill. It means that the fire and explosion were occurred during the routine working while working at the ship. Here are the error-producing conditions which had been discovered in this research, as follows: • There are 24 the number of EPC types out of 38 EPC. • There are 93 of EPC. • For sink accidents, an impoverished quality of information conveyed by procedures and person-person interaction and no obvious way to keep track of progress during an activity were mostly occurred EPC when the accidents were happened. • In the other hand, EPC operator inexperienced and poor of hostile environment was mostly occurred in fire and explosion accidents.

204


Fire and Explosion EPC Operator inexperience Poor environment Spatial and functional incompatibility Performance ambiguity Impoverished information Inadequate Checking Unreliable instruments

Total 5 4

Sink

EPC Impoverished information Progress tracking lack

Total 4 4

3

Lack of experience

3

3 3 3 3

Delayed/incomplete feedback Unreliable instruments Operator inexperience Absolute judgements required Spatial and functional incompatibility Inadequate Checking No diversity Unfamiliarity Knowledge transfer Channel overload Performance ambiguity Misperception of risk Educational mismatch Time shortage Technique unlearning Objectives conflict Low morale

3 3 3 3

Unclear allocation of function

3

Low morale No diversity Inconsistency of displays Task pacing Unfamiliarity Time shortage Delayed/incomplete feedback Lack of experience Progress tracking lack

3 2 2 2 1 1 1 1 1

2 2 2 2 1 1 1 1 1 1 1 1 1

The last step of HEART methodology is calculating the human error probability, based on the equation above. This HEP could show us, how far human factors affected the marine accidents. William already obtain the range number of human error probability between 0 to 1. If the final calculation results of the HEP is more than 1, it will be considered as 1. Because that means that the accidents were absolutely because of human error. The higher number were caused by the nominal human unreliability as well. In the generic task it has been ranked the highest nominal human unreliability was unfamiliarity of the situation, it means that the unfamiliarity situation made the seafarer difficult to take action or take judgement.

Fire and Explosion HEP

Sink Accidents HEP 3,00 2,50 HEP

HEP

2,00 1,50 1,00 0,50 0,00

1

2

3 4 5 6 7 8 Number of Accidents

9

1,60 1,40 1,20 1,00 0,80 0,60 0,40 0,20 0,00

1 2 3 4 5 6 7 8 9 10 11 12 Number of Accidents

Figure 3. Fire and explosion human error probability.


205

Consideration and Discussion As Indonesia’s vision, that Indonesia is going to be a global maritime axis [7], a lot of works that has to do in order to gain that vision. Not only develop the industry, but also develop the human, especially seafarer knowledge about safety behavior in the sea. According to the result of Indonesia marine accidents in sink, fire and explosion accidents, the most occurring number for generic task in sink is fairly simple task performed rapidly or given scant attention. In the other hand in fire and explosion accidents, routine, highly-practiced, rapid task involving relatively low level of skill is the generic task which mostly occurred and the fairly simple task performed rapidly or given scant attention is the second place to cause the accidents. It shows that the generic task between sink, fire and explosion is quite similar. The accidents which occurred because of seafarer cannot maintain their focus and attention while doing their duties. Maintaining focus and attention are important while working to increase the awareness of safety action. It is related to the IMO Resolution A.947(23) – Human Element Vision, Principles and Goals for the Organization, that recognized the need of increasing focus on human to significantly reduce the maritime casualties. In the other hand the error-producing conditions for every accident are different. For sink accident, the most occurring numbers for EPC are impoverished information and progress tracking lack. Communication among seafarers is an important thing to maintain while working on board. The information about ship conditions has to be deliver well without any loss of information between seafarers. The fire and explosion accidents error-producing number which mostly occurring are operator inexperienced and poor environment. In mostly cases of this accident the seafarer cannot handle emergency situation well, fire and explosion particularly. The lack of practice made they were not ready to handle the urgent situation. Furthermore, based on the records of marine accidents data, the working environment where the accidents occurred was poor. The importance of maintaining working environment is corresponding to maintain the risk of physical damage or harm [16]. Therefore, to keep clean the working environment, particularly in engine room, where there is high probability of oxygen, heat and spill oil can be mix then become fire and explosion, is very important. Conclusions The conclusions of this study are as follow: 1. The generic task of accidents is quite similar between sink, fire and explosion. Because mostly the marine accidents occurred in routine works or in simple job, where the seafarer didn’t give any attention and focus to their works. 2. The type of common EPC in every types of accidents is different. It is because every accident has its own characteristic of EPC. In sink accidents, impoverished information and progress tracking lack has the highest number EPC. Moreover, in fire and explosion accidents, Operator inexperience and poor environment are the most occurring number. 3. The awareness of safety behavior in Indonesia seafarer has to be increased. Indonesian seafarers need to practice emergency response in some emergency conditions. Maintaining the working environment to be conducive is important to minimize the risk of physical damage or harm. 4. The applicability of HEART methodology to analyze the marine accidents in particularly, as follows: a. HEART methodology can apply well to analyze the marine accidents. b. It is difficult to obtain the value of assessed proportion effect, since this number is subjective obtain by the assessor or researcher.

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