IMO Assembly Resolution A.884_B (2.1)

Continued...

SECTION 3

REPORTING PROCEDURES

3.1 To facilitate the flow of information from casualty investigations, each report should conform to a basic format as outlined in IMO Assembly resolution A. 849(20) - Code for the Investigation of Marine Casualties and Incidents.

3.2 Reports should be made to IMO in accordance with established procedures***.

3.3 Persons and/or organizations with a vested interest in a report should be given the opportunity to comment on the report or relevant parts thereof before the report is finalized.

The final report should be distributed to relevant parties involved and preferably be made public.

***MSC/Circ.827, MUC/Circ.333 of 9 December 1997 reports on marine casualties and incidents, inter alia.

SECTION 4

QUALIFICATIONS AND TRAINING OF INVESTIGATORS

4.1 Many and varied contributory factors can play a significant part in the events preceding a marine casualty or incident. The question of who should be charged with the responsibility for investigating and analysing human factors therefore becomes important The skilled marine casualty and incident investigator generally is the person best suited to conduct all but the most specialized aspects of human factor investigation.

4.2 An investigator should have appropriate experience and formal training in marine casualty investigation. The formal training should include specific training in the identification of human factors in marine casualties and incidents.

4.3 In some cases, a human factors specialist may be of significant value in the investigation.

APPENDIX 1

THE IMO/ILO PROCESS FOR INVESTIGATING HUMAN FACTORS

The following is a process that provides a step-by-step systematic approach for use in the investigation of human factors. The process is an integration and adaptation of a number of human factor frameworks - SHEL (Hawkins, 1987) and Reason's (1990) Accident Causation and generic error-modelling system (GEMS) frameworks, as well as Rasmussen's Taxonomy of Error (1987).

The process can be applied to both types of occurrences, i.e., accidents and incidents. The process consists of the following steps:

1. collect occurrence data;
2. determine occurrence sequence;
3. identify unsafe acts (decisions) and ~e conditions;

and then for each unsafe act (decision),

1. identify the error type or violation;
2. identify underlying factors; and
3. identify potential problems and develop actions.

Steps 3 to 5 are useful to the investigation because they facilitate the identification of latent unsafe conditions. Step 6, the identification of potential safety problems is based extensively on what factors were identified as underlying factors. At times, an unsafe condition may be a result of a natural occurrence; in that case the investigator may jump from Step 3 to Step 6. At other times, an unsafe act or decision may result from an unsafe condition which itself was established by a fallible decision; in such a case, the investigator should proceed through Steps 3 to 6.

Step 1 - Collect Occurrence Data

The first step in the human factors investigation process is the collection of work-related information regarding the personnel, tasks, equipment and environmental conditions involved m the occurrence. A systematic approach to this step is crucial to ensure that a comprehensive analysis is possible and that the logistical requirements of collecting, organizing and maintaining a relevant occurrence related database are met.

For complex systems, where there are numerous interactions between the component elements, there is constant danger that critical information will be overlooked or lost during an investigation.

Use of the SHEL model as an organizational tool for the investigator's workplace data collections helps avoid downstream problems because:

1. it takes into consideration all the important work system elements;
2. it promotes the consideration of the interrelationships between the work system elements; and
3. it focuses on the factors which influence human performance by relating all peripheral elements to the central liveware element

At this step, the process attempts to answer the more simplistic questions concerning "what, who, and when" and then moves to more complicated questions of "how and why". The resulting data becomes, for the most part, a collection of events and circumstances comprised of acts and conditions. Some of these will be of interest as unsafe acts and unsafe conditions.

There are four components to the SHEL model:

• Liveware - L
• Hardware - H
• Software - S
• Environment - E

The SHEL Model is commonly depicted graphically to display, not only the four components, but also the relationships, or interfaces, between the Liveware and all the other components. Figure 1 attempts to portray the fact that the match or mismatch of the interfaces is just as important as the characteristics of the block themselves. A mismatch can be a source of human error and identification of a mismatch may be the identification of a safety deficiency in the system. Figure 2 also depicts how this model can be applied to a complex system where multiple liveware, hardware, software and environmental element exist

Figure 1.
(Adapted from Hawkins, 1987) SHEL Model

Liveware (Central Component)

The most valuable and flexible component; m the system is the human element, the Liveware, placed at the centre of the model. Each person brings his or her own capabilities and limitations, be they physical, physiological, psychological, or psychosocial. This component can be applied to any person involved with the operation or in support of the operation. The person under consideration interacts directly with each one of the four other elements. The person and each interaction, or interface constitute potential areas of human performance investigation.

Liveware (Peripheral)

The peripheral Liveware refers to the system's human-human interactions, including such factors as management, supervision, crew interactions and communications.

Hardware

Hardware refers to the equipment part of a transportation system. It includes the design of workstations, displays, controls, seats, etc.

Software

Software is the non-physical part of the system including organizational policies, procedures, manuals, checklist layout, charts, maps, advisories, and increasingly, computer programs.

Environment

Environment includes the internal and external climate, temperature, visibility, vibration, noise and other factors which constitute the conditions within which people are working. Sometimes the broad political and economic constraints under which the aviation system operates are included in this element. The regulatory is a part of the environment in as much as its climate affects communications, decision making control, and coordination.

Step 2 - Determine Occurrence Sequence

As the investigator moves to addressing questions of "how and why", there is a need to link the data identified in the first step of the process. Reason's (1990) model of accident causation, utilizing a production framework, can he used by an investigator as a guide to developing an occurrence sequence. As well, Reasons model facilitates further organization of the work system data collected using the SHEL model, and an improved understanding of their influence on human performance. The occurrence sequence is developed by arranging the information regarding occurrence events and circumstances around one of five production elements, i.e., decision makers, line management, preconditions, productive activities, and defences.

The production elements themselves are basically aligned m a temporal context. This temporal aspect is important organizing factor since the events and circumstances that can lead to an accident or incident are not necessarily proximate in time nor in location to the site of occurrence. By establishing a sequential ordering of the data, Reasons (1990) concept of active versus latent factors is introduced.

Active factors are the final event or circumstances which led to an occurrence. Their effect is often immediate because they occur either directly in the system's defences (e.g, disabled warning system) or at the site of the productive activities (i.e., the integrated activities of the work system's liveware, software and hardware elements), which would indirectly result in the breaching of the system's defences (e.g., use of the wrong procedure).

Underlying factors may reside at both the personal and the organizational levels; they may be present in the conditions that exist within a given work system (referring to the preconditions element in the model). Examples of underlying factors include inadequate regulations, inadequate procedures, insufficient training, high workload and undue time pressure.

In practice, Steps 1 and 2 may not be mutually exclusive. As the investigator begins the data collection step, it would be only natural that attempt be made to place the information, albeit often fragmentary in the preliminary stages of an investigation, into the context of an occurrence sequence. To facilitate this concurrent activity, the SHEL and Reason models can be combined as illustrated in Figure 2.

Figure 2.
SHEL and Reason Hybrid Model

The data collected during an investigation (i.e. events and circumstances) can be organized, using multiple components of the modified SHEL model, into a framework surrounding an occurrence template (in this case the occurrence scenario), based upon the Reason model. Causal factors, i.e., the unsafe acts/decisions and conditions are thereby identified

Steps 3 - 5 - An Overview

Steps 3 to 5 are based upon the GEMS framework. The framework provides "pathways" that lead from the identification of the unsafe act/decision (Step 3) to the identification of what was erroneous about the action or decision (Step 4) and finally to its placement within, a behavioural context (i.e., a failure mode within a given level of performance in Step 5). The GEMS framework illustrated in Figure 3 is particularly useful in exploring hypothetical reconstructions of the occurrence facts.

Step 3 - Identify Unsafe Acts/Decisions and Conditions

In Step 3 of the process, the investigation takes on a reductionist nature where the information gathered and organized using the SHEL and Reason frameworks is used to initiate identification of occurrence causal factors, i.e., unsafe acts/decisions and conditions. An unsafe act is defined as an error or violation that is committed in the presence of a hazard or potential unsafe condition. Decisions, where there are no apparent resultant actions but which have a negative impact on safety, should also be considered as unsafe acts. An unsafe condition, or hazard as noted above, is an event or circumstance that has the potential to result in a mishap. There may be several acts, decisions and/or conditions which are potential unsafe candidates, thus necessitating assessments of the occurrence facts. The SHEL and Reason hybrid tool (refer to Figure 2) can provide a useful base for conducting such iterative assessments.

When an unsafe act, decision or condition is identified, the focus shifts to determining the genesis of that particular act or condition. Further investigation and/or analysis may reveal other unsafe acts/decisions or conditions antecedent to the causal factor that was initially identified.

As noted earlier, several unsafe acts and decisions may be identified throughout Steps 1 and 2 of the process. The last unsafe act precipitating the occurrence often provides a convenient starting point for reconstruction of the occurrence. This last act or decision differs from the others, in that, it can be viewed as the definitive action or decision which led to the occurrence, i.e., the last act or decision that made the accident or incident inevitable - the primary cause of the initial event. Although it is usually an active failure the last unsafe act or decision can be embedded in a latent unsafe condition, such as a flawed design decision which led to a system, failure.

Step 4 - Identify Error or Violation Type

This portion of the process, i.e., Step 4, is initiated for each unsafe act/decision by posing the simple question, "what is erroneous or wrong about the action or demon that eventually made it unsafe?"

The identification of the type of error or violation involves two sub-steps (see Figure 3):

Figure 3.
The GEMS Framework
(Adapted from Reason, 1990)

Unintentional or Intentional Action

First it is necessary to determine whether the error or violation was an unintentional or intentional action. "Did the person intend action"? If the answer to that question is no, then it is an unintentional action. Unintentional actions are actions that do not go as planned; these are errors in execution.

If the answer to the question "Did the person intend the action"? is yes, then the action is intentional. Intentional actions are actions that are carried out as planned but the actions are inappropriate; these are errors in planning

2) Error Type or Violation

The second subset is the selection of the error type or violation that best describes the failure, keeping in mind the decision regarding intentionality. There are four potential error/violation categories, i.e., slip, lapse, mistake and violation. A slip is an unintentional action where the failure involves attention. These are errors in execution. A lapse is an unintentional action where the failure involves memory. These are also errors in execution. A mistake is an intentional action, but there is no deliberate decision to act against a rule or plan. These are errors in planning. A violation is a planning failure where a deliberate decision to act against a rule or plan has been made. Routine violations occur everyday as people regularly modify or do not strictly comply with work procedures, often because of poorly designed or defined work practices. In contrast, an exceptional violation tends to be a one-time breach of a work practice, such as where safety regulations are deliberately ignored to carry out a task. Even so, the goal was not to commit a malevolent act but just to get the job done.

Step 5 - Identify Underlying Factors

The designation of separate activities implied by Steps 4 and 5 may be somewhat arbitrary in terms of what actually occurs when an investigator attempts to reveal the relationship between the occurrence errors/violations and the behaviours that lead to them. In simplest terms, a behaviour consists of a decision and an action or movement. In Step 3, the action or decision (i.e., unsafe act or decision) was identified. In Step 4, what was erroneous regarding that action or decision was revealed. In Step 5, the focus is now placed on uncovering the underlying causes behind the act or decision of an individual or group. To do so it is important to determine if there were any factors in the work system that may have facilitated the expression of the given failure mode (and hence the error/violation and the unsafe act). These factors have been termed underlying factors. These factors can be found by examining the work system information collected and organized using the SHEL or Reason frameworks in Steps 1 and 2. The re-examination of these data again emphasizes the iterative nature of this investigative process where it may even be deemed necessary to conduct further investigations into the occurrence.

Step 6 - Identify Potential Safety Problems and develop Safety Actions

The identification of potential safety problems is based extensively on what factors were identified as underlying factors. Once again this underscores the importance of the application of a systematic approach to Steps 1 and 2 of the process which sets the foundation for the subsequent analysis steps. Where appropriate, the potential safety problems can be further analysed to identify the associated risk to the system and to develop safety actions.

References

Edwards, E (1972). Man and machine: Systems for safety. In Proceedings of the BALPA Technical Symposium London.

Hawkins, F.H. (1987). Human factors in flight. Aldershot, UK: Gower Technical Press.

Nagel, D.C. (1988). Human error in aviation operations. In E.L. Weiner and D.C. Nagel (Eds.), Human factors in aviation (pp. 263-303). San Diego, CA: Academic Press.

Norman, D.A (1981). Categorization of action slips Psychological Review, 88 (1), 1-15.

Norman, D.A (1988). The psychology of everyday things. New York: Basic Books.

Rasmussen, J. (1987). The definition of human error and a taxonomy for technical system design. In J. Rasmussen, & Duncan, and J. Leplat (Eds.), New technology and human error. Toronto: John Wiley & Sons.

Reason, J (1990). Human error. New York: Cambridge University Press.

APPENDIX 2

AREAS OF HUMAN FACTOR INQUIRY

The following questions are designed to aid the investigator while investigating for human factors. Skilful questioning can help the investigator eliminate irrelevant lines of inquiry and focus on areas of greater potential significance

The order in which the questions should be asked will depend on who is being interviewed and on his or her willingness and ability to describe personal behaviour and personal impressions. Also, it may be necessary to verify, cross-check or augment information received from one person by interviewing others on the same points.

These areas of inquiry can be used in planning interviews. The following questions are not intended as a checklist, and some may not be relevant in the investigation of a particular accident '

1 Safety Policy

1. Does the company have a written safety policy?
2. Is there a designated person for shipboard safety matters in the company?
3. When did a company Representative last visit the vessel or when were you last in contact with the company?
4. When were you last provided safety training? What was the training and how was it provided?
5. When was the last emergency drill (e.g., fire, abandon ship, man-overboard, pollution response, etc) and what did you do during the drill?
6. Was appropriate personal protective equipment provided and did you use it?
7. Are you aware of any personal accidents which occurred on board in the period prior to the accident?

2 Activities prior to incident

1. (If the ship was leaving port at the time of the accident) In general, how did you spend your time while the ship was in port?
2. (If the ship was approaching port or at sea at the time of the accident) How long has the ship been on passage since its last port or terminal operation?
3. What were you don immediately to coming on watch or reporting for duty, and for how long? Recreational activity? Physical exercise? Sleeping? Reading? Watching T.V.? Eating? Paperwork? Travelling to vessel?
4. Specifically what were you doing approximately 4 hours,……1 hour,……….30 minutes……..before the accident?
5. What evolution was the ship involved m when the accident occurred? What was your role during that evolution?
6. Immediately prior to the accident, what were you thinking about?
7. At any time before the accident, did you have any indication that anyone was tired or unable to perform their duty?

3 Duties at the time of accident

1. Where were you on the ship when the accident occurred?
2. What specific job or duty were you assigned at the time? By whom? Did you understand your assignment? Did you receive any conflicting orders?
3. How often have you performed this job in the past (on the specific ship involved in the accident)?

4 Actual behaviour at time of accident

1. Precisely where were you located at the time of the accident?
2. What specific task were you performing at the time of the accident?
3. Had you at any time since reporting for duty found that you could not concentrate (focus your attention/keep your mind) on a task you were trying to perform?

5 Training/Education/Certification/Professional Experience

1. How long have you been assigned to this ship? Have you requested that your assignment be lengthened or shortened?
2. How long have you filled your crew position? What other crew positions have you held on this ship?
3. How long have you held the certificate indicating your qualifications?
4. Before being assigned to this ship, did you work on other ships? If so, what crew positions have you held?
5. What is the longest time you have been to sea in a single voyage? How long have you been at sea on this passage? What was your longest single passage

6 Physical condition

1. Were you feeling ill or sick at any time in the 24 hours immediately before the accident. If so, what symptoms did you have? Did you have a fever, vomit, feel dizzy, other? Also, did you tell anyone? What do you believe the cause was?
2. When was the last meal you had prior the accident? What did you eat? Was it adequate?
3. Do you exercise regularly while on board? When did you last exercise (before the accident)?How long was the session?

7 Psychological, emotional mental condition and employment conditions

1. When was the last time you felt cheerful or elated on board the ship, and what were the circumstances that generated this emotion?
2. When was the last time you were sad or depressed or dejected, on board the ship? Why? Did you talk about it with anyone else?
3. Have you had to make any difficult personal decisions recently? Have you had any financial or family worries on your mind recently?
4. Have you been criticized for how you are doing your work lately? By whom? Was it justified?
5. What was the most stressful situation you had to deal with on the voyage (prior to the accident)? When did the situation occur? How was it resolved?
6. What are the contractual arrangements for all crewmembers?
7. Have there been any complaints or industrial action in the last (12) months?

8 Workload/Complexity of Tasks

1. What is the shipboard organization?
2. Is the shipboard organization effective?
3. What is your position in the shipboard organization (i.e., who do you work for, report to or assign duties to)?
4. What is the nature of your work? Sedentary? Physically demanding?
5. Was anyone involved in the accident impaired due to heavy workload?

9 Work-period/rest-period/recreation pattern

1. What is your normal duty schedule?
2. Are you a day worker or a watchstander?
3. What was your duty schedule on the day before the accident and during the week before the accident?
4. Were you on overtime at the time of the accident?
5. How long had you been on duty, or awake performing other work, at the time of the accident?
6. When was your last period of sleep? How long did it last? How often did you awaken during your last sleep period? Did you awaken refreshed? If not, what would have made your sleep period more restful?
7. How do you normally spend your off-duty time while on board? Play cards? Read? Listen to music? Watch T.V.? Other?
8. When was your last extended period of off duty time when your were able to rest?

10 Relationship with other crewmembers and superiors/subordinates

1. Who among the crew would you consider to be a friend?
2. Do you find any members of the crew unpleasant to be with?
3. Do you have difficulty talking with any of the crewmembers because of language barriers?
4. Have any new crewmembers recently joined the ship? Have you had a chance to get acquainted with them?
5. Did you have any argument recently with another crewmember?
6. In an emergency, would you trust your fellow crewmembers to come to your assistance?
7. Has another crewmember ever offered to take your place on watch or perform a duty for you to let you get some extra rest?
8. What was the subject of your last conversation with another crewmember before reporting for duty (when the accident occurred)?
9. Have you talked with any other crewmembers since the accident. If so, what was the subject of your conversation? Have you talked with anyone else about the accident prior to being interviewed?

11 Living conditions and shipboard environment

1. Do you consider your personal area on board the ship to be comfortable? If not, how would you like it to improved?
2. Prior to the accident, did you have any didifficulty resting as a result of severe weather, noise levels, heat/cold, ship's motion, etc.?

12 Manning levels

1. Is the manning level sufficient in your opinion for the operation of the vessel?

13 Master's standing orders

1. Are there written standing orders to the whole crew complement from the Master?
2. Did the Master/Chief Engineer provide written or verbal standing orders to the watchkeeping personnel?
3. Were the orders m conflict with the company safety policy?

14 Level of automation/reliability of equipment

.1 In your opinion, was the system reliable?
.2 Were them earlier failures in the system?
.3 Were the failures repaired by the crew or shore-based workers?

15 Ship design, motion/cargo characteristics

.1 Did you observe anything out of the ordinary on this passage concerning the ship design, or motion or cargo characteristics?

Questions 16-24 SHORESIDE MANAGEMENT

16 Scheduling of work and rest periods

1. What is the company's work schedule and relief policy?

Manning level

1. How is the manning level determined for your fleet?

18 Watchkeeping practices

1. Do you require the master to stand watch?
2. Do you leave the watchkeeping practices to the discretion of the Master?

19 Assignment of duties

1. Do you leave this matter to the Master?

20 Shore-ship-shore support and communications

1. How do you support the vessel's Master?

21 Management policies

1. Does the company have a written safety policy?

22 Voyage planning and port call schedules

1. How does the Master plan the voyages?

23 Recreational facilities

1. Are welfare/recreational services and facilities provided on board?

24 Contractual and/or industrial arrangements and agreements

1. What are the contractual agreements for all crewmembers?
2. Have there been any complaints or industrial action m the last (12) months?

25 National/international requirements

1. Are the management/Master complying with the requirements and recommendations of the applicable international conventions and Flag State regulations?

APPENDIX 3

DEFINITIONS
COMMON HUMAN ELEMENT TERMS

Human error A departure from acceptable or desirable practice on the part of an individual or group of individuals that can result in unacceptable or undesirable results.

Diminished human performance:

Emotional: A physiological state of agitation or disturbance which can affect an individual's normal ability to perform required tasks.

Panic: A sudden overpowering fear that reduces the ability to perform required tasks.

Anxiety A state of uneasiness and distress about future uncertainties which may reduce the ability to properly focus on a required task.

Personal problem: A problem which preoccupies the emotions and reduces the ability to perform required tasks. Examples include physical disabilities, death or illness in the family, marital and other relationship problems, health concerns, financial problems, anger, or poor interactions with shipmates.

Mental impairment Diminished mental ability tat can reduce or impede an individual's normal ability to perform the mental pan of required tasks.

Alcohol use: Consumption of alcoholic beverages which diminishes an individual's abilities to perform required tasks. Examples include drinking on or too close to duty which can impede an individual's abilities; drunkenness on duty; drinking off duty which results poor performance while on duty; and excessive drinking over a longer period of time which results in a permanent decrease in mental abilities.

Drug use: Use of medicine or a narcotic which effects an individual's abilities to perform required tasks There are many different effects on mental and physical capabilities that can result from the use of legal and illegal drugs, such as extreme drowsiness to a false sense of competence to hallucinations. Mental abilities of the user may also be distracted by the constant need to obtain additional drugs. In addition, individuals may not be aware of the "side-effects" of legal drugs and may take them while on duty or forget to report taking them.

Inattention: The loss of attention, notice or regard; neglect. Examples include failing to monitor displays; not maintaining a proper lookout; forgetting to perform an assigned duty. Inattention may also be the result of other causes such as a personal problems fatigue, drugs, boredom, or hearing problems.

Injury. Physical damage to the body which causes a decrease in mental or physical abilities. Examples include a head injury and injuries such as a smashed finger or a severe burn where pain causes distraction and a loss of mental ability.

Mental illness: Psychotic or erratic behaviour; depression; hallucinations; unexplainable, or other forms of abnormal behaviour.

Physical illness: Sickness which produces a decrease in mental or physical abilities but, not generally termed as mental illness. Examples include: the general disability accompanying colds and flu; hallucinations due to high fever; migraine headaches: seasickness; and even severe indigestion and exposure to toxic substances.

Diminished Motivation: Lack of will or desire to perform well resulting in a decrease of an individual's normal performance of required tasks.

Deliberate misaction: Purposely taking an incorrect action or purposely failing to take the correct action. Examples include dereliction of duty; refusal to obey commands; sabotage, theft or ignoring procedures.

Fatigue: A reduction in physical and/or mental capability as the result of physical, mental or emotional exertion which may impair nearly all physical abilities including: strength; speed; reaction time; co-ordination; decision making or balance.

Low morale: A problem with individual or group motivation as shown by reduced willingness, confidence, or discipline to perform assigned tasks. Examples/causes may include interpersonal conflict amongst the crew, officers with poor interpersonal skills, lack of a strong corporate or shipboard safety culture, excessively long tours of duty.

Lack of self-discipline: Inadequate ability of an individual to control personal conduct. Examples include loss of temper, or unprofessional behaviour.

Visual problem: A reduced visual, acuity due to a specific physical disability. Causes may include eye injury causing total or partial blindness; not wearing prescribed glasses or contacts; inability to adequately adapt to darkness.

Excessive workload: Diminished physical or mental capability as the result of the sum total of all the mental and physical tasks a human must perform within a prescribed time resulting in a diminished job performance.

Marine environment

Mental action:

Lack of situational awareness: An incorrect understanding of the current situation winch can lead to a faulty hypothesis regarding a future situation or a situation which is based upon incorrect beliefs leading to compounded errors that can substantially increase the risk to the ship. Examples include arriving at a hypothesis without confirmation of which direction an oncoming ship will steer incorrect interpretation of alarms on board ship (e.g. seawater contamination of a fuel system during high seas).

Lack of perception: When an individual does not properly understand that a problem or situation exists. Examples include misreading a dial, mishearing a command, misunderstanding a garbled radio message, thinking you smell engine oil when its actually crude, not noticing a list to starboard. overestimating the distance to die dock.

Incorrect recognition: The misdiagnosis of a particular situation or problem once it has been perceived. It may be perceived that a problem or situation exists, however, the identification is incorrect. Examples include misdiagnosis of a sounded alarm that sounds similiar to other alarms on board ship, incorrect recognition of a visual display alarm on the bridge.

Incorrect identification: The incorrect identification of a problem or hazard once it has been recognized that the problem or hazard exists. The alarms on a display panel may have identified a particular hazard to the ship (e.g. low fuel oil pressure), however, the individual may have misinterpreted the alarm and identified the problem incorrectly.

Resolutions