Abstract
This research aimed to identify and map the common patterns of human and organizational causes underlying two types of marine accident: groundings and collisions. Generalizing patterns of causality from relatively unique and individual accident events required a structured and exploratory analytical approach. Two complementary human factor analysis tools were employed to analyse a set of 30 detailed marine accident reports produced by the Australian Transport Safety Bureau. Common patterns of causality were identified for both groundings and collisions. Groundings commonly resulted from a failure to adequately plan a passage, coupled with either a problem locating the vessel, or communication problems on the bridge. Collisions often involved a fishing vessel and a bulk carrier or cargo vessel, and commonly resulted from both a problem identifying the existence or speed of the other vessel and, again, an inadequate planning process. Generalizing these common causal patterns from a number of accidents identifies a range of points at which crews, managers and policymakers can intervene to forestall the development of these accidents. The method developed here may also be productively extended and applied to other accident types and used as an ongoing risk management tool.
Highlights
Understanding the human and organizational factors underlying major shipping accidents is a topic of key importance for maritime policy and management
Accident investigations often focus on the role of human error---the mistakes, unsafe acts or violations committed by crew members
Studies consistently estimate that around 80% of causes in marine accidents are attributable to human factors [1, 2]
Summary
Understanding the human and organizational factors underlying major shipping accidents is a topic of key importance for maritime policy and management. Accidents at sea can cause severe harm, leading to loss of life, environmental damage and serious financial costs. As such, they are typically investigated extensively in order to learn from them and to improve risk management, both within individual companies and across the industry. There is a growing recognition of the influence of organizational context and situational factors in provoking and shaping errors Situational factors such as inappropriate equipment or clumsy procedures can provide routine error traps for people to fall into. Likewise, organizational factors, such as production pressures or decisions that leave crew under-resourced, set the stage for poor performance [3]. As a leading scholar in this field, James Reason [4], has pithily observed, to understand and manage human error we need to focus less on the human condition and more on the conditions in which people work
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