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INTERNATIONAL MARITIME ORGANIZATION

IMO

E

MARITIME SAFETY COMMITTEE72nd sessionAgenda item 15

MSC 72/INF.914 February 2000ENGLISH ONLY

ROLE OF THE HUMAN ELEMENT

Report on the investigation into near misses

Submitted by Japan

SUMMARY

Executive summary: This paper presents conclusions of the investigation into near missesrelating to operations on ships’ navigation bridges, and the need forconsideration of the importance of the human element in operationson the navigation bridge.

Action to be taken: Paragraph 4

Related documents: MSC 69/INF.16 and MSC 71/INF.8

Investigation on near miss incidents through a questionnaire and interviews of seafarers

1 Japan has conducted an investigation on near miss incidents relating to operations onships' navigation bridges through a questionnaire and interviews of seafarers (captains, officersand pilots) of Japanese flag ships. With regard to the results of the questionnaire, more than2,000 answers were obtained and its details were submitted to the Committee (MSC 71/INF.8,annex)

2 It has been found, through the near miss investigation by questionnaire to seafarers, thatabout 60 % of near misses were caused by, or related to, human error. It has also been found thatfurther precise investigation is necessary in order to identify concrete measures to avoid nearmisses. Consequently, interviews with seafarers (captain and officers) were carried out to obtaindetailed information on near miss cases. The analysis of these near miss incidents is given atannex to this paper.

3 The cause of near miss incidents due to the human element has been defined throughanalysis of the interview of the near miss incidents. Good co-operation among seafarers on thebridge would be a major way of avoiding near miss incidents. Consequently, the followingmeasures are recommended to support good co-operation on the bridge:

.1 wide use of automatic ship’s position indication systems such as a combination ofGPS and ECDIS;

.2 introduction of a device that obtains information on other ships actively, such asAIS;

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.3 introduction of automatic ship’s position guidance systems;

.4 preparation of a manual containing judgment criteria and standardization of workprocedures;

.5 establishment of systematic training such as BRM training; and

.6 establishment of a supporting system including outboard elements such as pilot,tugboat, VTS.

Action requested of the Committee

4 The Committee is invited to note the recommendations in light of the role of the humanelement in marine casualties.

***

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ANNEX

ROLE OF THE HUMAN ELEMENT IN MARITIME CASUALTIESREPORT ON THE INVESTIGATION INTO NEAR MISSES

I. The Analysis of The Near Miss Incidents

1.1 The way of analysis

Work of the officer of the watch depend on watch system (watch level) in the bridge. The watchlevel is defined for the purpose of this investigation as shown in Table 1.

Table.1 Definition of watch level

Work Command Trafficwatch

Communi-cation

Navigation Others Steering Lookout

Relatedequipment

RadarARPA

VHFetc.

Positioningdevices

Engine telegraphEngine indicatorRecording log

Watch Level 1 Officer of the watch (OOW) Able Seaman (AB)Watch Level 2 Master OOW AB LookoutWatch Level 3 Master Extra officer OOW AB Lookout

Duties of the officer of the watch and how he carry them out have been analyzed anddefined through interview survey. Then the processing model (watch model) of the officer of thewatch has been prepared.

The duties, which the officer of the watch carries out, depend on the watch levelmentioned above. It has been found through the near miss investigation by questionnaire toseafarers in 1997 that about 30% of near misses were experienced during the officer of the watchworked with co-operator . Therefore, on this occasion effort was made to analyze near missincidents in watch level 2 and 3 which require better relationship for co-operation works.

1.2 The entire watch model on the bridge

The entire watch model on the bridge prepared through analysis of interview survey asshown in Fig.1.

1.3 The individual watch model on the bridge

It is assumed that each personnel on the bridge are assigned functions and the entirewatch model is constituted. Now the functions of each personnel have been analyzed, focusingon the near miss incidents in watch level 2 and 3.

The outlines of assigned functions for each personnel are as follows, and the processingmodels of them are shown in Fig.3 – 7.

(1) Lookout: To collect non-processed information about traffic environment around the ship,and report to the Master and/or the duty officer.

(2) Helmsman: To steer by the order of the Master. To monitor the information about steeragesuch as a rudder angle, rate of turn and effect of the rudder etc, and also the condition about

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navigational equipment such as a gyrocompass, autopilot and steering system. To report tothe Master and/or duty officer whenever he has detected any deficiencies.

(3) Officer of the watch (OOW): He shall be mainly in charge of grasping ship's position andmonitoring the operation of navigational equipments. He shall advise the Master of theprocessed real-time information. In addition, he shall advise the Master of ship's course etc.for avoidance of grounding.

(4) Extra officer (In case of the watch level 2, OOW plays this function concurrently.): In theheavy traffic water passage, he shall collect the information about traffic environment,engage in the communication with outside and report to the Master of processed real-timeinformation. In addition, he shall advise the Master of his suggestion of ship handling forcollision avoidance to assist Master’s decision etc.

(5) Master: With referring to the report from the officer and/or the lookout, and the informationcollected by himself, he shall decide the intention. In addition, he shall concretely givedetailed order to the officer, helmsman and/or lookout.

(6) Pilot: Even if the pilot is commanding the ship, the ultimate responsibility to the safenavigation belongs to the master. However, the pilot is in a position of acting Master's, nearmiss incidents caused by the pilot were analyzed as those caused by the Master.

1.4 The cause of near miss incidents

Aforementioned watch models are shown in Figures 3 – 7, and " " marks indicates thecause of near miss, and the situation of the incidents are also shown in the vicinity of the " "mark.

The causes of the near miss incidents are estimated as follows:

(1) Duties assigned

If definite duties were assigned, the ability (resources) of each personnel is used to thefullest extent and the necessary function can be accomplished. However, each personnelare not coordinated functionally, because duties assigned is indefinite. In consequence,the burden are concentrated on the Master, and near miss incidents occur throughoversight and misunderstanding.

The following are considered as the cause of “near miss incidents ”:

(a) The Master does not give clear instructions to the personnel on the bridge.

(b) The level of the capability of the individuals is below the expected standard.

(2) The quantity and quality of the information

As a near miss occurs by the error of judgment of the situation or future prediction of thesituation, the judgment or prediction is made taking full account of the collectedinformation, marine traffic regulations, practical knowledge and so on. The judgment andprediction of the situation are greatly influenced by the accuracy of the information. The

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accuracy of the information depends on the quantity and quality of information.Therefore, many of the errors of judgment and prediction of the situation are consideredto originate from the inadequacy of task performed for the collection and processing ofthe information. The following points seem to be the reason why the collection andprocessing of information was performed properly:

(1) Necessary information is not being collected.(2) The collection of the inaccurate information.(3) The error in the procedure for information processing.(4) Omission of the information processing.

(3) Sharing information

By sharing the information collected among personnel on the bridge, i) it will be of helpin the process within processing – decision making – execution in a subjective function,and ii) all the functions on the bridge can be verified. However the individual function isnot properly connected with those of other personnel, as the information is not sharedamong personnel on the bridge appropriately. Consequently, the burden is focused on theindividual and even the crosscheck among personnel on the bridge is not possible. Theproblem of "the communication" and the shortage of "the education and training" areserious factor in not alarming the information appropriately.

(4) The decline of the ability and consciousness to safety

The decline of technical ability and shortage of the experience of seafarers, and alsocarelessness caused by being accustomed to the work bring in, the decline ofconsciousness to safety which is pointed out as a cause of the near miss incidents.

(5) The burden of the positioning

The main role of OOW is the getting of the ship's position. In the case that it is the best ofhis ability or it may not be able to process within the required time, the extra officer helpsthis function. However, the lookout that is a part of function of the extra officer will beneglected, therefore Master himself must collect and process the information, because theinformation regarding the situation of the surroundings is not transmitted to the Master.The burden concentrates on the Master is being induced by spending time with theacquisition of the ship’s position which is an essential information for safe navigation.

(6) The co-operation among seafarers

The flow of information among personnel on the bridge forms layer structure that theinformation is gathered in bottom (lookout, helmsman) and middle (OOW, extra officer)layer, and transferred to the top (Master) layer as in raw or processed in middle layer asshown in Fig.2. Most of the necessary information to navigate can be collected on thebridge although they are not complete.

The major cause of near miss incidents could be concluded that the necessary informationfor safe navigation is not transmitted to the Master because these information remain anywhereof bottom or middle layer.

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2 Discussion and conclusions

The cause of near miss incidents due to human element has been defined through analysisof the interview survey of the near miss incidents.

Good co-operation among the crew on the bridge would be major way of avoiding nearmiss incidents.

Consequently the following measures would be useful in reducing near miss incidents:

(1) Wide use of automatic ship’s position indication system such as combination ofGPS and ECDIS.

(2) Introduction of device that obtain information of other ship actively such as AIS.

(3) Introduction of automatic ship’s position guidance system.

(4) Preparation of a manual for the judgment criteria and standardization of workprocedures.

(5) Establishment of systematic training such as BRM training.

(6) Establishment of supporting system including outboard element such as pilot,tugboat, VTS.

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