Human Error A Stubborn Problem

By U.K. Chamber of Shipping’s Policy Manager Adrian Mundin 

Shipping industry statistics state that around 90 percent of world trade is carried by sea. Key sea lanes are already busy and as world economies expand, the number and size of ships trading internationally, currently 50,000 vessels, will increase. The natural hazards of being at sea remain the same, but the increased congestion will add to the risk of collision or grounding. Whilst technology, particularly in the form of electronic navigational aids, has done much to reduce incidents in recent years, they do continue to occur with predictable frequency.

Machinery failure or the extremes of the weather may in some cases be the cause of incidents at sea, but human error remains a stubborn contributing factor. Whereas in the case of machinery or structure, where precise failures mechanisms are sought out, poor training, a lack of experience, complacency and sometimes fatigue are all too easily cited as the causes of human error, often with little further analysis. 

Recent research into the human element, however, has tried to categorize and explain the types of behavior and root causes. The often quoted statistic that 80 percent of marine accidents were attributable to human error is perhaps misleading, since all have some human input. Material failure may be down to poor design or construction, extreme weather might be a failure to forecast or take appropriate avoiding action, and thus all accidents should be viewed as preventable.

In examining the human element, there are many factors, but generally an individual’s performance is affected by their relationship with the job, the organization and culture within which they work and the environment. At sea, the importance of valuing individual crew members, the work they do and engaging them in the development of a safety culture on board cannot be overstated. 

New technologies, which are intended to reduce the workload of seafarers and increase safety, do not always achieve the desired effects. The seafarer may have had little input to the design, which maybe unnecessarily complex, making operation confusing. Even if adequate training is carried out, the skills necessary fade rapidly.  

Thus with any equipment, the relationship between human and machine must be properly thought out. Interaction should be intuitive with the operator considered part of the system. Training must be adequate to ensure that seafarers understand the technology, but there must also be emphasis on complete familiarity with the operation of equipment actually carried on board if competence is to be achieved.

Scrutiny of incidents and the subsequent investigation is essential if things are to improve. Lessons identified must be used to improve procedures and make up any gap in skills. Strong operational leadership is critical and all members must be brought in an organization’s safety culture. Commitment of senior managers must be demonstrated by visiting and discussing issues and incidents with staff at the front line. 

There will always be situations where there has been a wilful transgression and blame is appropriate and justified, however, a “just culture” of near miss reporting, where blame does not discourage individuals from reporting incidents, is strongly recommended. Such a system provides useful leading indicators and it is known that organizations using it suffer fewer actual accidents. 

The loop must be properly closed and once a report is generated and procedures, including the need for training, must be examined and altered as necessary. It is important that responses do not needlessly lead to yet another check list or another layer of process. The administrative burden that such a bureaucratic approach presents was possibly part of the problem in the first place and less may well be better. Much of the answer is in encouragement and showing staff that reports are taken seriously and change is possible.

The above offers a just snap shot of the human element in accidents. In conjunction with industry, the MCA have produced a very good guide, “The Human Element - a guide to human behaviour in the shipping industry,” which includes more on taking risks, why we break rules and prevention through good communication. 

The subject was also recently covered at a popular seminar with members here at the U.K. Chamber. Case studies described by accident investigators demonstrated what could go wrong, but noting the numbers present it was clear that members are taking the issue seriously. Some very powerful presentations from industry described the importance of leadership and the changes necessary to achieve a strong safety culture. There is much to do to spread best practice more widely and the chamber will continue to take a close interest in the development and application of this important subject.