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Human factor presentation, Maritime Institute of Technology, Baltimore, April 27th
As the world's largest marine mutual and a major insurer of American merchant tonnage, the UK P&I Club has become increasingly concerned about the contribution of human error to its major insurance claims.
In the past 16 years, the UK Club has dealt with over 6,100 protection & indemnity claims for more than $100,000. That's just two per cent of the total but an extraordinary 72 per cent of the amounts paid out.
Spread across all ship types, the UK Club has found that 54 per cent by number and 62 per cent by settlement costs are essentially or largely attributable to human error. Deck officers (21 per cent), crew (16 per cent), shore persons (11 per cent), pilots (4 per cent) and engineering officers (2 per cent) are at fault in most large claims cases.
UK Club Loss Prevention Director Karl Lumbers told delegates at the Maritime Operations and Human Factor conference on April 27th that while injuries and suffering are incalculable, the commercial impact could be roughly assessed at $1.5 million a day.
The protection & indemnity clubs in the International Group have over 90 per cent of merchant tonnage on their books. It has become apparent that investigating and categorising the human error component in incidents and accidents is a growing factor in determining loss prevention initiatives.
Mr. Lumbers was speaking to delegates at the Maritime Institute of Technology, Baltimore at a conference organised by Marine Log and sponsored by the US Coast Guard, US Maritime Administration, SOCP and National Cargo Security Council.
He said that underlying factors are often involved in marine accidents and incidents. The immediate reason for things going wrong might be obvious but the contributory causes ran deeper. Shortcomings in procedures, practices and equipment across the shipping operations spectrum might create the conditions giving rise to incidents, many of which could be avoided.
A few months ago, the UK Club launched No Room for Error, a DVD/video which draws a link between unsafe acts or the immediate causes of incidents and system failures or shortcomings behind the scenes. The former are known as active failures. The latter are termed latent failures and can be categorised as procedures, hardware, design, maintenance management, error enforcing conditions, housekeeping, incompatible goals, communications, organisation, training and defences.
The DVD shows five scenarios of incidents involving collisions, deaths, pollution, cargo and dockside damage - the main areas where protection & indemnity insurance cover applies. In each case, the contribution of underlying factors is vividly portrayed.
The opening sequence concerns a collision which ensues when a tanker's inexperienced third officer misjudges his new ship's manoeuvring characteristics and hits an oil rig support vessel.
This active failure is supplemented by latent ones. Senior officers' workloads mean they are too busy to question the third officer's experience or to brief him properly, such that he cannot find the night orders. These "error enforcing conditions" are supplemented by an "organisational" failure in not correcting or replacing charts and the "incompatible goal" of commercial pressure.
Latent failures are also highlighted in respect of a containership which fails to replace lashing gear in good time, the asphyxiation of two men in a ro-ro tank, a tanker's ruptured shoreline which causes serious pollution and damage to a coral reef by a vessel under pilotage.
Mistakes and oversights by human beings are a constant factor.
Mr. Lumbers highlighted the significance of the human contribution to claims-causing marine incidents. Most involve hazards, targets and events. Typical hazards are extreme heat, materials under pressure, flammable and toxic material, moving equipment and the weather.
Targets or "objects of harm" include individuals, assets, the natural environment and even company reputations. Events include collisions, explosions, oil spills and injuries. Incidents stem from breaches of hazard controls or target defences, intended or unintended acts by human beings and chains of events.
Accidents and incidents emanate from "errors" and "violations."
Errors stem mainly from incorrect or incomplete knowledge or the way information is handled. They are unintended and may be due to memory failure (lapse) or attentional failure (slip) but may not necessarily incur immediate consequences.
They occur when people carry out routine, highly practised tasks very efficiently but overconfidently; where rules do not cater adequately for changes in situations; and where known methods just do not work, necessitating the slow, hard exercise of thinking things through.
Hard defences are fail-safe designs, engineered safety features and mechanical barriers. Soft defences are procedures, rules, regulations, safety instructions and training. These are more easily circumvented than hard defences.
"Given time and freedom to explore a situation, people can often produce solutions," explained Mr. Lumbers. "However, often they will not have time, especially in emergencies. Knowledge of the problem may be patchy and inaccurate. There are distinct limits to the amount of information individuals can hold when making on the spot calculations. Fear and other emotions may impinge on reasoned action, producing knee-jerk or over-learned and inflexible responses.
"There needs to be continual amendment of procedures to cover changed working conditions, new legislation, new equipment and, most particularly, the prohibition of actions that appear to have contributed to recent accidents."
Turning to the other major category of human error, Mr. Lumbers explained that violations stem mainly from motivational factors, shaped by attitudes, beliefs, social norms and organisational culture. They are centred in the nature of the workplace; approach to safety culture; suitability of rules, regulations and procedures; quality of tools and equipment; and whether supervisors and managers turn a "blind eye" to get the job done.
They are usually intended but can be unintended and even unknowing, involving deviations from rules, regulations and safe operating procedures and increased risk to perpetrators.
It follows that violations can only be reduced by changing attitudes, beliefs, norms and cultures which tacitly condone non-compliance.
"Any deviation (or violation) from operating procedures may create increased risk and danger. Everyone is fallible and capable of breaking the rules but human beings tend to circumvent both safety controls and defences, sometimes with remarkable cunning.
Mr. Lumbers concluded: "Information and training are highly relevant but there's always something beyond people's control that can hurt them. This points to an unceasing requirement to improve awareness to reduce error and to enhance a sense of responsibility and self discipline to cut down on violations."
For further information:
Karl Lumbers/Nick Whitear
Thomas Miller P&I Ltd
Tel: +44 (0) 20 7283 4646
e-mail: nick.whitear@thomasmiller.com
karl.lumbers@thomasmiller.com
Issued by: Martin Rowland/Sharon Cunningham
Dunelm Public Relations
Tel: +44 (0) 20 7480 0600
Fax: +44 (0) 20 7480 0606
e-mail: info@dunelmpr.co.uk
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