Safety Science 86 (2016) 245257

Contents lists available at ScienceDirect

Safety Science
journal homepage: www.elsevier.com/locate/ssci

Classification of human errors in grounding and collision accidents using

the TRACEr taxonomy
A. Graziano, A.P. Teixeira, C. Guedes Soares
Centre for Marine Technology and Ocean Engineering (CENTEC), Instituto Superior Tcnico, Universidade de Lisboa, Portugal

a r t i c l e i n f o a b s t r a c t

Article history: This paper applies a Human Error Identification tool called Technique for the Retrospective and Predictive
Received 18 July 2015 Analysis of Cognitive Errors to the analysis of ship accidents. Grounding and collision accidents investi-
Received in revised form 28 December 2015 gation reports involving sixty-four vessels published by the UKs Maritime Accident Investigation Branch,
Accepted 26 February 2016
the Transportation Safety Board of Canada and the National Transportation Safety board of the United
States of America are coded and analysed using the taxonomy of the Technique for the Retrospective
and Predictive Analysis of Cognitive Errors. A total of two hundred and eighty-nine errors performed
Keywords:
by the operators are coded. The results of the codification process are analysed with the objective of iden-
Grounding and collision accidents
Human and organisational factors
tifying the main task errors, cognitive domains and the technical equipment involved in grounding and
Taxonomy for coding accidents collision accidents and the factors that affect the performance of the operators. This identification is a
Technique for the Retrospective and necessary step towards safety improvements resulting from dealing with the identified problems. A dis-
predictive Analysis of Cognitive Errors cussion on the use of the taxonomy of the Technique for the Retrospective and Predictive Analysis of
TRACEr Cognitive Errors is provided and it is proposed to combine it with some elements of the CASMET approach
CASMET to accident investigation so as to improve the applicability of the methodology to the analysis of ship
accidents.
2016 Elsevier Ltd. All rights reserved.

1. Introduction organisational factors, which may also contribute to ship accidents

Several maritime safety regulations have been developed and
adopted after the occurrence of serious maritime accidents. How-
ever, it was only after the capsize of the Herald of Free Enterprise
in 1987 that IMO (International Maritime Organization) started
looking at human factors in a different perspective (Schrder-
Hinrichs et al., 2013). In fact, although technology on board vessels
has advanced quickly in the last one hundred years, the same can-
not be said for the way human and organisational factors are
addressed (Schrder-Hinrichs et al., 2012).
The study of human factors and their contribution to accidents
is essential as statistically it has been found that they are impli-
cated in 80% of marine casualties (Guedes Soares and Teixeira,
2001). Moreover, the human error itself has to be considered not
only produced by individuals or end-users but also by the
organisation (e.g. Reason, 1990; Hollnagel 2005) that can involve
the safety culture (e.g. Guldenmund, 2000) and the structure or
policies of a shipping company (Strauch, 2015). The core point
must be to emphasise not only end-user/crew errors but also
Corresponding author.
E-mail address: c.guedes.soares@centec.tecnico.ulisboa.pt (C. Guedes Soares).
(Guedes Soares et al., 2000).
In the last decades several approaches for error classification,
from now on Human Error Identification (HEI) have been devel-
oped (Shorrock and Kirwan, 2002), including SHERPA Systematic
Human Error Reduction and Prediction Approach (Embrey, 1986),
GEMS Generic Error Modelling System (Reason, 1990), CREAM
Cognitive Reliability Error Analysis Method (Hollnagel, 1998),
HEIST Human Error Identification in Systems Tool (Kirwan,
1994) and HFACS Human Factors Analysis and Classification
System (Shappell and Wiegmann, 1997, 2000), among others.
Some approaches have been also developed and used in the
maritime sector including in the offshore oil and gas industry
(e.g. Okstad et al., 2012) and, particularly, in the shipping trans-
portation industry for coding ship accidents. The European
research project CASMET (Casualty Analysis Methodology for Mar-
itime Operations) (Caridis, 1999) has developed a methodology for
shipping accident investigation and a taxonomy for coding the
information in a database (Kristiansen et al., 1999). The CASMET
approach became one of the pillars of EMCIP (EC, 2009), the Euro-
pean Marine Casualty Information Platform hosted by the Euro-
pean Maritime Safety Agency (EMSA), which is a web-based
platform used to support the investigation process and to help
investigators by providing support documents and information

http://dx.doi.org/10.1016/j.ssci.2016.02.026
0925-7535/ 2016 Elsevier Ltd. All rights reserved.
246 A. Graziano et al. / Safety Science 86 (2016) 245257
(e.g. user manuals, lists of contacts, news, events and reporting
problems and changes, etc.) (Correia, 2010). Both CASMET and
EMCIP represent the casualty by the sequence of accidental events
following the Sequentially Timed Events Plotting (STEP) method
(Hendrick and Benner, 1986).
In general, the main reason for coding accidents in a database is
to store valuable information from a large number of entries and
organise them within certain parameters in order to be useful for
safety improvements and to support the development of advanced
risk models for particular accidental scenarios (Anto and Guedes
Soares, 2002).
Mazaheri et al. (2015) have analysed a large number of ground-
ing accident reports and near-misses with the objective of identi-
fying the most important elements that should be considered for
developing evidence-based risk models such as Bayesian Belief
Networks, as done also by Akhtar and Utne (2014). Mazaheri
et al. (2015) have used a new version of the HFACS (Human Factor
Analysis Classification Scheme) framework adapted for grounding
accidents, a practice that has been also followed in other studies
such as e.g. by Chen et al. (2013) who have proposed a HFACS
framework for general maritime accidents that takes into account
the IMOs approach for investigating and analysing human factors
involved in marine casualties and incidents. Accidents analysis
provides also important information on the root causes of marine
accidents in specific locations and conditions such as the ones
occurring in the Arctic Region, so as to identify safety measures
to control the risks expected with the increasing trend of shipping
traffic in Polar Regions (Kum and Sahin, 2015).
Important steps have been given on the study of the complexity
of the Human Error (HE) in the maritime transportation industry
by knowledge transfer from other domains, such as aviation
(Kontogiannis and Malakis, 2009). In this context, the TRACEr
(Technique for the Retrospective and predictive Analysis of Cogni-
tive Errors) taxonomy, originally developed for Air Traffic Control
(Shorrock and Kirwan, 2002), has been recently adapted for ship
accident investigation by Hofmann and Schrder-Hinrichs (2013).
The TRACEr technique can be used both predictively (e.g. perfor-
mance analysis) and retrospectively (accident investigation) and
is mainly focused on the humanmachine interface, taking into
account the cognitive framework of the end user and the external
factors affecting his performance. Moreover, the TRACEr taxonomy
allows the analyst to describe the internal and external manifesta-
tion of the error even if the causes have not been discovered yet.
Last but not least TRACEr takes into account psychological (e.g.
stress, mind-set, decision making, etc.) physical (e.g. bodily fatigue,
intoxication, etc.) and external factors (e.g. organisational factors,
weather, training, etc.) that when combined, form a rich picture
of the event (Shorrock and Kirwan, 2002).
In this paper the TRACEr taxonomy is used to code a set of 52
grounding and collision accidents involving 64 ships occurred in
the period from 2004 to 2013. An exploratory application of the
TRACEr methodology to ship accidents has been introduced by
Graziano et al. (2015), while here a systematic application to a rep-
resentative set of accidents is reported and statistical results are
presented. The objective is to characterise collision and grounding
accidents in terms of task errors, technical equipment and cogni-
tive domains involved in these types of accidents along with the
Performing Shaping Factors (PSF) that affected the erroneous acts,
which is particularly useful to support the development of
advanced risk models for accident scenarios of manageable size,
such as Bayesian Network models.
From a methodological point of view the analysis carried out
adopts an approach that combines important features of the CAS-
MET approach to reconstruct the sequence of the task errors that
contributed to the accident, itself inspired in the STEP method
proposed by Hendrick and Benner (1986), which has not been
considered in the original TRACEr methodology proposed by
Shorrock and Kirwan (2002) and later adapted by Hofmann and
Schrder-Hinrichs (2013). The paper is organised as follows. First
the TRACEr taxonomy is briefly described and applied to the
analysis and codification of the accident reports. Then the results
of the codification process are analysed and used to identify the
main characteristics of ship collision and grounding accidents.
Finally, a discussion is provided on the benefits and shortcomings
of the TRACER methodology to code maritime accidents and
several possible improvements are identified.
2. Tracer taxonomy
As explained by Hofmann and Schrder-Hinrichs (2013), the
TRACEr methodology was developed on the basis of two models:
(i) Model of Human Information Processing; (ii) Simple Model of
Cognition, better known as SMoC. The first model was developed
by Wickens (1992) as basis for task selection and for the investiga-
tion of the effects of physical parameters on cognitive processes.
The SMoC was developed by Hollnagel (1998) and contains the
essential elements of cognition (Interpretation, Planning/Choice,
Observation/Identification, Action/Execution) and their possible
interactions.
The main focus of TRACEr is on humanmachine interface and
on the cognitive processes of the operator and was develop to cap-
ture the various layers of the error production (Shorrock and
Kirwan, 2002).
TRACEr has a modular structure including eight taxonomies or
classification schemes that can be divided into three main groups
which describe: (i) the context of the incident, (ii) the production
of the error (operator context), and (iii) the recovery of the inci-
dent, as presented in Table 1 and illustrated in Fig. 1 (Hofmann
and Schrder-Hinrichs, 2013).
Fig. 1 shows that the taxonomy does not only take into account
the external and observable manifestation of the task error (Exter-
nal Error Modes, EEMs) but goes deep in the cognitive domain that
potentially applies to the task error under analysis (Shorrock and
Kirwan, 2002). The Internal Error Modes and Psychological Error
Modes complete the description of the cognitive domain giving a
complete description of which of the cognitive function failed
and in what way. The category Performance Shaping Factors helps
to classify all factors that could have influenced the performance
of the crew members.
Although a thorough explanation of the taxonomy is beyond the
scope of this paper, a short description of its main elements is now
given.
2.1. Context of the incident
As already shown in Table 1 the Context of the Incident is defined
by three main categories: (i) Task Error; (ii) Error Information; (iii)
Causality Level. The category task error describes the operator error
Table 1
TRACEr taxonomy (Hofmann and Schrder-Hinrichs, 2013).
TRACEr 1st level TRACEr 2nd level
Context of the incident 1.Task Error
2. Error Information
3. Casualty Level
Operator context 4. External Error Mode (EEM)
5. Cognitive Domain
6. Internal Error Mode (IEM)
7. Psychological Error Mechanism (PEM)
8. Performance Shaping Factors (PSF)
Error recovery 9. Error Recovery
 A. Graziano et al. / Safety Science 86 (2016) 245257
Fig. 1. TRACEr framework adapted for Ship Accident Investigation. Adapted from Hofmann and Schrder-Hinrichs, 2013.
in terms of the task that was not performed satisfactorily and led to
the incident (e.g. Supervision, Navigation, Mooring operations etc.).
In this category all the information that can help to understand the
context of the incident is taken into account. During the coding of
a task error is thus relevant to identify the location where (e.g. Bridge,
Deck, Engine Room) the task has been performed and who per-
formed it (e.g. Captain, Pilot, First Officer, Bosun, AB, etc.). The Task
Error is therefore chosen according to the identified location since
for each one a list of possible tasks and subtasks is available for cod-
ification, as shown in Table 2 for the Bridge location. Furthermore,
the taxonomy considers that each Task Error is related to only one
Location, one Operator and one User Material (technical equipment).
Therefore, if the error, for example, involves two user materials (e.g.
Radar and AIS), two task errors must be created.
The category Error Information instead, deals with the equip-
ment involved in the error, denoted as User Material in the taxon-
omy (e.g. Radar, GPS, ECDIS, AIS, Alarm Panels, etc.) and which
information concerning the vessel was not taken into account
(e.g. size and dimension, stability of the vessel, condition of naviga-
tional aids, etc.). The technical equipment is directly related to the
location where the error has been performed. Last of the first group
of categories is the Casualty Level that classifies the error as: Causal,
Contributory, Compounding or Non-Contributory.
2.2. Operator context
The core of the TRACEr methodology is the operators cognitive
process and the context in which the operator makes an error
Table 2
List of the possible user tasks and subtasks available for the Location: Bridge.
User Task User subtask
Internal Between officers, between officers and captain, etc.
Communication
External Communication between vessels, Officer and Pilot,
Communication etc.
Hand-over/take-over Between officers, between officers and captain, etc.
Safety drills Not performed with care, etc.
Supervision Of bridge tasks, of deck work, etc.
Navigation Satellite navigation, Radar navigation, etc.
Traffic Monitoring Monitoring of equipment, Monitoring of charts, etc.
Voyage planning Execution, Manoeuvring, etc.
Other Other
247
when performing a task. TRACER taxonomy considers five steps
for coding the operator context, which are: The External Error
Mode (EEM); Cognitive Domain; Internal Error Mode (IEM); Psy-
chological error mechanism (PEM); and Performance Shaping Fac-
tor (PSF) (Table 1). The view point of the coding, in this case, moves
from the context of the accident to the error production, analysing
in detail which external and internal factors may have influenced
the crew member in an erroneous act. The External Error Mode cat-
egory is helpful to classify the external and observable manifesta-
tion of the actual or potential error (Shorrock and Kirwan, 2002),
which is context free and independent of any cognitive process.
It is important to use this category as an objective way to classify
the erroneous act free from the operator performance. EEMs are
classified in three main areas: Selection and quality, Timing and
Sequence and Communication. This category is often used only
for error prediction due to its low descriptive nature.
The Cognitive Domain category focuses on the cognitive frame-
work that potentially applies to the error coded. The cognitive
domains are: (i) Perception; (ii) Memory; (iii) Decision-Making;
(iv) Action; (v) Violation. In the first four categories the error is
non-intentional while in category Violation the error is consid-
ered as an intended violation of rules.
The categories Internal Error Mode and Psychological Error Mode
are strictly related to the cognitive domain chosen. Both represent
a better explanation of the cognitive domain by providing a
description of what cognitive function failed, or could fail, and in
what way (Shorrock and Kirwan, 2002). In other words the IEMs
describe the internal taxonomy of the seafarers error within each
cognitive domain while PEMs describe how the error occurred in
terms of psychological mechanism within each cognitive domain
Table 3
Example of IEMs and PEMs taxonomy related to the cognitive domain: Decision
Making.
Cognitive Domain: Decision Making
IEMs PEMs
Mis-projection Misinterpretation
Poor decision/planning Failure to consider side/long effects
Late decision/planning Mind set
No decision/planning Knowledge/competency problems
Decision freeze or overloaded
Risk cognition failure
248 A. Graziano et al. / Safety Science 86 (2016) 245257
(Hofmann and Schrder-Hinrichs, 2013). It is important to keep in
mind that for each cognitive domain there is a set of pre-defined
IEMs to choose, linked to a limited set of PEMs. Table 3 shows
the IEMs and PEMs related to Decision Making.
The last category of the framework under the operator context
level is the Performance Shaping Factors (PSF), which helps to clas-
sify all factors that could have influenced the performance of the
crew member. The PSF categories used by TRACEr are: (i) Personal
Factors (e.g. cognitive fatigue, stress, etc.); (ii) Aspects of commu-
nication/information (e.g. lack of information, no training, etc.);
(iii) Internal/external environment (e.g. weather, time of the day,
etc.); (iv) Organisational Factors (e.g. manning characteristics,
organisational policies, etc.); (v) Training/competence (e.g. no
training, lack of experience, etc.); (vi) Others.
2.3. Error recovery
The last first level category (in Table 1) is Error Recovery that is
useful to understand at a certain point if a barrier, which was set to
prevent an erroneous act, worked or not. It is quite clear that when
the barrier works the entry can be classified as a near-miss, while if
the barrier fails the error leads to the accident. In the analysis per-
formed only accidents are taken into account. TRACEr adopts the
Hollnagel (2004) proposal that classifies the barriers as: (i) Physical
Barrier; (ii) Functional Barrier; (iii) Symbolic Barrier; (iv) Incorpo-
real Barrier.
3. Accident codification and analysis
For the purpose of this paper, 52 accidents reports involving 64
vessels have been analysed and coded using the TRACEr taxonomy.
The accident reports used have been published by the UKs Mar-
itime Accident Investigation Branch (MAIB), the Transportation
Safety Board of Canada (TSB) and the National Transportation
Safety Board of the United States of America (NTSB) and cover
grounding and collision accidents in a period from 2004 to 2013.
The accidents analysed have produced 289 entries (task errors)
coded using the TRACErs taxonomy described in the previous sec-
tion. The analysis covered:
 52 accident reports involving 64 ships (33 reports published by
MAIB, 14 by TSB and 5 by the NTSB);
 32 groundings and 32 collisions;
 289 task errors.
An accident is typically caused by several task errors and each
one has to be identified from the accident report and coded sepa-
rately using the TRACEr taxonomy. One important aspect when
analysing an accident is to identify the sequence of events that lead
to the outcome of the accident. As TRACEr does not give any guid-
ance on how to reconstruct the sequence of tasks errors, a tabular
format with some similarities to the STEP method (Hendrick and
Benner, 1996) was adopted for structuring and ordering all events
identified from the accident report, as already suggested by the
Table 4
Illustration of the sequence of main events/task errors identified from the accident report.
Event No. Actor/User
1. Additional lookout not on watch Captain
2. Satellite Navigation not performed 1st/Chief
correctly Officer
... ...
... ...
CASMET methodology. In this format illustrated in Table 4, the
main events (task errors) are ordered in rows to reflect their
sequence in time and are related to the main actor, task, location
and equipment involved in the task error (if any) along with any
relevant contributing factor (e.g. fatigue, stress, time pressure,
etc.).
3.1. Context of the accident
From the analysis of the coded collision and grounding acci-
dents, 96.5% of the errors have been performed on the Bridge
where the main actor involved, despite of the grade, has been
the Officer of the Watch (from now on OOW), while only 3.5%
(10 out of 289) of the erroneous acts have been performed in the
Engine Control Room. It is also important to mention that 98.3%
of the errors (e.g. causal, contributory, compounding or non-
contributory) that led to collision have been performed on the
Bridge, which was expected as the safe and proper operation of
the ship is the main task the officer of the watch. The accidents
where a licensed pilot was on board are 20% (16 vessels out of
64) and 14% correspond to erroneous acts performed by the pilot.
Furthermore in 16.9% of the accidents an additional lookout was
not present on the bridge.
After having identified the location on board where the erro-
neous act was made and identified who performed it, the next step
is to identify the Task (or task errors) and Subtask the operator was
performing when the error occurred, together with the Technical
Equipment involved, if any. The analysis indicates that 70.2% of
the errors performed and coded involved a technical equipment.
3.1.1. Task errors
The User Task taxonomy provides a set of categories for each
location (e.g. Bridge, Engine Control Room (ECR), and Deck). In this
paper, since 96.5% of the errors were performed on the Bridge, the
categories related to the Engine Control Room (ECR) and Deck have
not been taken into account. The User Task categories for the
Bridge are: External Communication, Hand-over Take over, Inter-
nal Communication, Navigation, Other, Supervision, Traffic Moni-
toring and Voyage Planning. Each of the eight categories is linked
to a set of predefined subtasks with a more descriptive meaning.
For example, when the vessel is underway and the OOW forget
to plot/check the position, the Task associated to such error would
be just Traffic Monitoring that can be better characterised by the
Subtask monitoring of paper charts. This increased level of detail
is particularly relevant to associate the task error with the techni-
cal equipment involved and for further statistical analyses.
The percentages of the User Task categories at the Bridge loca-
tion, are shown in Fig. 2. The main Task Error found is Navigation
with a percentage of 28.7%. Navigational errors are strongly con-
nected to the conduction of the vessel, while underway, inbound-
ing or out bounding from a port/channel, with pilot on board or not
(e.g. Pilotage) and using instruments (e.g. Satellite Navigation,
Radar Navigation etc.) or not (e.g. Dead-Reckoning). Errors such
as the Officer on Watch was not aware of the vessel position while
User task Location User Material / Contributory factors
Equipment
Voyage Bridge None Organisational Procedures, Time
planning pressure
Navigation Bridge GPS Fatigue
... ... ... ...
... ... ... ...
 A. Graziano et al. / Safety Science 86 (2016) 245257 249

35%

30%
28.7%
27.2%

25%

20%

15% 12.9% 11.8%

10% 8.2% 8.2%

5% 2.5%
0.4%
0%

Hand-over,
Navigaon

Communicaon

Other
Supervision

planning

communicaon
Monitoring

Voyage

take over
Trac

External

Internal
Fig. 2. Percentages of Task Error categories for the location: Bridge.

14%
12.5% 20%
17.2%
12%
18%
16%
10% 14%
8.2% 12%
8% 10%
5.7% 8% 6.1%
6%
6%
4% 2.9%
4%
2.2% 2% 0.4% 0.7%
2% 0%
of Bridge Tasks

Watchkeeping
of Mooring
of Anchoring

of Cargo Handling
0%
Pilotage
reckoning

Navigaon

Navigaon
Satellite
Dead-

Radar

Navigaon Supervision
Fig. 3. Percentages of the subtasks coded under task: Navigation. Fig. 4. Percentages of the subtasks coded under task: Supervision.

changing course, the Officer did not change the course in time to
avoid collision or also the vessel was proceeding too fast unno-
ticed are all navigational errors, which are causal or contributory
to the accident. As illustrated in Fig. 3, the main subtask related to
Navigation is Pilotage 12.5% (percentage referred to the grand
total (g.t.)) therefore the mistake was performed either by the pilot
or any of the bridge team members and was strictly linked to the
act of piloting a ship (e.g. the Pilot ordered to change course, the
Pilot was not able to handle the ship turn, the Pilot did not commu-
nicate his passage plan to the bridge team members). Satellite
Navigation (8.2% of g.t.) is associated to the vessel underway and
to the technical equipment involved (e.g. ECDIS, ECS, GPS etc.)
while on the other hand Dead-reckoning (5.7%), which is the
process of navigation based on speed, course and estimated
position, does not involve any technical equipment.
The second main category identified is Supervision (27.2%),
which is also the most generic of all. This category groups all those
errors related to tasks of control and surveillance of ship activities
(e.g. generic bridge activities, mooring, cargo handling, mainte-
nance work etc.). In general the category is related to the subtask
of bridge tasks (17.2% of the overall subtasks), as it can be seen
in Fig. 4, which although has a very generic meaning, it is very
effective to classify errors that otherwise do not fit/match in any
of the available options. The absence of additional lookout (both
if dismissed or not called on the bridge) has been considered as a
contributory error, especially to grounding accidents, and has been
classified of bridge tasks. In addition, not checking the physical and
mentally liability of the officer/master taking duty and not switch-
ing on crucial technical equipment (usually BNWAS and Echo
Sounder) were both considered as of bridge tasks. This classifica-
tion should not be confused with the case of wrong handling of
equipment, which has been coded differently. The watchkeeping
subtask consists of a lack of attention while trying to keep a proper
lookout on the bridge. This category has been considered for acci-
dents where often the operator fall asleep for which the subtask
watchkeeping is more specific than the generic of bridge tasks. Last
but not least the subtask of anchoring was added to the original
taxonomy in order to classify those errors performed by the officer
on watch while the vessel was at anchor. Errors such as not plot-
ting the bridge swinging circle, not checking the ship position at
anchor or not deploying enough cables length for the anchor, have
all been coded as Supervision of anchoring.
250 A. Graziano et al. / Safety Science 86 (2016) 245257
The third category is Traffic Monitoring (12.9%) which typically
involves a technical equipment, and therefore is the one more used
to the study of humanmachine interface. The category has only
two main subtasks which are Monitoring of Equipment (11.5%)
and Monitoring of charts (1.4%). The first subtask mentioned
gather together all those errors related to the wrong handling of
equipment (e.g. ship on course of collision not acquired on the
Radar, OOW did not set warning distances on the Radar, ECDIS
guard zone absent etc.) or those associated with a lack of supervi-
sion of the equipment itself (e.g. OOW was unaware of the position
of the vessel, the OOW forgot to monitor the AIS etc.). The second
one instead, is connected to wrong handling and monitoring of the
nautical charts (e.g. position was not plotted on the charts, etc.).
Within Voyage Planning (11.8%) all the errors connected to the
planning, execution, appraisal, monitoring of the voyage plan were
taken into account. Recalling Regulation 34 of SOLAS Chapter V,
prior to proceeding to sea, the master shall ensure that the intended
voyage has been planned using the appropriate nautical charts and
publications for the area concerned, taking into account the guidelines
and recommendations developed by the Organization. The voyage
plan therefore shall take into account any relevant ships routing
system, anticipates all the possible hazards and adverse weather
conditions, takes into account all marine environmental protection
measures and ensure sufficient sea room for the safe passage of the
ship throughout the voyage. Since the plans should be approved by
the ships master prior to the commencement of the voyage or pas-
sage, it is not surprising that 58% of the errors of Voyage Planning
have been performed by the Captain. The subtask with the highest
percentage is clearly Planning with 7.5% of the grand total (see
Fig. 5). The planning should be prepared covering the entire voyage
or passage from berth to berth, including those areas where the
services of a pilot will be used (IMO, 1999). Errors of wrong pas-
sage plan, poor passage plan, wrong waypoint set, wrong anchor-
ing area decided were all codified as Planning.
Proceeding in the analysis it has been found that both Internal
Communication and External Communication have the same per-
centage of 8.2% of the grand total (see Fig. 2). Those two categories
take into account errors of communication or no-communication
between officers on the bridge (3.9%), Pilot and the Bridge team
members (2.9%), officer and lookout (1.1%) or external communica-
tion such as with another vessel (4.3%) or between vessel and the
Vessel Traffic System (VTS) (1.8%), as shown in Fig. 6.
The external manifestation of those erroneous acts affect the
quality of the information transmitted/recorded by the operator:
8% 7.5%
7%
6%
5%
4%
3%
1.8%
2% 1.4%
1.1%
1%
0%
Appraisal Execuon, Monitoring Planning
Manouvering
Voyage Planning
Fig. 5. Percentages of the subtasks available for Voyage Planning.
5%
4.3%
5% 3.9%
4%
4% 2.9%
3%
3%
1.8%
2%
2% 1.1% 1.1%
1% 0.7%
0.4% 0.4%
1%
0%
Vessel and VTS
Between Pilots
Between Vessels
Pilot and Bridge Team
Vessel and Ashore
Bridge Team and Sup.
Pilot and Tugs
Between Ocers
Ocer and Lookout
External Communicaon Internal Communicaon
Fig. 6. Percentages of the subtasks available for Internal and External
communication.
The Master did not perceive the VTS suggestions, No effective com-
munication with the Engine Room, the two pilots did not agree
clearly the meeting point are examples of errors in communication.
It is also important to mention that in 93% of the External Commu-
nication errors, the main technical equipment involved was the
Very High Frequency (VHF) radio. The last category of the analysis
with a percentage of 2.5% is Hand-over/take-over, which groups
those errors performed while writing night orders or crucial infor-
mation not transmitted by or to the OOW during the take-over or
hand-over.
3.1.2. Technical equipment (TE)
The identification of the technical equipment (TE) used when
performing a task error that lead to an accident is important for
designing a human centred environment in order to fulfil the need
of the users especially from an ergonomic point of view. Fig. 7
shows that the main TE involved in 21.6% of the user tasks is the
Radar (e.g. No bridge team member was monitoring the radar, tar-
get not acquired, OOW misinterpreted the closest point of
approach CPA, etc.). In addition, the VHF radio has been found to
be present in 11.3% of the task errors followed by paper charts in
10.3% (e.g. vessel position not plotted, wrong vessel position, poor
passage plan, etc.).
The version of TRACEr adapted for ship accident investigation
considers as technical equipment the Electronic Chart Display &
Information System (ECDIS) that complies with IMO regulations.
According to IMO (2006), the Electronic Chart Display and Informa-
tion System (ECDIS) means a navigation information system which
with adequate back-up arrangements can be accepted as complying
with the up-to-date chart required by regulations V/19 and V/27 of
the 1974 SOLAS Convention, as amended, by displaying selected infor-
mation from a system electronic navigational chart (SENC) with posi-
tional information from navigation sensors to assist the mariner in
route planning and route monitoring, and if required display addi-
tional navigation-related information.. In few words a generic elec-
tronic chart display and information system can be used on board
as a primary mean of navigation instead of Paper Charts if it fol-
lows the performance standards adopted by IMO in SOLAS Regula-
tion 19 of Chapter V. Moreover any ship can still keep Paper Charts
as primary mean of navigation but also carry on board an Elec-
tronic Chart System (ECS), which as stated in ISO 19379 is a nav-
igation information system that electronically displays vessel position
 A. Graziano et al. / Safety Science 86 (2016) 245257 251

25%
21.6%
20%

15% 11.3%
10.3%
10% 6.7% 6.2% 6.7% 6.2% 7.2%
5.2% 4.6%
5% 2.1% 2.6% 3.1% 2.6% 2.1%
0.5% 1.0%
0%

VHF
AIS

Autopilot

BNWAS

ECDIS

ECS

GPS

Handbooks

Other communicaon

Radar
Decision support

Echo Sounder

Engine room controls

External equipment

Paper Charts

Passage Plan

Steering panel
systems

devices
Fig. 7. Percentages of the Technical Equipment not taking into account the errors where no TE was involved.

and relevant nautical chart data and information from an ECS Data- equipment was switched off the task error was considered
base on a display screen, but does not meet all the IMO requirements compounding to the accident and coded as Supervision of bridge
for ECDIS and is not intended to satisfy the SOLAS Chapter V require- tasks (Graziano et al., 2015). Fig. 8 shows the percentage of
ments to carry a navigational chart. (ISO, 2003). To be coherent technical equipment involved in the different task errors. It can
with both definitions the ECS has been added to the taxonomy be seen that most of errors in traffic monitoring tasks involved
and considered separately from the ECDIS. The first one counts the Radar and the use of ECDIS. The radar together with the
for 6.7% while the second counts for 6.2% (see Fig. 7). Relying on BNWAS and the Papers Charts are also present in Supervision task
an ECS instead of using Paper Charts as primary mean of navigation errors. As already mentioned, the radar is an important TE involved
has been considered a contributory error to the accident during the also in many errors in navigation tasks although in this case the
coding procedure. ECDIS and ECS have been involved only in faulty interaction with the steering panel has also an important
grounding accidents for a total of 20% of the errors performed. presence in the task errors.
Last relevant TE is the Bridge Navigational Watch Alarm System
(BNWAS) with the 5.2%. It is important to underline that with the 3.2. Operator context
entry into force of Resolution MSC.282(86) (IMO, 2009), IMO
amended SOLAS Chapter V, Regulation 19, requiring that all new While the previous sections addressed the error identification,
cargo ships over 150 g.t. and all new passenger ships constructed including the location where the error took place and the person
after 1st of July 2011 shall be equipped with a BNWAS. For the who executed it, the present focuses more on the external and
existing vessels over 3000 g.t. the deadline for equipping the internal factors that may have or not influenced the performance
BNWAS was no later than 1st of July 2012 and for the cargo vessel of the operator. According to Table 1, five steps are necessary to
over 500 g.t. no later than 1st of July 2013. Even though at the time outline and understand the internal and external context in which
of many accidents the BNWAS was not mandatory, if this the end user was operating. First of all, the External Error Mode

12% 10.8%
10% 9.3%

8% 6.7%
6.2%
6% 5.2%
4.1%
3.6% 3.6% 2.1% 3.6%
4% 3.1% 3.1%
2.6% 2.1% 2.1%
1.5% 1.5% 1.5% 1.5%
2% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0%
0.5% 0.5% 0.5% 0.5%
0%
AIS

AIS
GPS

GPS

GPS

GPS
BNWAS
VHF

ECS

VHF

ECS

ECS

ECS
Radar

Radar

Radar

Radar
ECDIS

ECDIS

ECDIS
Engine room controls

Engine room controls

Engine room controls

Autopilot
Other communicaon devices

Decision support systems

Decision support systems

Echo Sounder

Echo Sounder

Other communicaon devices

Decision support systems

Steering panel

Handbooks
Steering panel

Handbooks

Handbooks
Paper Charts

Passage Plan

Paper Charts

Paper Charts

Paper Charts

Passage Plan
External equipment

External Comm. Navigaon Other Supervision Trac Monitoring Internal comm. Voyage planning Hand/take-over

Fig. 8. Percentage of technical equipment involved, divided by task error category.

252 A. Graziano et al. / Safety Science 86 (2016) 245257

40%
19% 69.2% 11.8%
35%

30%

25% 31.5%
20%
14.3%
15%
10.0% 10.4%
9.0%
10%
5.4%
3.6% 2.5% 3.6%
5% 2.2% 2.2% 1.1% 2.2% 0.4% 0.4% 1.1% 0.4%
0%

Wrong acon on right obj.

Right acon on wrong obj.
Omission
Info. not recorded

Acon too early

Incorrect info. recorded

Wrong acon on wrong object

Acon too lile

Acon too late

Acon too long

Unclear info. recorded

Acon too much

Info. not transmied

Acon in wrong direcon

Incomplete info. transmied

Info. not sought/obtained

Unclear info. transmied

Communicaon Selecon and quality Timing and Sequence

Fig. 9. External Error Modes (EEMs).

(EEM) of each task error has been analysed in order to obtain an then the related Internal Error Mode (IEM) (Fig. 10) and the Psy-
immediate and quick description of the observable manifestation chological Error Mechanism (PEM) (Fig. 11), which give the possi-
of the error (Fig. 9). From the analysis of the task errors, 69.2% bility of characterising the psychological errors in depth using
EEMs of Selection and Quality have been found, which means that three layers of description. The analysis showed that the Cognitive
the operator made an error in the way he decided of implementing Domains related to the task errors are 43% of Decision-Making, 24%
an action (14.3% Action in Wrong Direction and 10% Wrong action of Perception, 15.8% of Action, 9.7% of Memory and 7.5% of
on right object) or not implementing an action (31.5% Omission). Violation.
19% are EEMs of Communication, which suggests that there was Within the Decision Making cognitive domain the analyst must
an error in communicating/perceiving crucial information while consider that the user/crew member received the crucial informa-
11.8% are EEMs of Timing and Sequence, which means the action tion necessary to perform the action, processed it correctly, but
decided was right but there was a timing error in implementing came to a wrong conclusion and therefore took a wrong decision.
it (e.g. action too early, action too long, action too late etc.) Shortly the crew member was asked to make decisions and per-
When applying TRACEr it is essential to identify the Cognitive form cognitively functions in both demanding and normal condi-
Domain that best applies to the error under consideration, and tions. In other words the crew member lost situational

20%
17.6% 17.9%
18%
16%
14%
11.1%
12%
10% 8.6%
8% 5.7%
6% 4.3% 4.7% 4.3%
4% 2.5% 2.5% 1.8% 2.5% 2.5%
1.8% 1.8% 2.2% 1.8% 1.4%
2% 0.7% 0.4% 1.1% 0.7% 0.7% 0.4% 0.4%
0%
Info/data entry error

Not-performed acon

Timing Error

Unclear Info.

Unclear informaon recorded

Late decision/planning

No decision/ planning

Poor decision/planning

Forget temporary info.

Omied or late acon

Late detecon

Mishear

Misread

Mis-see

Intended Violaon

Roune Violaon
Info. not transmied

Necessary info. was not transmid

Selecon error

Unclear info. Recorded

Misprojecon

Forget to ask/share info.

Forget to Monitor

Necessary info. was not transmid

No detecon

Visual mispercepon

Exceponal Violaon

Acon Decision-Making Memory Percepon Violaon

Fig. 10. Percentages of Internal Error Modes (IEMs), grouped by cognitive domain.
 A. Graziano et al. / Safety Science 86 (2016) 245257 253

16%
14.3% 15.1%
14%
12%
10%
8% 6.5%
5.7% 6.1%
6% 5.0% 4.7%
3.9% 3.9% 2.9% 3.9%
4% 3.2%
2.5% 2.2% 2.5%
0.7% 1.8% 1.4% 1.8% 0.7% 1.4% 0.7%
2% 0.4% 0.4% 0.7% 1.1%
0.4% 0.7% 0.4% 0.4% 0.7% 0.4% 0.7% 0.4% 0.4% 0.4%
0%

Miscommunicaon

Vigilance
Expectaon
Fague

Knowledge/ Competency problems

Fague

Expectaon

Expectaon
Fague
None

None

None

Discriminaon failure, Confusion

None
Overloaded

None

Stress/pressure
Confusion

Other slip

Confusion
Habit Intrusion

Mind set

Risk cognion failure

Mental Block
Intoxicaon

Decision freeze or overload

Intoxicaon

Overcondence

Intoxicaon

Overcondence
Tunnel Vision
Failure to consider side or long eect

Memory overloaded
Distracon/preoccupaon

Distracon/preoccupaon

Distracon/preoccupaon
Manual variability

Misinterpretaon
Competency problems

Acon Decision-Making Memory Percepon Violaon

Fig. 11. Percentages of Psychological Error Modes (PEMs), grouped by cognitive domain.

awareness (SA) which often is presented as a predominant concern
in system operation together with the impact of design features,
workload, stress, system complexity and automation on operators
(Asami and Kaneko, 2013). In models based on Naturalistic
Decision-Making (NDMM) the SA is defined as the perception of
elements in the environment within a volume of time and space, the
comprehension of their meaning and the projection of their status in
the near future (Endsley and Jones, 2004) and it follows a chain
of three-level model (Stanton et al., 2001): Level 1: Perception of
the elements in the environment; Level 2: Comprehension of the
current situation; Level 3: Prediction of the future status.
In TRACEr the Situational Awareness is not addressed deliber-
ately but its three-level model has been included in the taxonomy.
Specifically, the Decision-Making cognitive domain group together
the Level 2 and Level 3 of the chain, while the Level 1 has been
included within the Perception cognitive domain.
The main IEM considered in the framework of Decision Making
are Poor Decision/Planning 40.8% (17.6% of the grand total) and No
decision/planning 25.8% (11.1% of the g.t.) followed by Misprojec-
tion 20% (8.6% of the g.t.) and Late decision/planning 13.3% (5.7%
of the g.t.) (see Fig. 10). Errors such as not using sound signals in
restricted visibility, switching off necessary TE, changing course
without taking into account the decided passage plan are all errors
classified in this domain. In addition failing in complying with rel-
evant and mandatory regulations has been considered a decision
making error because it was considered that the operator was
aware of the regulation (e.g. BNWAS switched off, etc.) but decided
not to comply showing both a lack of judgment and failure in
recognising risks and consequences.
The high percentage of Decision-Making errors is quite surpris-
ing especially if one takes into account that the safety community
is moving towards the creation of resilient socio-technical systems,
where resilience is intend the intrinsic ability of a system to adjust
its functioning prior to or following changes and disturbances
(Steen and Aven, 2011). One of the foundation of Safety-II principle
is that performance variability is always present and necessary
because people, during the decision-making process, adjust what
they do to match current demands and resources, in order to
ensure things to go right (Hollnagel, 2014). The outcome of the
analysis has shown that the capacity of the crew members to
adjust their performance to a new condition of the system is very
low since almost one error out of two is linked to a lack of decision-
making. Furthermore, considering the PEMs related (Fig. 11), in
35% of the errors the operator was not able to recognise the link
between his decision and a possible unfortunate outcome (Risk
Cognition Failure, 15.1% of the g.t.) while in 33.3% of the cases he
presented the inability of being proactive (Failure to consider side
or long effects, 14.3% of the g.t.). In 11.7% of the errors the operator
misinterpreted the information perceived (e.g. the position of the
ship was not accurate etc.).
Although Decision Making has the highest overall contribution,
the peak value can be found in the cognitive domain Perception,
due to the IEM No Detection (17.9%) (Fig. 10). In the adapted ver-
sion for ship accident investigation, the information perceived by
the operator/crew member are not anymore only those displayed
on TE but also detected personally (e.g. a ship on collision course
detected by a lookout etc.). With regards to the Perception cognitive
domain, Shorrock (2007) states Controllers have a substantial
amount of information, and must maintain their performance contin-
uously and consistently for periods of up to 2h at time over a shift,
which is not different compared to what happens for an OOW left
to handle administrative burden, watchkeeping, operational dis-
turbances etc., with a 4 h on/4 h off shift, which in the worst case
scenario can be 6 h on/6 h off (e.g. small dry cargo vessels, engaged
in short sea trade, manned with just two deck officers). The high
value of No Detection suggests that often the operator does not
observe the information of the technical equipment involved (e.g.
Echo Sounder, Radar ARPA alarms, GPS, ECS, etc.) and therefore
take actions on wrong prerequisites.
Furthermore not paying enough attention to the vessel position,
not identifying a ship in route of collision or an off-route not recog-
nised are all errors classified in the Perception cognitive domain.
By analysing the Perception PEMs shown in Fig. 11, the main psy-
chological causes where Expectations 26.9% (6.5% of g.t.) Vigilance
254 A. Graziano et al. / Safety Science 86 (2016) 245257

25.4% (6.1% of g.t.), Tunnel Vision 19.4% (4.7% of g.t.) and Distrac- categories of Perception and Decision Making since on one hand
tion/Preoccupation 13.4% (3.2% of g.t.). When considering Expecta- the operator could make a wrong decision on the assumption of
tions the information was not read properly since the operator unclear/wrong information recorded and on the other the user
was influenced by an expectation tendency, often triggered by reli- could miss an entire flow of information if forgetting to monitor
ance on some other member of the Team Bridge or overconfidence. a crucial equipment or forget temporarily information.
In errors linked to Tunnel Vision the operator was too focused on In the Violation cognitive domain fall all those deliberate and
one instrument losing then situational awareness of the surround- intentional but not malicious contraventions of procedures that
ing environment or of others TE involved in the task. Those errors finally led to an incident. From the reports analysed it has been
have been found being very common in stressful situation such as very difficult to clarify whether or not the users performed an erro-
Pilotage, inbound/outbound from/to Ports and channels or high neous intentionally although errors in which the OOW left the
density traffic Areas. Additionally, Distraction/Preoccupation and bridge unmanned and when the master did not leave any night
Vigilance failures were common in cases of fatigued officers, lack orders were all coded as a deliberate violation of the procedures
of additional lookout on the Bridge during night-watch hours or and coded in this cognitive domain.
when the atmosphere on the vessel was not appropriate for
watchkeeping.
4. Grounding and collision accidents
It is also important to mention how the quality itself of the
information, beside the physical/cognitive attitude of the operator,
4.1. Grounding accidents
can be an issue in the Perception process. In many cases the flow of
information in such high-automation environment (or high traffic
Grounding is a type of accident that involves the impact of a
areas) can easily become a torrent where all the information
ship on seabed or waterway side (Mazaheri et al., 2013). Typically
are difficult to process for an OOW, especially if is fatigued (36%
groundings are more related to failures of ship systems (e.g.
of the perception errors) or not trained (31% of the perception
machinery and steering failures) than collisions and contacts acci-
errors). In other cases the information can be of poor quality (e.g.
dents that show a closer relation to human errors. The groundings
poor visibility due to fog or bad weather) while in other circum-
can be grouped into drift and power groundings where drift
stances the operator was ordered to focus on a single TE by the
includes all those groundings with no engine power while power
Master losing thus situational awareness.
means that the engine is running. Both types of accidents have
The third cognitive domain is Action involved in 15.8% of the
been analysed and coded.
task errors. TRACEr considers an error of Action when the operator
Fig. 12 shows the main task errors involved in the groundings
received the crucial information, processed it correctly, decided on
analysed. The high percentage of Supervision errors (33%) is not
a right course of action but made an error in the implementation of
surprising as in 22% of the groundings coded the OOW fell asleep
the decision. Many of the errors of navigation concerning wrong/
on the bridge or left it unmanned and in 32% of the erroneous acts
late planned alteration of course, setting inappropriate safety
occurred in the absence of an additional lookout despite it was
zones on Radar or ECDIS, collision avoidance manoeuvres are all
required. The majority of the grounding-related subtasks are
error falling in this cognitive domain. To be more specific, 27.3%
supervision of bridge tasks (20.5%). With regards to navigational
are IEMsTiming errors (4.3% of the g.t.), which means that the
tasks, errors on both Satellite Navigation and Pilotage count for
operator made an error in the timing of the implementation of
7.8% each. 15.7% of the errors are associated to voyage planning
the action, 15.9% are Selection Error (2.51% of the g.t.), which
tasks (e.g. wrong waypoint considered in the planning, no plan
means that the operator selected the wrong technical equipment
for the change of course, passage plan not planned effectively
to perform a task and other 15.9% are Information not transmitted
etc.). The main TE involved, excluding the 27% errors with no tech-
errors, which means that the operator did not transmitted crucial
nical equipment involved, are Paper Charts (11.5%) and Radar
information to the involved parties. With regards to PEMs
(10.8%), while if considered together ECS and ECDIS count for
(Fig. 11), the main psychological aspects influencing the operator
15.1%. The main EEM is Omission 34.3%. The main Cognitive
performance have been found to be Distraction/Preoccupation in
Domain category is Decision Making (38.6%) followed by Percep-
25% of the cases (3.9% of the g.t.), which can be also related to vig-
tion (31.3%), which are linked to the IEMs of Poor decision/plan-
ilance issues, and Habit Intrusion as well in 25% of the cases.
ning (15.1%) and No detection (25.9%) and the PEMs of Risk
The last two cognitive domains analysed are Memory (9.7%) and
Cognition Failure and Distraction/Preoccupation, which account
Violation (7.5%). In the Memory cognitive domain the operator for-
for 13.3% each. The analysis of the Performance Shaping Factors
got or did not recall temporary or long-term information, previous
(PSFs) shows that the task errors were affected by two main organ-
action or planned actions (Shorrock and Kirwan, 2002) or in other
isational PSFs: Organisational Procedures (36.1%) and Staffing
terms, the user did perceive the information but did not deal cor-
Characteristics (26.5%). For External/Internal PSFs, Atmosphere on
rectly with the perceived critical situation or the crucial informa-
the vessel (29.5%) and Time of the day (26.5%) were the main con-
tion due to not remembering correctly or not knowing what to
tributors. Moreover, almost one-fourth of the task errors leading to
do (Hofmann and Schrder-Hinrichs, 2013). Even though in Air
grounding accidents were influenced by PSFs related to Personal
Traffic Management, memory is a critical determinant of perfor-
Factors such as bodily fatigue (22.3%), to Training/competence
mance of the operators, in the maritime industry lapses of memory
such as Inadequate training/instructions (22.9%) and to aspects of
are not known to be a major contribution to accidents and inci-
communication/information such as Miscommunication (27.7%).
dents. Air traffic controllers need to use working memory and
long-term working memory to form and manipulate a picture of
several aspects both of aircrafts and the airspace under control 4.2. Collision accidents
(Shorrock, 2005) while situational awareness related skills of sea-
farers are more connected to perception of right information and The majority of the collision accidents happen in circumstances
decision making. The main IEM that counts for 48% of the errors where ships on a collision course collide without performing eva-
of Memory (4.7% of the g.t.) is Forget to Monitor where the opera- sive actions or after these attempts fail (Kaneko, 2013). It is indeed
tor forgot to monitor the technical equipment involved in the task true that in the recent years there has been a rapid development of
(usually Radar monitoring or AIS monitoring). Errors in this new navigational systems (e.g. VTS, ARPA, AIS, ECDIS, etc.) followed
domain were considered right in the middle of the two previous by new IMO requirements with the main aim of increasing the
 A. Graziano et al. / Safety Science 86 (2016) 245257 255

40%
35.4%
35% 33.1%

30%
24.1%
25%
18.6%
20% 15.7% 15.0%
15% 13.3%
11.4%
7.8% 8.8%
10% 6.2%
4.8%
5% 2.4% 2.7%
0.6%
0%

Navigaon
Other
Navigaon

Supervision
Supervision

Internal communicaon

Internal communicaon
Hand-over, take over

Hand-over, take over

External Communicaon

External Communicaon
Voyage planning

Voyage planning
Trac Monitoring

Trac Monitoring
Grounding Collision

Fig. 12. Main user task errors for grounding and collision accidents.

level of safety of modern ships (Pedersen, 2010). Although these for analysing the cognitive process, the context of the operator
technical innovations have increased the capabilities of seafarers and the various layers of the error production based on the
they have also shown to contribute to accidents at sea due to decomposition of the task errors in External/Internal Error Modes
over-reliance on those systems (Lutzhoft and Dekker, 2002). (EEM/IEM) and in psychological error mechanisms. This is of
Fig. 12 shows the task errors involved in the collision accidents paramount importance for identifying areas where improvements
analysed. The main category identified is Navigation errors are needed, for example, by adopting human-centred design
(35.4%) that includes all the failed evasive actions taken to avoid approaches so that particular issues related to humanmachine
collisions and in detail the three main user subtasks involved in interaction can be corrected (Anto et al., 2014). In fact, the sub-
the accidents are Pilotage (19.5%), Monitoring of equipment stantial number of task errors involving equipment indicates that
(14.2%) and of bridge tasks (12.4%). The main TE found, excluding better designs could have eventually avoided some of the acci-
the 36% errors with no technical equipment involved, are the Radar dents coded.
(21.2%) and the VHF radio (14.2%), showing that in several cases the TRACEr, as most of the accident and human error classification
OOW violated the rules of the Convention on the International Reg- schemes, relies to some extent on the experience, background and
ulations for Preventing Collisions at Sea (COLREGs), in particular knowledge of the analyst, which can influence the way the acci-
rule 7(b) that states proper use shall be made of radar equipment dent is coded. Some issues have been noted when classifying super-
fitted and operational, including long range scanning to obtain vision and particularly navigational tasks, typically when the
early warning of risk of collision and radar plotting or equivalent function is simultaneously performed by the same person on dif-
systematic observation of detected objects. The main EEM is ferent levels (e.g. Radar and Charts and ECDIS, etc.). The subtasks
Omission (27.4%) but the most important aspect on the collision watchkeeping and of anchoring were not available in the original
accidents is the 17.7% of Action too late, which indicates that taxonomy and were added by the authors due to the shortage of
frequently the evasive actions are performed too late, often due some elementary navigational subtasks. It is also suggested to dis-
to a late detection, and the Action in wrong direction (14.2%). tinguish between ECS and ECDIS, as specified by IMO (2006). How-
Concerning the cognitive domains, almost half of the errors ever, the ability to easily add new tasks and subtasks showed great
(49.6%) are classified as Decision Making linked to the IEMs of flexibility and adaptability of the method to fulfil both the require-
Poor decision/planning (21.2%), No decision/planning (10.6%) and ments of the coder and the focus of the analysis (e.g. legal, techni-
Late decision/planning (9.7%) and to the PEMs of Failure to consider cal, scientific, navigation, safety, etc.).
long/side effects (18.6%) and Risk cognition failure (17.7%). In As mentioned before the Tracer taxonomy has been developed
terms of influencing factors, 55.7% of the task errors were affected to classify human-related errors. However, an accident typically
by Organisational Procedures while 39.8.% by the Staffing involves many events. Most of them are attributed to human errors
Characteristics Organisational PSFs. Time of the day (26.5%) and in specific tasks but some are clearly related to equipment failures.
Atmosphere on the vessel (19.4%) were the main contributors related Therefore, it is important that the methodology that supports the
to Internal/External PSFs. Moreover, as regards to influencing factors analysis and the codding of the accidents is able to: (i) identify
associated to Personal Factors, Training/Competence/experience the sequence of events that lead to the accident and their interac-
and aspect of Communication/Information, the main contributors tion; (ii) distinguish between task errors and technical failures
were respectively bodily fatigue (39.9%), Inadequate training/ events (Guedes Soares et al., 2000).
instructions (33.6%) and Miscommunication (15%). These two aspects represent the main limitations of the TRACEr
methodology. Being a human error identification tool, the TRACEr
5. TRACEr, final discussion taxonomy cannot be applied to code technical failures. For exam-
ple, when a collision is caused by the malfunctioning of the steer-
The systematic analysis and codification of maritime accidents ing gear, which could not be attributed to an actor, this event is not
using TRACEr has shown that the taxonomy is particularly useful considered nor coded by TRACEr, as it is not directly related to a
256 A. Graziano et al. / Safety Science 86 (2016) 245257
task error, although the equipment failure would eventually
involve a human error if the failure is analysed in detail.
The lack of clear guidance to determine the events sequence
encourages the analyst to rely on other available methods. In the
present case an approach with some similarities to the STEP
method (Hendrick and Benner, 1996) was adopted, as already sug-
gested by the CASMET methodology. This allowed identifying the
sequence in time of the task errors and their characteristics, which
were then coded using the TRACEr taxonomy.
However, from a more technical perspective, this sequence
should include also equipment failure events (i.e. systems or com-
ponents that do not function as intended due to some sort of
breakdown) along with their location, failure type and immediate
physical cause of failure. Some of these capabilities are already
available in other accident analysis methodologies in the maritime
sector such as in CASMET and in EMCIP. It is therefore important to
combine these important elements of already established method-
ologies with the TRACEr taxonomy that is very comprehensive and
detailed in coding the important role of the human errors to ship
accidents.
6. Conclusions
A new method to analyse accidents has been proposed by com-
bining the accident analysis methodology of CASMET with the
Technique for the Retrospective and predictive Analysis of Cogni-
tive Errors (TRACEr) to identify the main task errors, technical
equipment and cognitive domains involved in the accidents.
This approach was used to analyse and code grounding (32 ves-
sels) and collision (32 vessels) accidents. As a consequence of the
type of accidents selected, from the 289 task errors coded 96.5%
were performed on the Bridge and only 3.4% in the Engine Control
Room (ECR) and, therefore, the analysis carried out has only cov-
ered the analysis of bridge task errors.
It was found that the majority of the user failures fall in the task
error category Navigation (28.7%), which is strongly related to the
conduction of the vessel underway, inbounding or out bounding
from a port/channel, if the pilot is on board or not (e.g. Pilotage)
and if the OOW is using instruments (e.g. Satellite Navigation,
Radar Navigation etc.) or not (e.g. Dead-Reckoning). The great
amount of errors related to Supervision of bridge tasks (17.2%)
has shown a fragile bridge environment often influenced nega-
tively by organisational and internal/external environment perfor-
mance shaping factors. The technical equipment involved in the
majority of the accidents is the Radar with 21.7% of the grand total.
With regards to the internal context within which the operators
perform the erroneous acts, the main cognitive domains involved
is Decision Making (43%) suggesting that the operator received
the crucial information necessary to perform the action, processed
it correctly, but came to a wrong conclusion and thus took a wrong
decision. The high percentage of errors falling in this cognitive
domain indicates that the capacity of the crew members to adjust
their performance to a new condition of the system is very low.
Furthermore the main Internal Error Mode (IEM) is No Detection
17.9% (e.g. not paying enough attention to the vessel position,
not identifying a ship in route of collision or an off-route not recog-
nise, etc.) falling in the cognitive domain of Perception, which
implies that often the operators fail to observe the information of
the technical equipment involved (e.g. Echo Sounder, Radar ARPA
alarms, GPS, ECS, etc.) and therefore take actions on wrong
prerequisites.
The analysis of the grounding and collision accidents separately
revealed that errors on Supervision of bridge tasks have a high
incidence on grounding accident and the main instruments/
equipment involved are Paper Charts and the Radar (10.8%).
Moreover the main Cognitive Domain category in groundings is
Decision Making and Perception with the main IEM No detection
and the task errors are mainly affected by organisational and
External/Internal PSFs.
On the other hand collisions typically involve errors in Naviga-
tion tasks that include the use of the Radar and the VHF radio. Task
errors are frequently associated to Decision Making cognitive
domain and linked to the IEMs of Poor decision/planning, and are
often affected by PSF related to Organisational Procedures, Staffing
Characteristics, fatigue and Inadequate training/ instructions.
Acknowledgement
This paper is a contribution to the project CYCLADES (Crew-
Centered Design and Operations of Ships and Ship Systems),
funded partially by the European Commission, through the con-
tract n FP7-SST-2012-RTD-1 313972.
References
Akhtar, M.J., Utne, I.B., 2014. Human fatigues effect on the risk of maritime
groundings a Bayesian Network modelling approach. Saf. Sci. 62, 427440.
Anto, P., Guedes Soares, C., 2002. Organisation of Databases of Accident Data. In:
Risk Analysis III. WitPress, Southampton, Boston, UK, pp. 395403.
Anto, P., Teixeira, A.P., Guedes Soares, C., 2014. Integration of human factors into
the ship design process. In: Guedes Soares, C., Lopez Pena, F. (Eds.),
Developments in Maritime Transportation and Exploitation of Sea Resources.
Taylor & Francis Group, London, UK, pp. 443452.
Asami, M., Kaneko, F., 2013. Development of vessel collision model based on
Naturalistic Decision Making model. In: Amdahl, J., Ehlers, S., Leira, B.J. (Eds.),
Collision and Grounding of Ships and Offshore Structures. Taylor & Francis &
Group, London, UK, pp. 4956.
Caridis, P., 1999. Casualty analysis methodology for maritime operations. Final
report of the European Research project CASMET, 4th RTD Framework
Programme, Project no. WA-97-SC.2085.
Chen, S.-T., Wall, A., Davies, P., Yang, Z., Wang, J., Chou, Y.-H., 2013. A Human and
Organisational Factors (HOFs) analysis method for marine casualties using
HFACS-Maritime Accidents (HFACS-MA). Saf. Sci. 60, 105114.
Correia, P., 2010. European Marine Casualty Information Platform a common EU
taxonomy. In: Proceedings of the 5th International Conference on Collision and
Grounding of Ships (ICCGS), Espoo, Finland, June 1416, 2010, pp. 1317.
EC, 2009. Establishing the fundamental principles governing the investigation of
accidents in the maritime transport sector and amending Council Directive
1999/35/EC and Directive 2002/59/EC of the European Parliament and of the
Council, Directive 2009/18/EC of the European Parliament and of the Council of
23 April 2009.
Embrey, D.E., 1986. SHERPA: a systematic human error reduction and prediction
approach. Paper Presented at the International Topical Meeting on Advances in
Human Factors in Nuclear Power Systems. Knoxville, Tennessee.
Endsley, M.R., Jones, D.G., 2004. Designing for Situation Awareness: An Approach to
User-Centred Design, second ed. Taylor & Francis Group, New York.
Graziano, A., Teixeira, A.P., Guedes Soares, C., 2015. Application of TRACEr taxonomy
for the codification of grounding and collision accidents. In: Guedes Soares, C.,
Santos, T.A. (Eds.), Maritime Technology and Engineering. Taylor & Francis
Group, London, UK, pp. 215226.
Guedes Soares, C., Teixeira, A.P., 2001. Risk assessment in maritime transportation.
Reliab. Eng. Syst. Safe. 74, 299309.
Guedes Soares, C., Teixeira, A.P., Anto P., 2000. Accounting for human factors in the
analysis of maritime accidents. In: Cottam, M., Harvey, D., Pape, R., Tait, J. (Eds.),
Foresight and Precaution, Rotterdam, Balkema, pp. 521528.
Guldenmund, F.W., 2000. The nature of safety culture: a review of theory and
research. Saf. Sci. 34, 215257.
Hendrick, K., Benner, L., 1996. Investigating Accident with STEP. CRC Press.
Hofmann, S., Schrder-Hinrichs, J.U., 2013. CyClaDes Task 1.2 Incident and accident
analysis. Document ID Code: CY112.00.02.041.041, WMU.
Hollnagel, E., 1998. Cognitive Reliability and Error Analysis Method (CREAM).
Elsevier Science, Oxford.
Hollnagel, E., 2004. Barriers and Accident Prevention. Ashgate, Hampshire/
Burlington.
Hollnagel, E., 2005. Human reliability assessment in context. Nucl. Eng. Technol. 37
(2), 159166.
Hollnagel, E., 2014. Safety-I and Safety-II: The Past and Future of Safety
Management. Farnham, UK, Ashgate.
IMO, 1999. Guidelines for Voyage Planning, Resolution A.893(21), International
Maritime Organization.
IMO, 2006. Adoption for the revised performance standards for Electronic
Chart Display Systems ECDIS, Resolution MSC.232(82), International Maritime
Organization.
 A. Graziano et al. / Safety Science 86 (2016) 245257
IMO, 2009. Adoption of amendments to the International Convention for the Safety
of Life at Sea, 1974, as amend, Resolution MSC.282(86). International Maritime
Organization.
ISO, 2003. Ships and marine technology ECS databases Content, quality,
updating and testing, ISO 19379:2003, International Organization for
Standardization.
Kaneko, F., 2013. An improvement on a method for estimating number of collision
candidates between ships. Collision and Grounding of Ships and Offshore
Structures. Taylor & Francis Group, pp. 2737.
Kirwan, B., 1994. A Guide to Practical Human Reliability Assessment. Taylor &
Francis, London.
Kontogiannis, T., Malakis, S., 2009. A proactive approach to human error detection
and identification in aviation and air traffic control. Saf. Sci. 47 (5), 693706.
Kristiansen, S., Koster, E., Schmidt, W.F., Olofsson, M., Guedes Soares, C., Caridis, P.,
1999. A new methodology for marine casualty analysis accounting for human
and organisational factors. In: Proceedings of the International Conference on
Learning from Marine Incidents, London, 2021 October 1999, paper 14, pp. 1
14 (RA).
Kum, S., Sahin, B., 2015. A root cause analysis for Arctic Marine accidents from 1993
to 2011. Saf. Sci. 74, 206220.
Lutzhoft, M.H., Dekker, S.W.A., 2002. On your watch: automation on the bridge. J.
Navigat. 55 (1), 8396.
Mazaheri, A., Montewka, J., Kujala, P., 2013. Modeling the risk of ship groundinga
literature review from a risk management perspective. WMU J. Marit. Affairs
269297. http://dx.doi.org/10.1007/s13437-013-0056-3.
Mazaheri, A., Montewka, J., Nisula, J., Kujala, P., 2015. Usability of accident and
incident reports for evidence-based risk modeling a case study on ship
grounding reports. Saf. Sci. 76, 202214.
Okstad, E., Jersin, E., Tinmannsvik, R.K., 2012. Accident investigation in the
Norwegian petroleum industry common features and future challenges. Saf.
Sci. 50 (6), 14081414.
257
Pedersen, P.T., 2010. Review and application of ship collision and grounding
analysis procedures. Mar. Struct. 23, 241262.
Reason, J., 1990. Human Error. Cambridge University Press, Cambridge.
Schrder-Hinrichs, J.U., Hollnagel, E., Baldauf, M., 2012. From Titanic to Costa
Concordia a century of lessons not learned. WMU J. Marit. Affairs 11, 151167.
Schrder-Hinrichs, J.U., Hollnagel, E., Baldauf, M., Hofmann, S., Kataria, A., 2013.
Maritime Human factors and IMO. Marit. Policy Manage.: the flagship journal of
international shipping and port research 40 (3), 243260.
Shappell, S.A., Wiegmann, D.A., 1997. A human error approach to accident
investigation: the taxonomy of unsafe operations. Int. J. Aviat. Psychol. 7 (4),
269291.
Shappell, S.A., Wiegmann, D.A., 2000. The Human Factors Analysis and Classification
SystemHFACS (No. DOT/FAA/AM-00/7). FAA Civil Aeromedical Institute,
Oklahoma City.
Shorrock, S.T., Kirwan, B., 2002. Development and application of a human error
identification tool for air traffic control. Appl. Ergon. 33, 319336.
Shorrock, S.T., 2005. Errors of memory in air traffic control. Saf. Sci. 43 (8), 571588.
Shorrock, S.T., 2007. Errors of perception in air traffic control. Saf. Sci. 45 (8), 890
904.
Stanton, N.A., Chambers, P.R.G., Piggott, J., 2001. Situational awareness and safety.
Saf. Sci. 39 (3), 189204.
Steen, R., Aven, T., 2011. A risk perspective suitable for resilience engineering. Saf.
Sci. 49 (2), 292297.
Strauch, B., 2015. Can we examine safety culture in accident investigations, or
should we? Saf. Sci. 77, 102111.
Wickens, C.D., 1992. Engineering Psychology and Human Performance, second ed.
Harper Collins, New York.