Human Error Investigation

Trika Pitana
Dept. of Marine Engineering
Institut Teknologi Sepuluh Nopember (ITS), Surabaya
2018
 Outline
• Steps of Human Error Investigation
• SHEL Model
• Reason Model
• GEMS Framework
• Conclusion
 Human Element Investigation
1. Collect occurrence data,
2. Determine occurrence sequence,
3. Identify unsafe acts (decisions) and
unsafe conditions;
And then for each unsafe act (decision):
4. Identify the error type and violation,
5. Identify underlying factors,
6. Identify potential safety problems and
develop safety actions.
 Collect Occurrence Data
• Investigation any works related to
environment, personnels, task and
equipment
• Tool: SHEL(Software-Hardware-
Environment-Liveware) Model
 SHEL Model
• Focusing human element contribution to
marine casualties.
 Liveware
• L = human being who is related to accident
Interaction of person subject to an accident
investigation
• Human element is mainly influenced by
individual factors:
– Physical (kondisi fisik)
– Physiological (fungsi alat-alat tubuh): Any
factors that could affect the physiological
abilities of a person should be investigated. This
could include such factors as health, stress,
lifestyle, fatigue, alcohol/drug consumption and
incapacitation.
– Psychological (mental status)
– Psychosocial(hub sosial)
 Hardware
• Hardware refers to the
equipment used in the
transportation process. It
refers to ergonomic aspects
of workstations, displays etc.,
too.
Environment
• Environment includes the
internal and external climate,
temperature, visibility,
vibration, noise and other
factors which constitute the
conditions within people are
working.
 Software
• Software is the non-physical
part of the system including
organizational policies,
procedures, manuals,
checklist layout, charts,
maps, advisories and
computer programs.
• All this material should be
part of the ISM system.
Interrelation SHEL Component
• This field covers human interactions and
communication breakdown between individuals by
consideration of the following aspects:
– Oral communications (misinterpretations,
misunderstandings, improper languageusage)
– Crew interaction (crew compatibility in terms of
personality, knowledge,experience etc.)
– Work management factors (Hierarchy, Bridge Team
Management)
– Supervision (Controlling)
– Regulatory requirements (encourage to “bend rules”)
– Some failures occurred during these interactions are
easy to identify if written procedures, reports, records
etc. or even tapes are available. Some of them can
be identified through
– carefully interviewing only.
Liveware-Hardware
• This area refers to human-machine
interaction. Any design limitations and
peculiarities in workstation
configuration should be considered.
Furthermore workspace factors, such
as space, noise, illumination etc.
can affect the performance of the
system and should be investigated
therefore. Apart from this correct
usage of available equipment as well
as proper functioning should be
inquired.
Software-Liveware
• These interactions refer to the information
transfer between the human and supporting
systems. These factors are usually easy to
trace, due to the fact that they can be found in
the written parts of the ISM system. Special
reference is made to checklists, standing
orders and manuals. In recent years
computerisation was introduced in shipping,
too. Therefore the proper usage of
computer programmes should be
investigated, too. Furthermore special
consideration is given towards the proper
certification of the system. This means the
operators (officers and crew) need to be
certified according to their duties and the ISM
system, equipment, programmes etc. should
be type-approved if required in the
international conventions.
Liveware-Environment
• As already mentioned the
environment is divided into three
parts:
– Internal – climate, personal comfort,
physical working conditions
– External – weather
– Infrastructure or supporting services
– contributes to reducing safety or
limited choice of actions (restricted
water depth, limited navigability of
waters etc.)
Determine Occurrence Sequence
 Decision Maker
• Decision makers set the goals for the system
as a whole according to the input from the
environment (market, political conditions etc.).
They specify on how these goals should be met.
They even allocate the necessary resources for
this purpose to the line management (money,
equipment, people, time etc.). Special
consideration is given to optimise the use of
resources in order to achieve a maximum
outcome of the production process.
 Line Management
• Line management refers to specialists in
the different departments that implement
the strategic goals of the decision makers
within their specific spheres of operation.
For shipping business this could mean –
Head of the operations department,
Supervisors of the fleet, Head of the
crewing area. On board a ship line
management applies to the master.
 Pre Condition
• Apart from decision makers and line management a
reliable, motivated and knowledgeable workforce and
suitable equipment is necessary to start and to maintain
a production process. This includes work schedules,
maintenance programmes, as well as environmental
conditions, such as training, motivation etc. in order
to permit efficient and safe working. This is a very wide
spread area on board ships. Apart from technical
aspects of equipment special consideration needs to
given to the crew. Structure, origin (number ofdifferent
nationalities) etc. should be considered. Furthermore it
should be observed whether the shipping company or a
crewing agency has recruited the crew.
 Productive Activities
• The productive activities concentrate on
the actual performances of the humans
and the machines. This means for
shipping that all process started from
loading and unloading up to navigation
and maintenance should be included.
 Defences
• Production can always cause risks. Ships may cause
accidents which could lead to damage of human life, as
well as to environmental disasters. Therefore appropriate
measures should be taken in advance to reduce this risk.
Some of them are required by the international
conventions (basic standards for equipment,
maintenance, manning of ships, training of crews
etc.), some of them have been identified by the
shipping companies themselves, e.g. during ISM
implementation etc. A simple example for such
defences is a lookout during nighttime to assist the
watch officer.
The Human Element accident
Causation
GEMS
Collecting Evidence

VIDEO
 Assignment
• Please find out one of marine accident in
Indonesia.
• Analysis the causes of marine accident in
Indonesia by using SHELL Model
• Please submit the report within a week
(due date: May 28, 2018)
• Please make a group (member = 2
persons for each group)
 Format
• Times new roman
• Space 1.5
• A piece of paper = 2 pages
• Margin = 3 cm for all
• Cover
• Font 12
 References:
• Schroede, J.W(2003), Marine Casualtie Investigation
Hand Out
 Conclusion
• You have known the principle of human
element investigation