Human Factors Accident Classification System - Coursework Example

Running Header: Human Factors and Risk Management Student’s Name: Instructor’s Name: Course Name & Code: Date of Submission: Table of Contents Table of Contents 2 Introduction 3 Human Factors Accident Classification System (HFACS) and Attilio Levoli 4 Vessel specifications 4 Accident Scenario 4 Accident Causation 6 Human Factors Accident Classification Scheme (HFACS) 7 Unsafe Acts 7 Pre-conditions for Unsafe Acts 8 Unsafe supervision 9 Organizational influences 9 A HFACS classification for the Atilio Levoli 10 Lessons and results of HFACS classification 11 Conclusion 12 Works Cited 13 Introduction This report explains Atilio Levoli accident that occurred on Lymington Banks in the West Solent South Coast of England in June 3, 2004. The vessel was on its way to Barcelona when the accident took place. This is when double hulled chemical tanker Attilio Levoli ran aground. This made the vessel to suffer bottom plate indentation forward with no hull penetration. There was nobody on the board that was injured and no pollution that occurred. Various Accident causation models have evolved and changed with time. Various earliest models focused on individual accident –proneness without incorporating extra-personal factors. One such early theory includes Heinrich’s original domino theory of accident modeling. Other theories are P-theory according to Benner and Swiss-Cheese model of Accident Causation by Reason. The later has revolutionized common views of accident causation. This has led to development of other schemes like Human Factors Accident Classification Scheme (HFACS). HFACS was developed originally from data from military (U.S. Air Force Safety Center and U.S. Army Safety Center) and civilian organizations (Federal Aviation Administration and National Transportation Safety Board). They are various levels of HFACS that include Unsafe Acts, Pre-Conditions for Unsafe Acts, Organizational Influences, and Unsafe Supervision that follow from Reason’s (1997) layers of ‘Swiss-cheese’. The key purpose of investigating the accident is to determine the causes as well as circumstances in order to improve life safety at sea as well as avoid the occurrence of such accidents in future. Human Factors Accident Classification System (HFACS) and Attilio Levoli Vessel specifications Attilio Levoli was the oil/chemical, IMO Type II tanker made in 1995 at Ancona, Italy. It has no cargo tank that is in contact with the outer shell plating, it has a J shaped ballast tanks surrounding the cargo tanks. It was operated and owned by Marnavi S.p.A. which is an Italian company. Her classification society is Registro Italiano Navale and Bureau Veritas which is a dual classification. She was registered in Italy and manned by 16 crews of various nationalities with its port of registry being Naples. The 16 crews included Italians, a Russian chief officer and Ukrainian second officer, fitter, and first engineer. Her compliment included one engineer cadet and one deck cadet. Attilio Ievoli was made of steel with overall length of 115.5m, as load draft of 6.5m aft and gross tonnage of 4450. It has oil type engine geared drive to a single screw with service speed of 14 knots. It has bow thruster with controllable propeller. The vessel operated between North European and Mediterranean ports (Great Britain, Marine Accident Investigation Branch & Great Britain, Dept for Transport 23). Accident Scenario Attilio Ievoli accident occurred on 3 June, 2004 at 1632 (UTC+1). It occurred at Lymington Banks, West Solent 50° 43.’5N 001°30.’7W. There were 16 persons on board with no injuries or fatalities. There was 1 metre square indentation with approximate 4 meters inboard form the forward end of the port side bilge keel. It had an extensive scoring of the bottom paintwork. Attilio Levoli left for Rotterdam from Antwerp on 28 May 2004 and onwards to Southampton. She arrived through eastern Solent and anchored at 0645 on June 2 morning to await a berth at Fawley Marine Terminal. At 1540, the pilot boarded the vessel which berthed at1730 at Fawley. Fawley Terminal safety officer and cargo surveyor boarded the vessel at 1805 with inspections cargo and vessel being completed at 2000. At 1445, the pilot boarded the vessel and discussed the departure plan with the master. According to pilot, he expected Attilo Levoli to depart through the East Solent, however, he was advised by the master that he had planned to use west Solent route which was shorter with the next port being Barcelona. Second officer returned to the bridge after moving the flag where he fixed a position on the chart at 1600. After sometime, the master instructed the second officer to take down the second officer to take the pilot flag down. Another position was fixed by second officer on the chart at 1610 as the vessel was abeam of the West Lepe buoy. He informed the master that the vessel was on the planned track northern part. However, the master did not hear this report. Another position at 1610 was plotted by the cadet; this placed Attilio Levoli on the track. The 1610 position of the second officer was rubbed off the chart perhaps after being mistaken for a position plotted during the last visit by the vessel. The second officer on returning to the bridge looked at the chart and mentioned to the cadet that the 1610 position was incorrect. Another position at 1618 was also plotted on the chart being used placing the vessel on the track. However, nobody remembered who plotted it. On passing Yarnouth at 1631, the master reported his position to Southampton VTS. Attilio Levoli started to vibrate after sometimes and the engine begun to labor. The chief engineer left the bridge and went to engine room while the master noted that Hurst point Castle was on his port bow. This made him to change to manual steering from automatic in order to put the helm to port; however, this did not have any effect on because the vessel was already aground on the banks of Lymington that is 0.5 mile north of the planned track. After sometimes, Southampton VTS assisted after being called and they informed Solent Coastguard. This made the coastguard emergency action plans to be activated. Attilio levoli refloated at 1805 and moved on with no assistance and at 1920 she anchored between Yarmouth and Hampstead. This allowed divers and other inspectors give a clearance (International Maritime Satellite Organization 45). Accident Causation The earliest models focused on individual ‘accident-proneness’ without incorporating extra-personal factors. It concentrated on individual factors like personality without being supported effectively by scientific evidence. There was no accident causation that was complete without referring to the accident modeling Heinrich’s original domino theory. Causation was described in a linear way in the original domino theory where one domino hits another and finally the causes of the accident. It was proposed by Heinrich that injury (5th domino) is essentially caused by an accident (4th domino). He went ahead to propose that the accident is caused by unsafe acts/conditions (3rd domino) that is caused by a person (2nd domino). The 2nd domino according to Heinrich is influenced by the social environment (1st domino). It was concluded that removal of one of them may result the accident from taking place. The versions of this model that were updated clarified the initial phases of the domino theory; this included lack of control by the management. It included job related factors in the personal domino (Wiegmann & Shappel 2). More dynamic, non-linear, and complex approach to accident causation was suggested by the theories that followed. In 1970s, Benner was one of the strongest advocates for a perspective on accident causation that was more sophisticated. According to his Multi-linear Events Sequencing Method, Benner concluded that accidents can be understood as a combination of actions by factors like technology, people, and objects among others. This model is based on a process theory referred to as P-theory; it states that an imbalance caused by initial events in the system starts a chain of events which eventually leads to the accident. The model of accident causation has evolved to Swiss cheese model by Reason. This model has revolutionized the common views of accident causation. According to Reason’s model of accident causation, they are four levels of human failure that influence each other. According to this model, active failures are not considered to exist in isolation from preconditions for organization influences, unsafe supervision or unsafe acts. Holes in the cheese or absent defenses of the safety management system in the model allow for an accident trajectory to move to a point whereby there is property loss or even injury. The causal factors at all the levels require to be addressed within the organization in order for an accident prevention and investigation to be successful. The “Swiss cheese” model of human error causation has organizational influences, unsafe supervision, preconditions for unsafe acts, and unsafe acts or active failure that eventually lead to mishap (Wiegmann & Shappel 2). Human Factors Accident Classification Scheme (HFACS) Unsafe Acts Human Factors Accident Classification Scheme (HFACS) describes four levels of failure that include unsafe acts, preconditions for unsafe acts, unsafe supervision and organizational influences. They follow from the layers of Swiss-cheese from Reason (1997). Unsafe acts can be caused due to errors or violations. Errors represent physical or mental activities of persons that fail to attain anticipated results. Violation can be referred to as willful ignorance of the regulations and rules that govern the flight safety. Errors are further classified into skill-based, perpetual, and decision errors while violations include exceptional and routine errors. Skilled based errors are a result of memory or attention failure. This includes losing one’s place or even forgetting to do something. Decision errors can be grouped into procedural errors, problem solving errors, and poor choices. Decision errors usually take place when wrong procedures are followed or when a decision is misdiagnosed or not recognized. Failure to understand a problem or lack of response options or formal procedures also results to an error. Routine violations are naturally habitual and are usually tolerated by the authorities. Exceptional violations usually appear as isolated departures from authority rather than an indication of individual typical behavior. They are usually not condoned by management or authority (Reason 42). Pre-conditions for Unsafe Acts There is need to identify underlying conditions that cause unsafe acts. These may be classified as substandard conditions of operators and substandard practices they do. Substandard conditions of operator adverse mental conditions were created in order to account for those conditions which affect performance. Sub-standards conditions of operators can further be divided into adverse mental states, adverse physiological states, and physical/mental limitations. Adverse physiological states are those conditions of physiological or medical conditions which preclude safe operations. Physical fatigue, medical abnormalities and myriad of pharmacological are known to affect the performance. Physical/mental limitations are the occasions when the mission requirements are beyond individual capability to control them. Substandard practices of operators can as well be categorized into personal readiness and crew resource mismanagement. Crew resource management involves good communication skills as well as team coordination which have been mantra of personnel psychology for decades. According to Personal readiness, individuals are expected to show up while being ready to perform at optimal levels. Personal readiness occurs when individuals fail to prepare mentally or physically for the duty (Reason 769). Unsafe supervision There are four categories of unsafe conditions that include supervisory violations, failure to correct a known problem, planned inappropriate operations, and inadequate supervision. Inadequate supervision occurs when the supervisor fails to provide a chance of succeeding. Avoiding inadequate supervision requires supervisor to provide leadership opportunities, motivation, training opportunities and guidance. Planned inappropriate operations in most instances leads to jeopardize of crew rest and eventually affecting the performance. Although those conditions are unacceptable during normal operations, they are unavoidable during emergencies. Failure to correct a known problem refers to deficiencies among the individuals, training and equipment that are allowed to continue unabated. Supervisory violations are occurs when supervisors willfully disregards rules and regulations. Failure to enforce regulations and rules that exist is also regarded as violations at the supervisory level. Organizational influences Upper-level management affects directly the supervisory practices as well as operator’s actions and conditions. Such influences revolve around resource management, operational processes, and organizational climate. Resource management comprises of realm of corporate-level decision that regards allocation as well as maintenance of assets by the organization such as monetary, human resources, and facilities. The two main objectives of resource management are safety, on-time, and cost effective operations. Climate refers to various organizational variables that influence the performance of workers. The policies and culture of the organization is a good indicator of climate. Operational process is the corporate decisions as well as rules that govern organization’s activities. It also includes use and establishment of standardized operating procedures for maintaining checks and balances (Fields 54). A HFACS classification for the Atilio Levoli Fatigue was not an issue in the Atilio Levoli accident. The master in Attilio Levoli was not involved in the cargo work within the port and he had benefited from a rest the whole night. The second officer had also rested although he had a slight risk fatigue rating according to Fatigue Analysis tool. The cadet has also rested as he maintained his 4 on, 8 off, sea watch routine within the port. Human factors failures started with the decision by the master to use the west Solent although he knew it was contrary to instructions in the Company. Visibility and sea conditions were good and it was possible for 4-hour saving of steaming time. This is through the use of western passage other than eastern passage. The crew members did not appear to have clear information of their roles and responsibilities and that of their own at the time of pilot departure at 1600. There was no coordination of task performance hence little overtime management as well as supervision. The overall result was that there was no shared appreciation of Attilio Levoli’s position by the bridge team at the time of grounding. Culture on had different attitudes to the hierarchy importance. Second officer was reluctant to question the competence or authority by the master. Lack of accurate positional awareness and poor management of team contributed to the failure. On the bridge team management, there was no briefing that took place with assumptions that the jobs to be done were known. Cadet and second officer did not know who was responsible of fixing positions on the chart. Furthermore, the master had not clarified. The second officer was not able to concentrate on vessel’s position monitoring as he was used to more menial tasks like taking down the pilot flag. This responsible was supposed to taken by the cadet. The cadet assumed the vessel was on track when he was plotting positions on the chart. However, this did not confirm her positions as a minimum of two lines are required other than one line that was in use. Procedures were not used as the two radars available to bridge team were not used correctly. Although the port radar was fully operational, it was not in use as chief engineer was sitting in front of it checking Ums alarms as well as performing his voyage and fuel consumption calculations. Lessons and results of HFACS classification It is crucial that workers in all areas of operations to receive training and where necessary refresher training so as to improve their performance and reduce any risks occurrences. All internal procedures should be put in place and verified so as to comply with the instructions of the company. Social and cultural issues should be considered when appointing and training workers or crews. This will assist in the improvement of capability and effectiveness of various teams. There is also need of improving team work standards in order to reduce the chances of failure that may occur. Communication and cultural differences should as well be put into consideration in order to minimize the effects it may have on the performance of the organization. The workers and operators should be trained on the importance of good operation of their machines in order to ensure that there are no hindrances or incorrect operations that might cause accidents or undesired consequences. Conclusion Atilio Levoli accident occurred mainly because of the ignorance of various crucial aspects that could have assisted in prevention of the accident. The accident occurred on Lymington Banks in the West Solent South Coast of England in June 3, 2004. Accident causation models have evolved and changed with time. Various earliest models focused on individual accident –proneness without incorporating extra-personal factors. One such early theory includes Heinrich’s original domino theory of accident modeling. Other theories included P-theory according to Benner and Swiss-Cheese model of Accident Causation by Reason. They are four levels of failure that include unsafe acts, preconditions for unsafe acts, unsafe supervision and organizational influences which are described by Human Factors Accident Classification Scheme (HFACS). Atilio Levoli accident can be analyzed using four levels of failures including unsafe acts, unsafe supervision, organizational influences, and pre-conditions for unsafe acts. Eliminating and improving these failure levels will ensure that the accident does not take place or its occurrence is minimal. Works Cited Fields, D.L. Taking the Measure of Work. Thousand Oaks, California: Sage Publications, 2002. Great Britain, Marine Accident Investigation Branch & Great Britain, Dept for Transport. Report on the investigation of the grounding of the Italian registered chemical tanker Attilio Levoli on Lymington Banks in the west Solent, South Coast of England, 3 June 2004. London: Marine Accident Investigation Branch, 2005. International Maritime Satellite Organization. Lloyd’s maritime directory, volume 1. London: Lloyd’s of London Press, 2007. Reason, J. Managing the risks of organizational accidents. Aldershot, England: Ashgate, 1997. Reason, J. “Human error: models and management”. British Medical Journal, 320.2 (2000): 768- 770. Reason, J. “Combating omission errors through task analysis and good reminders”. Quality and Safety in Health Care, 11.3 (2002): 40-44. Wiegmann, D. & Shappel, S. A human error approach to aviation accident analysis: the human factors analysis and classification system. England: Ashgate Publishing, Ltd, 2003. Read More