Human Factors in Maritime Accidents and Claims – What Marine Underwriters Must Look For Capt. Tim Wilson

Why are human factors important to underwriters?

• Human Factors are the most significant cause of loss

• Risk is significantly influenced by the effectiveness of human factor management by operators

• The extent to which losses arise from human factor issues that go to potential unseaworthiness and illegality may be seriously underestimated

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• Accident video

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Genuine Fortuitous Human Factor Incidents:

Crew Error

• may be one off or more systemic

• happens despite high competence/effective management

• to err is human - even for the competent

Should be reducing through effective Safety Management Systems and the introduction of Resource Management

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• Deficient level of knowledge, capability or skill

• Test is against the prudent & competent peer

• Can arise from: • Inadequate training

• Inadequate induction and information

• Inadequate professional upskilling

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Crew Incompetence

Crew Certification

• Minimum international requirements:

IMO’s STCW Convention and Code

• often vague

• often blatantly ignored by even highly regarded states

• mechanisms to ensure international consistency are ineffective

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Current STCW Certification does not necessarily equal competence!

STCW Requirements

Column 1 Column 2 Column 3 Column 4 Competence Knowledge, understanding and proficiency Methods of demonstrating

competence Criteria for evaluating competence

Manoeuvre and handle a ship in all conditions

Manoeuvring and handling a ship in all conditions, including:

1. manoeuvres when approaching pilot stations and embarking or disembarking pilots, with due regard to weather, tide, headreach and stopping distances

2. handling ship in rivers, estuaries and restricted waters, having regard to the effects of current, wind and restricted water on helm response

3. application of constant rate of turn techniques 4. manoeuvring in shallow water, including the reduction in under keel clearance

caused by squat, rolling or pitching 5. interaction between passing ships and between own ship and nearby banks 6. berthing and unberthing under various conditions of wind, tide and current

with and without tugs 7. ship and tug interaction 8. use of propulsion and manoeuvring systems 9. choice of anchorage; anchoring with one or two anchors in limited anchorages

and factors involved in determining the length of anchor cable to be used 10. dragging anchor; clearing fouled anchors 11. dry-docking, both with and without damage 12. management and handling of ships in heavy weather, including assisting a ship

or aircraft in distress; towing operations; means of keeping an unmanageable ship out of trough of the sea, lessening drift and use of oil

13. precautions in manoeuvring to launch rescue boats or survival craft in weather 14. methods of taking on board survivors from rescue boats and survival craft 15. ability to determine the manoeuvring and propulsion characteristics of

common types of ships, with special reference to stopping distances and turning circles at various draughts and speeds

16. importance of navigating at reduced speed to avoid damage caused by own ship’s bow wave and stern wave

17. practical measures to be taken when navigating in or near ice or in conditions of ice accumulation on board

18. use of, and manoeuvring in and near, traffic separation schemes and in vessel service (VTS) areas

Examination and assessment of evidence obtained from one or more of the following

1. approved in-service experience 2. approved simulator training,

where appropriate 3. approved manned scale ship

model, where appropriate

All decisions concerning berthing and anchoring are based on a proper assessment of the ships manoeuvring and engine characteristics and the forces to be expected while berthed alongside or lying at anchor While under way, a full assessment is made of possible effects of shallow and restricted waters, ice, banks, tidal conditions, passing ships and own ship’s bow and stern wave so that the ship can be safely manoeuvred under various conditions of loading and weather

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Assessment

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Percentage of Masters who can do this?

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Training Standards

• Highly variable capability and standards • Relatively few centres of excellence

• Inadequate investment in teaching and infrastructure

• Highly variable quality of teachers

• Often held back by regulators

• Often compliance rather than competency driven

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Fatigue

• Fatigue is a major issue • MAIB: 82% of night time groundings due to fatigue

• Swedish Study: 72% of officers admitted to having slept

• Project Horizon: 45% of officers slept on watch

• Driven by 24 hr operations + management duties

• Compounded by manning levels

• Many ships well outside legal rest hours • 6 on/6 off/OMBO

• Falsification of records

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Systemic Mismanagement

• Systemic failure to follow normally accepted practice

• Should be prevented by ISM

• Often easily discoverable by those interested

• Traditionally the role of the marine superintendent

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Recognising Risk

Insurers could be more proactive in differentiating risk and applying pressure for improvements in training, certification and vessel operation, particularly the effectiveness of safety

management systems

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Risk: Possible Indicators

• Crew competence • Determined by quality of training institute and operator

• Certification/Nationality not a reliable proxy

• Crew manning levels

• Effectiveness of ISM

• Marine Superintendent and/or practice auditing

• Relationship between assured/manager

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Seaworthiness:

Reasonably fit in all respects to encounter the perils of the sea? • Many human factors issues are systemic

• Many vessels are technically unseaworthy because of crewing and management issues

Current insurance and commercial practice protects poor operators and removes incentives to improve ship operations:

• Assured vs Shipmanager

• Privity requirements in time policies: the Star Sea

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Conclusion

• Shipping has serious systemic human factor issues

• Human factors are a key risk factor for insurers

• Insurers could more to assist in improving standards

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