Human Factors and Safety Culture in Maritime Safety (Revised)
Human Factors and Safety Culture in Maritime Safety (Revised)
Human Factors and Safety Culture in Maritime Safety (Revised)
DOI: 10.12716/1001.07.03.04
ABSTRACT: As in every industry at risk, the human and organizational factors constitute the main stakes for
maritime safety. Furthermore, several events at sea have been used to develop appropriate risk models. The
investigation on maritime accidents is, nowadays, a very important tool to identify the problems related to
human factor and can support accident prevention and the improvement of maritime safety. Part of this
investigation should in future also be near misses. Operation of ships is full of regulations, instructions and
guidelines also addressing human factors and safety culture to enhance safety. However, even though the roots
of a safety culture have been established, there are still serious barriers to the breakthrough of the safety
management. One of the most common deficiencies in the case of maritime transport is the respective
monitoring and documentation usually lacking of adequacy and excellence. Nonetheless, the maritime area can
be exemplified from other industries where activities are ongoing to foster and enhance safety culture.
1 INTRODUCTION investigation of this accident, the initial emphasis was
focussed on plant deficiencies.
The strengthening of safety culture in an organization However, more thorough analyses also identified
has become an increasingly important issue for all organizational, cultural, and managerial issues and
high risk industries. A high level of safety showed a lack of an adequate safety culture.
performance is essential for business success in
intensely competitive global environment. The most In the nuclear industry, international
important objective is to protect individuals, society organizations such as the International Atomic
and the environment by establishing and maintaining Energy Agency (IAEA) recognized the important role
an effective protection against the respective hazards. that all regulators should play in monitoring safety
performance in the nuclear industry. Following the
This is achieved through the use of reliable Chernobyl accident, the IAEA published two guides
structures, systems and components as well as on safety culture (IAEA 1991 and 2002).
adequate clear procedures, and acting people which
are committed to a strong safety culture. More recently, the IAEA developed the following
definition for safety culture (IAEA 2006): “The
The term ‘safety cultureʹ first appeared in the assembly of characteristics and attitudes in
International Atomic Energy Agencyʹs initial report organizations and individuals which establishes that,
following the Chernobyl disaster. In the early as an overriding priority, protection and safety issues
receive the attention warranted by their significance.”
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According to (IAEA 2009), safety culture should be safety performance indicators (analyzing data on
based on a set of safety ‘beliefs’ (assumptions) and on indicators such as the number of safety tours
a code of conduct that reflects the right attitude to performed or near miss data).
safety which is held in common by all individuals in
the organization. Ultimately, the safety culture is Such a questionnaire which is often used as a first
manifested in individual and collective behaviour in step has to be carefully developed for the respective
the organization. needs and area. In the nuclear field, a so‐called IAEA
safety culture perceptions questionnaire has been
In the meantime, inquiries into many major elaborated with 132 questions in this survey. The
accidents such as the Kingʹs Cross fire, Piper Alpha purpose of this survey is to refine the current pilot
and the Herald of Free Enterprise and more recently version of the IAEA safety culture perceptions
the accidents in the Mexican Gulf (Deepwater questionnaire for future use in conducting safety
Horizon blow‐out) in 2010 have found faults in the culture assessments in the nuclear industry. This will
organisational structures, safety management systems be the topic of a meeting in August 2013 with invited
and the prevailing cultures, throwing the importance experts.
of safety culture into the spotlight.
An explorative study of Swedish masters’
The most recent event in the nuclear industry was perception of the concept of maritime safety including
in March 2011 when a magnitude 9.0 earthquake off safety culture is provided in (Mauritzson 2011).
the coast of Japan and the resulting tsunami caused
extensive damage at the Fukushima Daiichi nuclear In Finland, a maritime transport strategy is under
power plant. A full understanding has yet to emerge preparation, where also the safeguarding and
of what Japanese authorities and the nuclear industry development of the expertise in maritime industries,
have learned about safety culture implications at the in particular from the viewpoint of maritime safety
Daiichi plant, as facility and equipment damage from culture (Ministry of Transport and Communications
the earthquake and resulting tsunami has been the 2013).
initial focus of event studies. As with all major events, A safety culture assessment allows an organisation
getting to the underlying safety culture issues to better understand how its people perceive safety
requires more time and further analysis before all root and the companyʹs approach to safety
causes can be identified, but a recent report by the management. It allows the organisation to identify
Japanese Government strongly points to safety both strengths and weaknesses that then enable it to
culture issues (NAIIC 2012). continuously monitor and improve its approach to
Furthermore, an international experts’ meeting in safety.
May 2013 on human and organizational factors in As in every industry at risk, the human and
nuclear safety in the light of the Fukushima accident organizational factors constitute the main stakes for
recommended to strengthen human including maritime safety. Furthermore, several events at sea
organizational aspects and to improve the synergy have been used to develop appropriate risk models
between technology and human factors (e.g., Ryser (Chauvin 2011). Operation of ships is full of
2013). Moreover, a safety culture training course has regulations, instructions and guidelines also
been described with the main goal to develop addressing human factors and safety culture to
awareness of the importance of each individual’s enhance safety. However, management ashore and on
personal contribution to safety culture improvement board need not only to ensure that the formal skills
among workers and managers (Rusconi 2013). are in place but also ensure, encourage and inspire the
Although there is a wealth of information, articles necessary attitudes to achieve the safety objectives.
and reports relating to safety culture, there is still no
universal definition or model. Safety culture has been
defined in a variety of ways including (Berg 2011):
2 HUMAN FACTORS IN MARITIME SAFETY
The ideas and beliefs that all members of the
organisation share about risk, accidents, and ill‐ 2.1 Role of human factors
health,
A set of attitudes, beliefs or norms, Regulations and systems have not achieved the
A constructed system of meaning through which desired effects in averting marine accidents which are
the hazards of the world are understood, a result of human errors and account for 80% of those
A safety ethic. occurring worldwide.
The assessment of safety culture is key to Studies have shown (Rothblum 2000) that human
identifying a companies current level of safety culture error contributes to:
(known as its maturity or development level) in order 84‐88% of tanker accidents,
to identify how to learn and improve. There are a 79% of towing vessel groundings,
number of different assessment methods including: 89‐96% of collisions,
safety attitude surveys (using questionnaire to 75% of fires and explosions.
elicit workforce attitudes), These estimations are still valid. Thus, the
safety management audits (using an audit process maritime transport system is 25 times riskier than the
and trained auditor to examine the presence and air transport system according to the accounts for
effectiveness of safety management systems) deaths for every 100 km. Intensification of sea trade
safety culture workshops (involving a cross‐ for last ten years causes the increasing of potential
section of the workforce to consider perceptions of risk to the ship safety.
the safety culture and elicit improvement ideas)
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The implementation of the International Safety accident risk. The main weakness of this method lies
Management Code (IMO 2008) has played a in the lack or shortage of data related to accidents and
significant role in addressing this issue through incidents on maritime domains.
training and education of crew members but to some
extent casualties can be prevented by eliminating Even though the roots of a safety culture have
other indirect causes including hardware, such as been established, there are still serious barriers to the
equipment systems. breakthrough of the safety management (Lappalainen
& Salmi 2009).
It must be noted that if the possible cause of an
accident is human error, finding and eliminating the The poor reporting practises cause further
root cause of such errors is vital for preventing problems. The information about the non‐
recurrence ‐ whether it is related to human element, conformities, accidents and hazardous occurrences
hardware factors, organizations and management does not cumulate at any level of the maritime
factors. industry. The personnel of the other ships cannot
learn from the experiences of the other vessels. There
However investigation in human factors, main are no possibilities to interchange information about
cause of such accidents, is increased nowadays and incidents between the vessels. The company cannot
the methodologies to carry out such an investigation utilize the cumulative information when improving
are being developed by several institutions. These its safety performance. Companies do not have the
methodologies, adopted from the investigation on opportunity to learn from other companies’ mistakes
risk analysis are frequently based on the estimation of (Lappalainen & Salmi 2009). Under these
risk levels, whose values, in the case of human factor circumstances the national maritime administrations
investigation are not always clear. are powerless in their attempts to further develop the
maritime safety
In any case, a comprehensive risk assessment
consists of: The fundamental philosophy of the IMS Code
(IMO 2008) is the philosophy of continuous
1 Identifying the hazard in the system; improvement. The procedures for reporting the
2 Evaluating the frequency of each type of accident; incidents and performing the corrective actions are
3 Estimating accident consequences; the essential features of the continuous improvement.
4 Calculating various measures of risk, such as If this information is not provided the successful cycle
death or injuries in the system per year, individual of continuous improvement cannot function
risks or frequency of accidents of a particular kind. (Lappalainen & Salmi 2009).
For improvements in operability and working Operation of ships is full of regulations,
environment it is necessary to ensure that the instructions and guidelines which officers and crew
operability is not poor or inconvenient or is are expected to know and adhere to. A culture of
encountering obstacles during operations. Since it safety may perhaps be achieved through written
heightens the risk of an accident, it is important to instructions, but in the end it is a question of a
pay attention to the arrangement and layout of common mind‐set throughout the organisation.
equipment. Hence it is important that operators work Management ashore and on board need not only
in congenial and safe surroundings. ensure that the formal skills are in place but also
It is clear that total safety over ships operation can ensure, encourage and inspire the necessary attitudes
not be achieved, but it is possible to obtain a high to achieve the safety objectives. Statistics prove
degree on it. Research on the influence of human beyond doubt that investing in a good safety culture
factors over maritime accidents is, also, very difficult. provides results and pays off in the long term.
On the one hand we find that an accident involves the The effort of allocating various forms of human
interaction of individuals, equipment and error as verified accident causes is surely not a trivial
environment, as well as unforeseen factors (Caridis, task. Moreover, this difficulty is augmented in the
1999), and on the other hand, human factors comprise case of maritime transport, since the respective
operative human errors –derived from personnel own monitoring and documentation is usually lacking of
qualifications, or from their physical, mental and adequacy and excellence. Nonetheless, marine
personal conditions‐ and situational errors– derived industry can be exemplified from other sectors of
from work environment design, management industry (e.g. civil aviation, nuclear plants), where
problems, or human‐machine interface, amongst considerable load of attention is already given in
others pinpointing and revealing various involved aspects of
Being aware that risk is an inherent factor of human element extracted from comprehensive
maritime activity which can not be totally removed databases of safety relevant events.
and that errors are part of human experience, it is Human behaviour and performance can be the
expected that elements such as good management prevailing factors that prescribe the level of safety for
policies, effective training and having suitable numerous maritime transport procedures and
qualifications and experience, can reduce the practices of management (Martínez de Osés &
occurrence of human errors. Ventikos 2006). This means that they can also
The practical application of this kind of analysis influence, in a considerable degree, the protection of
seems clear: obtaining the cause parameters, both marine and coastal environment. Thus, a feasible way
direct and indirect parameters, from the studied to reduce the frequency and severity of naval
factor, one can better understand the root of the accidents is, by identifying the contributing factors to
presence of such a factor, and one can take specific the so‐called human error, and by investigating for
and direct corrective actions to try to minimize the
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methods, which will either eliminate or mitigate these visibility or heavy traffic) and also constitute
mistakes. supervisory violations. They may reveal some
difficulty for leaders to adapt their instructions to a
Over the last 40 years the shipping industry has changing situation may also reveal a poor safety
focused on improving ship structure and the culture (Chauvin et al. 2013).
reliability of ship systems in order to reduce
casualties and increase efficiency and productivity. Human reliability also influences the overall
Improvements can be seen in hull design, stability system reliability in automatic systems. This influence
systems, propulsion systems, and navigational can both be negative (e.g. human working error) or
equipment. Today’s ship systems are technologically positive (e.g. controlling system breakdowns or
advanced and highly reliable (Rothblum 2000). system problems). Human performance could be
defined as the human beingʹs execution of an action
Therefore, one further important aspect to reduce with the purpose of accomplishing a given task.
marine accidents is the collection and investigation of
near miss data as it is practice in other transport
industries like aviation.
2.2 Example of an accident
Incident and near miss reporting is used as a
proactive tool of safety management in many risk‐ The example provided in the following (Gard 2012)
prone industries. The ISM Code requires shipping deals with the accident grounding. A vessel is under
companies to establish a system for reporting way on an ocean crossing with course set out from
incidents and near misses. However, it has been start to end. The course is set out and the voyage
stated in several studies that incident and near miss planned on a small scale planning chart. The course is
reporting is deficient in the shipping industry. Near set to pass some small groups of mid‐ocean islands
miss reporting has been seen as the failing part of ISM and the CPA (Closest Point of Approach) is
code’s implementation and received resistance from considered and thought to be well on the safe side.
the users (Lappalainen, 2011). On a nice tropical night with calm seas and good
visibility, the vessel makes its approach to pass one
The aim of a recent report is to present experiences group of islands well on the port side some time after
and best practices of incident reporting in order to midnight.
offer information for improvement (Storgård et al.
2012). It is concluded in (Storgårdet al. 2012) that ‐ The chief officer observes during the last two
although some progress has been made in connection hours of his 1600‐2000 hrs watch that a slight breeze
with shared incident reporting systems in the and current are working together to set the vessel
shipping industry in the Baltic Sea area ‐ the sharing slightly off course and towards the islands ahead. He
of experiences and lessons learnt at industry level is therefore makes a correction to the course to
still in its infancy. compensate for the drift and setting to keep the vessel
on its intended course. When handing over the watch
The main objective of another report (Erdoğan at 2000 hrs, the chief officer makes the second officer
2011) was to identify some best practices about near‐ aware of this.
miss reporting from the companies that are active in
Swedish and Finnish shipping industry and believed The second officer continues to plot the positions
to have high level of safety within their organization throughout his watch and observes that the vessel is
The majority of the participants believe that near‐miss still drifting somewhat off course to the effect of
reporting in principle has a significant effect creating making the CPA to the islands ahead less safe than
and enhancing the safety culture. However, the actual planned. He therefore makes some minor course
benefits of the near‐miss reporting are reported as adjustments to compensate for drift and setting. At
being limited. Further, it seems that the companies are midnight the watch is handed over to the first officer,
not yet utilizing the reported data for establishing who is also made aware of the drift and the course
trends to improve the follow‐up and the awareness adjustments. At 0040 hrs the vessel runs aground at
within the organization full speed on the beach of a small low atoll. The beach
is mainly sand and pebbles and slopes at a low angle
Yet, the maritime casualty rate is still high. Why, into the sea so the vessel suffers minor damage but
with all these improvements, was it not possible to can not be re‐floated with its own power. A costly
significantly reduce the risk of accidents? It is because salvage operation follows.
ship structure and system reliability are a relatively
small part of the safety equation. The maritime The human aspect of this accident is discussed in
system is a people system, and human errors figure the following. The positions were plotted in the same
prominently in casualty situations (Rothblum 2000). small scale planning chart covering the entire ocean
where the voyage was planned and the course set out.
A recent analysis (Chauvin et al. 2013) shows that In a small scale chart it is difficult to accurately
most collisions are due to decision errors. At the measure small distances and observe small deviations
precondition level, it high‐lights the importance of the from the course between hourly plots. The reason for
following factors: poor visibility and misuse of using a small scale chart was probably that it was not
instruments (environmental factors), loss of situation considered necessary to conduct ʺmillimetreʺ
awareness or deficit of attention (conditions of navigation when crossing the ocean. The island on
operators), deficits in inter‐ship communications or which the vessel grounded was marked on the chart
Bridge Resource Management (personnel factors). At in use, but only as a small dot and the course was set
the leadership level, the analysis reveals the frequent to pass at what seemed to be a safe distance.
planning of inappropriate operations. In other words,
instructions given to the bridge team were The drift and current, however, worked together
inappropriate, given the situation requirements (poor to set the vessel off course towards the island and it is
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painfully obvious that the corrective actions taken by and when errors are encountered through which it is
the navigation officers were not adequate. possible to react with subsequent changes in practises
before serious incident or accident occurs. Accident
It can be concluded that the grounding would not investigation is part of the maritime safety culture ‐ a
have happened if: reactive one ‐ but an excellent observer point.
a large scale chart had been used for position In the Baltic Sea the maritime traffic is rapidly
plotting since it would then have become apparent growing which leads to a growing risk of maritime
that the course was heading gradually towards the accidents. Particularly in the Gulf of Finland, the high
island, and/or volume of traffic causes a high risk of maritime
a much wider passing had been planned in the accidents. The growing risks give us good reasons for
first place, and/or implementing the research project concerning
a considerable safety margin had been applied maritime safety and the effectiveness of the safety
when the corrections were made to compensate for measures, such as the safety management systems. In
drift and setting. order to reduce maritime safety risks, it is
It is also possible that proper look‐out and use of recommended in (Lappalainen et al. 2010) that the
radar could have been an issue. On the other hand, safety management systems should be further
the island was very low and it is arguable that it could developed.
not have been spotted visually in time in the dark The purpose of the METKU Project (Development
tropical night. It is unclear whether and why the of Maritime Safety Culture) which started 2008 was to
island was not seen on the radar, but it is a known study how the ISM Code has influenced the safety
fact that radars are subject to a lot of interference in culture in the maritime industry, to evaluate the
tropical waters and it could be that both the rain and development of safety culture in maritime industry
sea clutter settings had been adjusted to deal with and to examine the weaknesses found in the safety
that, thus at the same time removing or diminishing management systems of shipping companies
the radar image of the island. (Lappalainen et al. 2010). The main results found
One further example is the cruise ship Costa were that maritime safety culture has developed in
Concordia’s grounding at the Italian island of Giglio the right direction after the launch of the ISM Code in
in January 2012 which will probably labelled as the 1990´s (Heijari & Tapainen 2010). In this study it
human error (Porathe & Shaw 2012). has been discovered that safety culture has emerged
and it is developing in the maritime industry. Even
though the roots of the safety culture have been
established there are still serious barriers to the
3 MARITIME SAFETY CULTURE breakthrough of the safety management (Lappalainen
2008).
3.1 General aspects The ISM Code is seen as been effective over a
Safety culture can be viewed from many angles (Berg decade. However, the old‐established behaviour
2011). Typically, the environment close to safety which is based on the old day’s maritime culture still
managers of the organizations provides most of the occurs, e.g., there are still serious barriers to the
research material, and consequently the middle breakthrough of the safety management. These
management view dominates. Similarly, employee barriers could be envisaged as cultural factors
perspective is strong in internal material of the preventing the safety process. For more details see
organizations, typically work instructions and safety (Lappalainen et al. 2010).
management documentation. From the top However, experience has shown that there are
management viewpoint, lesser amount of practical perceived gaps between the desirable leadership
information is available. qualities, and what is currently being delivered. These
However, in shipping, and especially on board primarily concern:
ships the organization is hierarchic, due to tradition Clear two‐way communication,
and the need for clarity in emergency operations. “Tough empathy”,
Therefore, safety considerations depend strongly on Openness to criticism,
the actions of the masters and the officers of the ships, Empathy towards different cultures,
and the interactions of the land‐based organization Ability to create motivation and a sense of
(Räisänen 2009). community,
One typical feature of shipping is that ships are Knowing the crew’s limitations,
manned with crews of multiple nationalities, and the Being a team player.
much of it is carried out in international setting, Moreover, there are other important explicit
outside national legislations. These issues complicate barriers to effective safety leadership that relate to the
the communication and interactions within the ships, current structure of the industry, standards, practices
between them, and with the land‐based stakeholders. and economic pressures. These barriers would need
Moreover one has to emphasize the effects of to be addressed irrespective of the personal qualities
national culture, which is less prominent in related and skills of the Master.
safety discussions of other fields (Håvold 2005, Therefore, workshops on leadership and safety
Håvold 2007). culture for senior experts are regularly provided by
The prevailing goals, principles and procedures in the IAEA in the nuclear field, the next one in
an organisation, which can safeguard against errors September 2013. This workshop will focus on the
topics such as international standards for leadership
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and safety culture; lessons learned from severe events For the maritime area, one safety culture approach
and their relation to leadership and safety culture, can be illustrated by a pyramid as shown in Figure 1,
methods and tools for improving leadership and accompanied by the elements “lessons learned” and
safety culture. “safety as a value” which are important for the entire
organisation to succeed in a sound safety culture
Such training workshops are also helpful in the (Drouin 2010).
maritime field. Experience has shown that the
transformation of safety culture works being aware A further safety culture approach is illustrated in
that this process needs time (Goldberg 2013). Figure 2.
Operation of ships is full of regulations,
instructions and guidelines which officers and crew
are expected to know and adhere to. The ISM Code
has to a large extent codified what is known as good
seamanship.
A culture of safety may perhaps be achieved
through written instructions, but in the end it is a
question of a common mind‐set throughout the
organisation. Management ashore and on board need
not only ensure that the formal skills are in place but
also ensure, encourage and inspire the necessary
attitudes to achieve the safety objectives.
The safety culture aboard vessels trading in the
Baltic Sea is depicted in (Hjorth, 2013). The
investigation shows deficiencies in the safety culture
that prevails aboard and in shipping as a whole. The
safety culture aboard is influenced not only by the Figure 2. The ABS safety culture and leading indicators
crew and their shared agreements but also by the model according to ABS (2012).
surrounding systems, which are in turn influenced by
other surrounding systems. The central premise of this model, discussed in
It is slightly worrying that documents related to more detail in (ABS 2012) is that improvements in
leadership, just culture, etc., submitted in recent years organizational safety culture can lead to enhanced
have not received the attention they should. One safety performance.
critical step to evaluate how proactive IMO is will The first step is an assessment of the existing
certainly be the follow‐up to the Costa Concordia safety culture to identify areas of strength,
accident last year (Schröder‐Hinrichs et al. 2013). weaknesses of defences, and opportunities for
improvement against operational incidents, personal
injuries, etc.
3.2 Examples of safety culture approaches This model also incorporates a process for
The extent of good safety leadership (and more identifying an organization’s potential leading
broadly good safety management arrangements) indicators of safety. There are two ways of conducting
appears to be highly variable across companies. this process:
Safety management arrangements are generally most 1) By the identification of objective leading indicators.
highly developed in the tanker sector, and least This is done by correlating safety culture metrics with
highly developed in the dry cargo sector. safety performance data. This is the preferred
However, the research results (Little 2004) confirm approach because of its objectivity; because it utilizes
that a good safety performance can be achieved with metrics that the organization has collected; and it does
a committed leader who has the key qualities not require a survey of the workforce which can be
described above, without necessarily having the most time‐consuming.
sophisticated management arrangements. This can be done at three levels:
At the Organizational level,
Across Business Units,
Across the Fleet.
2) By the identification of subjective leading
indicators from a safety culture survey. These
indicators are based on the values, attitudes, and
observations of employees. This method may identify
potentially beneficial safety culture metrics not yet
tracked by the organization. This approach may be
used when the organization lacks sufficient metrics to
use the objective leading indicators process. There are
a number of criteria for undertaking a leading
indicators programme, and for each type of
Figure 1. Safety culture pyramid for the maritime area assessment.
according to Drouin (2010).
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4 CONCLUDING REMARKS AND OUTLOOK also influence whether or not an individual engages
in safe behaviours or not. The review also considered
In general, safety culture has been found to be the current status of attempts to address these human
important across a wide variety of organizations and factors issues prevalent in the maritime industry. The
industries. While initial studies of safety culture took review demonstrated that there are many “gaps” in
place in jobs that have traditionally been considered the maritime literature, and a number of
high‐risk, organizations in other areas are methodological problems with the studies undertaken
increasingly exploring how safety culture is expressed to date.
in their fields. Overwhelmingly, the evidence Maritime transportation is characterized by a level
suggests that while safety culture may not be the only of safety of the order of 10‐5 per movements which is
determinant of safety in organizations, it plays a inferior to that of air transportation (10‐6), however it
substantial role in encouraging people to behave is comparable to the level of safety of rail
safely. transportation and much higher than the level of
The essence of safety culture is the ability and safety of road transportation. Thus, for passenger
willingness of the organization to understand safety, transportation in Europe, the risk of fatality is
hazards and means of preventing them, as well as estimated at 1.1 for road transportation (for 108 person
ability and willingness to act safely, prevent hazards kilometre) and at 0.33 for ferry transportation
from actualising and promote safety. Safety culture (Mackay, 2000).
refers to a dynamic and adaptive state. It can be Within this context, the risk of accident and ‐ more
viewed as a multilevel phenomenon of social precisely ‐ the place of the human factor in this risks,
processes organizational dimensions, and are central issues. The human factor, indeed, seems to
psychological states of the personnel. be the main cause of incidents at sea (Hetherington,
In the nuclear field safety culture is still seen as an Flin & Mearns 2006) describing the factors that
important task (CNSC 2012), and also the German contribute to incidents and accidents: factors which
activities are ongoing (Berg 2008, Berg 2010, Kopisch cause a decrease in performance (fatigue, stress, and
& Berg 2012). health problems), insufficient technical and cognitive
capacities, insufficient interpersonal competencies
In February 2011, i. e. one month before the (communication difficulties, difficulties mastering a
Fukushima accident, a further international activity in common language), organizational aspects (safety
the nuclear field on safety culture started. The general training, team management, safety culture).
objective is to establish a common opinion on how
regulatory oversight of safety culture can be A closer look at the questions of human‐machine
developed to foster safety culture. It is intended that cooperation and at the role of automation in maritime
the output of the meeting will form the basis for a accidents is taken in (Lützhöft & Dekker 2002).
Safety Report Series document providing guidance on In the case of a crew or team working together, the
how regulators and licensees can deal with the safety shared mental representation is one of the elements at
culture components in order to continuously foster a the heart of the performance. The methods developed
positive safety culture. Moreover, the IAEA is also in cognitive psychology to analyze this mental
working on a document how to perform safety structure can be used to evaluate the impact of Bridge
culture self‐assessments. Resource Management (BRM) on the work of a crew
A recent publication (IAEA 2013) addresses the (Chauvin 2011). A study of this type was carried out
basics of regulatory oversight of safety culture, some years ago (Brun et al. 2005).
describes the approaches currently implemented at However (see Salas et al. 2006), these studies
several regulatory bodies around the world and, remain marginal and recent in the maritime field,
based on these examples, proposes a path to develop even though they are numerous and have been
and implement such a strategies and processes. developed for several years in the field of air
In the meantime, there are many demanding transportation.
aspects of seafaring such as the inability of employees Because human error (and usually multiple errors
to leave the worksite, extreme weather conditions, made by multiple people) contributes to the vast
long periods away from home, and motion of the majority of marine casualties it is necessary to prevent
workplace. Some of these are unchangeable and are a human error of paramount importance in order to
reflection of the nature of the domain. reduce the number and severity of maritime
However, it is possible to modify, supplement, accidents. Many types of human errors were
and introduce new strategies or interventions to described, the majority of which were shown not to be
potentially reduce the impact these factors have on the “fault” of the human operator. Rather, most of
the health and welfare of the individual seafarer these errors tend to occur as a result of technologies,
(Parker et al. 2002). work environments, and organizational factors which
do not sufficiently consider the abilities and
There are many human factors influencing safety limitations of the people who must interact with
in this domain as have been presented in this review: them, thus “setting up” the human operator for
fatigue, automation, situation awareness, failure.
communication, decision making, team work, and
health and stress. These issues were reviewed within This general problem is also discussed for CRG
a framework that proposed that these individual casualties (Kobylinski 2009).
factors can be contributory causes in accident Human errors can be reduced significantly. Other
causation, however the safety climate on ship will industries have shown that human error can be
349
controlled through human‐centered design. By The first step consists of defining what safety
keeping the human operator uppermost in our minds, culture is and understanding what is meant by safety
we can design technologies, work environments, and culture in the respective management organisation.
organizations which support the human operator and This requires identifying the characteristics of safety
foster improved performance and fewer accidents. culture to look at, and their sub‐components. These
first two steps are important because to measure
There is often a delay between the development of safety culture effectively, an organisation must define
weaknesses in safety culture and the occurrence of an and describe what it is attempting to measure.
event involving a significant safety consequence. The
weaknesses can interact to create a potentially The next (3rd) step of the process enters the
unstable safety state that makes an organization assessment stage, where the organisation carries out
vulnerable to safety incidents. Within the nuclear or commissions a survey to measure its own safety
industry, there have been a number of high profile culture. Surveys and other techniques contribute to
cases in different parts of the world that have been the identification of strengths and weaknesses of the
linked to a weakened safety culture. safety culture (4th step). On the basis of this
assessment an action plan is developed (5th step).
By being alert to the early warning signs,
corrective action can be taken in sufficient time to The actions are effected to improve safety culture
avoid adverse safety consequences. Both the (6th step).
organization (which could be a specific plant or
utility) and its regulators must pay attention to signs After a reasonable period (e.g. at least two years),
of potential weakness. safety culture can be assessed again iteratively to
determine if the situation has improved.
Some organizations that have encountered
difficulties with their safety culture have previously
been regarded as good performers by their industry
peers. Good past performance is sometimes the first
stage in the process of decline.
The investigation on maritime accidents is,
nowadays, a very important tool to identify the
problems related to human factor that, studied with
attention can be one mainstay to accident prevention
and to the improvement of maritime safety.
The long‐term positive trend in ship safety, with
year‐on‐year improvements, has now been reversed
(Madsen 2011). This is worrying. It’s time to take a
new look at the maritime industry’s safety culture. A
stronger focus on safety culture, safety training and
competence assessment is needed.
Statistics show that the shipping industry’s
accident frequency rate has started to rise from a
historically low level. Technology, rules and
compliance will never achieve the expected level of
safety unless there is a greater focus on the human
element.
Historically, the safety focus in shipping has been
on technical improvements. Most shipping company Figure 3. Safety culture enhancement process
employees dealing with the operation of vessels have
a technical background. Audits and inspections pay The iteration timeframe depends on the time
great attention to technical compliance. This technical required to carry out the assessment, define the plan
focus has resulted in major improvements to ship and put in place all planned actions and mature the
safety. But now it is time to focus more on the soft enhancement. The iteration should not occur too
issues. To improve maritime safety one needs to quickly, as safety culture takes time to change.
adopt a threefold approach:
Maintaining and enhancing safety culture needs
1 Improved safety culture, regular training, continuous awareness of cultural
2 Improved training schemes, transformation and an ongoing process of continuing
3 A formal competence assessment programme. improvement (Goldberg 2013).
The last two aspects are also addressed in (Chirea‐ Results of a recent study (Oltedal 2011) indicate
Ungureanu & Rosenhave 2012) recommending a cross several deficiencies in all parts of a traditional safety
cultural training to deal with the specific situation management system defined as:
onboard.
reporting and collection of experience data from
An organisation that decides to improve its safety the vessel;
culture should follow a systematic, closed‐loop data processing, summarizing, and analysis;
process. A typical enhancement process is presented development of safety measures and
in Figure 3. implementation.
350
The underreporting of experience data is found to ERRATA
be a problem, resulting in limitations related to the
data‐processing process. Regarding the development This paper is an updated and revised version of (Berg
of safety measures, it is found that the industry 2013). The update takes into account recent activities
emphasizes the development of standardized safety and insights regarding human factors and safety
measures in the form of procedures and checklists. culture, in the nuclear field but especially in the
Organizational root causes related to company maritime area. Moreover, it reflects questions which
policies (e.g., crewing policy) is to a lesser degree arise at the TransNav 2013 Conference in Gdynia in
identified and addressed (Oltedal 2011). June this year.
The most prominently identified organizational The revision of (Berg 2013) refers to the references
influential factors are the shipping companies of J. Lappalainen and his colleagues provided in the
crewing policy, which includes rotation systems, crew list of references below. I apologize that these basic
stability, and contract conditions, and shipboard contributions to the needs for an appropriate
management. The companies’ orientation toward maritime safety culture ‐ for reasons that are not
local management, which includes leadership comprehensible ‐ were missing in the original paper
training, educational, and other managerial support, (Berg 2013).
are also essential. The shore part of the organization is
identified as the driving force for development and
change in the shipboard safety culture. Moreover,
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