The Human Factors Analysis and Classification System - Coursework Example

Running Header: Human Factors and Risk Management Student’s Name: Instructor’s Name: Course Code & Name: Date of Submission: Abstract This report explores Human Factors Accident Classification System (HFACS) in an effort to develop a causal model from the Attilio Levoli accident report. The vessel specifications and scenario of accident have been discussed profoundly. Various causation models included in this report are individual model, domino theory, Multi-linear Events Sequence Method and Swiss-Cheese Model. HFACS explanation of 4 levels of failure which include: unsafe acts, preconditions for unsafe acts, unsafe supervision and organizational influence have also been analyzed. Attilio Levilo accident is also classified utilizing HFACS classification. Contents Abstract 2 Contents 3 Introduction 4 Vessel Specifications and Accident Scenario 4 Changes of Accident Causation Models 6 Four levels of analysis in HFACS 7 HFACS Classification for Attilio Levoli 8 Discussion of HFACS Classification 10 Conclusion 10 Works Cited 11 Human Factors and Risk Management Introduction The investigator role in any investigated incident is to evidence collection, evidence analyses, to draw conclusions founded on evidence, and develop recommendations from those conclusions. Regarding to the investigation role, it can be developed to eliminate chances of same accidents from happening or allocate blame or liability. Majority of marine equipment do have management systems that are electronically capable of recording information resulting to growing and large availability of evidence sources. According to Senders and Moray, there exist various models of accident process such as Heinrich’s original domino theory and model of Swiss-cheese (87). The description of cheese holes was done by utilization of original framework referred to as Taxonomy of unsafe operations created using more than 300 accidents of naval aviation acquired from US Naval safety center. The initial taxonomy from that time has been refined utilizing data and input from various military and organization of civilians. According to Douglas, this led to emerging of Human Factors Analysis and Classification Systems (HFACS) (3). There has been various accident investigations carried out and one example is the accident that involved an Italian tanker, Attilio levoli. On 3 june 2004, the double hulled chemical tanker attilio levili grounded on Lymington Banks in the west of Solent. The tanker loaded with styrene and toluene experienced indentation of bottom plate but no hull penetration. There was no pollution or injuries reported from the accident. Vessel Specifications and Accident Scenario The chemical/oil tanker Attilio Levoli built in 1995 was registered under ownership of Italian company, Marnavi S.p.a (Marine Accident Investigation Branch 2). The company was under management of Marnavi and port of registry of the vessel was Naples. Attilio Levoli was constructed in Ancona and its type is chemical tanker, IMO type II. It classification society was Registro Italiano Navale and Bureau Veritas (dual classification). Its overall length was 11.5m with loaded draft of 6.5m aft. The gross tonnage was 4450 with oil engine geared drive to a single screw. Its service speed was 14 knots with controllable pitch propeller and bow thruster. In 1445, the pilot boarded the vessel and shared the voyage with master. The pilot knew that vessel was to depart through the east Solent but the master instructed him to change plan and use the shorter route, west of Solent in order to proceed to Barcelona. Attilio Levoli was cleared of the berth at 1500. The master, chief engineer, the pilot, and cadet were inside the bridge. The master sat on chair of starboard at the combined conning console. The radar of port was unavailable to be used by team of bridge since the chief engineer sat at the port conning console. This required bending cross the master to get in touch with the radar controls. Before disembarking, it was noted that flag was flying within vicinity of radar scanner and master instructed second officer to displace the flag. The pilot disembarked the vessel at boarding point to the west. The second officer went back to the bridge and put position of 1600 on the chart. The cadet stood next to the steering section after returning to the bridge while evaluating autopilot. The second officer put another point on the chart to 1610 because the tanker was abeam of the West Lepe buoy. He told the master that the tanker was heading north of required route and got out of bridge to bring the pilot flag down. However, the report never got attention of the master. Also another position was plotted by the cadet at 1610 in order to put the vessel on the tract. When the second officer returned, he checked the chart and said to the cadet that he contemplated the 1610 location was wrong. 1618 position was plotted on the chart to put the vessel on track. The master reported his Southampton VTS position after passing Yarmouth at 1631. Marine Accident Investigation Branch reported that moment later, the vessel begun vibrating and its engine started to toil(6). The master changed the autopilot to manual although it had no impact since the tanker was already aground on the Lymington Banks. A yacht passing Lymington at 1635 informed Southampton VTS that Attilio Levoli was aground but attempt by coastguards to reach vessel via VHF radio was not fruitful until 1720. At this moment, the vessel staff informed the coast guard that the integrality of hull was intact. At 1805, Attilio Levilo refloated and sailed clear without aid and anchored at 1920 between Yarmouth and Hampstead Ledge to wait inspection of underwater. Changes of Accident Causation Models The oldest models of the process of accident were not considering extra-personal factors, instead they concentrated on accident proneness of an individual (Reason 79). It proposed that fewer individuals have a lot of accidents while majority have nothing. This resulted to more focus on factors of an individual such as personality. Theory of accident modeling known as Heinrich’s original domino theory, the causation was explained in a linear manner; one domino strikes another and actually causes to an accident. Heinrich suggested that every injury (5th domino) is as a result of accident (4th domino), that the accident is as a result of unsafe act or unsafe conditions (3rd domino) caused by an individual (2nd domino) impacted by social environment (1st domino) (Douglas 2). It was argued that elimination of single domino would block the accident occurrence. Theories that followed proposed a more dynamic, complex and non-linear method to causation of accident. Multi-linear Events Sequence Method suggested that accident can be comprehended as the integration of the actions of various factors (including people, technology, objects e.t.c.) over a period. This model is partially founded on theory of process referred to as p-theory, which indicates that instigating event results to imbalance in the system and begins a sequence of events that actually causes the accident. Swiss-Cheese Model has developed paradigm on accident causation (Laura and Deborah). In this model, active failure is not considered to exist in separation from precondition for unsafe supervision, organizational influence or unsafe acts. The more close accident is evaluated, the higher the likelihood of unearthing the other error causation elements. According to this model, absent or failed or holes in the cheese defenses of the system of safety management permit a trajectory of accident to shift to the position of some injury or property loss. Therefore, casual factors at various levels in organization are supposed to be looked into if any investigation of accident is going to be successful. Four levels of analysis in HFACS HFACS explains 4 levels of failure which include: unsafe acts, preconditions for unsafe acts, unsafe supervision and organizational influence. Unsafe act taxonomy can be divided into groups: violations and errors (Douglas and Scott 2). Errors represent the physical or mental undertakings of a person that fall short to attain their desired results. Violation is conscious ignorance of regulations and rules that administrate the safety of activity. There are 3 basics of types of errors: perceptual, decision and skill-based. Also violation is expanded in 2 forms: exceptional and routine. Precondition for unsafe acts are investigated to understand why the unsafe acts happened. It is categorized into major sub-divisions: sub-standard practices they commit and substandard conditions of operators. Substandard conditions of operators are expanded into adverse physiological states, mental/physical limitations and adverse mental states. Also substandard practices of operators are expanded into crew resource mismanagement and personal readiness. Unsafe supervision has indentified 4 categories: supervisory violations, failure to rectify known problem, planned inappropriate operations and inadequate supervision. Organizational influences have influence because upper level management imperfect decisions frankly impact on the practices of supervision as well as actions and conditions of operators. However, errors resulting from organization mostly go unobserved by professionals of safety because of lack of a vivid framework surrounding matters related to management of resources, operational processes and organizational climate (Wiegmann and Shappell 77). HFACS Classification for Attilio Levoli In the first level of failure that was committed by the master was Unsafe Acts under routine violation. He decided to take the vessel through the West Solent which was against the policy of company (Marine Accident Investigation Branch 19). The vessel was required to depart using East Solent route but master advised the pilot to use West Solent route because the former was shorter. This is routine violation because it habitual in nature as the master had decided to head to the English channel through the west Solent and Needles cannel, as he had carried out voyage on the earlier event 6 weeks before. The company did not take action on the first time violation of its policy hence it seemed to tolerate this kind of violation. It is also evident that bridge team had habit of setting alarm of echo sounder to zero which is against instructions of Marnavi S.p.a. The type of precondition of unsafe acts that was committed by the crew is substandard practices of crew resource mismanagement. This is because there was lack of communication in bridge team and it was made worse since there was no briefing took place and master assumed on the way job is going to be carried out. The second office communicated to master that the vessel was to the north of the actual route but the master did not respond. The second man did nothing more to draw attention of master to the eminent problem. The unwillingness to confront the master was thought to be caused by combination of communication practice on board and differences of culture. There exists some evidence that the master was on telephone conversation when second officer cautioned him that Attilio Levoli was not on correct course. Therefore, the master could not hear the voice from second officer (Accident Investigation Branch 19). Unsafe supervision was as result of inadequate supervision and failure to correct a known problem. Inadequate supervision is revealed because from the time of departure of pilot at 1600, the master did not give responsibilities and roles to his crew members. Performance of tasks was not coordinated and there existed little supervision and overt management. The result was that during the time of vessel grounding, the team of bridge had not discussed the appreciation of position of Attilio Levoli. There was failure to correct a known problem which was concerned with unavailability of the port radar to the second officer since chief engineer was utilizing the workstation to assess the alarms of UMS. Resource management is the major organizational influence to the causation of accident. There was no pilotage service for the west Solent and as a restricted waterway it was not put under surveillance of VTS. There were inadequate navigational buoys in the west Solent and there was no effective shipping control in Needles channel and west Solent. Discussion of HFACS Classification It is important for the supervisors to stick with organization rules since this would have eliminated unsafe act prior to grounding of Attilio Loveli. If the initial route and plan were followed the accident could have been eliminated. Also setting alarm of echo sounder to zero increased the probability of accident happening. The organization is supposed not to tolerate even slight bending of its rules and regulations. Crew resource mismanagement through lack of communication between the bridge team was disastrous and therefore teamwork and effective communication should be embraced in an effort to curb such incidents. In order to make sure that tasks and operation are carried out smoothly, it important to have adequate supervision in place. Organization has influence on management of resources. The responsible authority is required to mobilize needed resources in order to reduce occurrence of such accidents. This would include provision of buoys and adequate shipping control in the area. Conclusion The vessel involved in accident was Attilio Levoli owned by Marnavi S.p.a built in1995. The master instructed pilot to change plan and use the shorter route west of Solent in order to proceed to Barcelona. There has been change of accident causation models from oldest models to more dynamic, complex and non-linear models such as Swiss-cheese. Human Factors Accident Classification System (HFACS) is an important tool in build a causal model in order to take preventive measures in the future. Primary human factors failure that added to the accident was decision of master to change the plan and take the vessel via west Solent which was contrary to policy of the company. This judgment initial error was later aggravated by ineffective communication and teamwork in the bridge. The crew member did not seem to be clear as to their own and other members’ responsibilities and roles. There was no navigational buoys and pilotage service for the west Solent. Shipping control in Needles channel and west Solent was inadequate. Works Cited Douglas, Wiegmann. “The human factors analysis and classification system–HFACS.” Final Report 1.7 (2000): 1-15. Douglas, Wiegmann, and Scott, Shappell. Applying the Human Factors Analysis and Classification System (HFACS) to the Analysis of Commercial Aviation Accident Data (2001): 1-6. Laura, Mussulman, and Deborah, White. “The human factors analysis and classification system,” Business Services Industry. July-Aug. 2004. 17 Aug. 2010. < http://findarticles.com/p/articles/mi_m0FKE/is_4_49/ai_n6363911/ >. Marine Accident Investigation Branch. Report on the Investigation of the Grounding of the Italian Registered Chemical Tanker Attilio Ievoli on Lymington Banks in the West Solent, South Coast of England 3 June 2004 (2005): 1-35. Reason J. Human error. New York: Cambridge University Press, 1990. Senders, J, and Moray, N. Human Error: Cause, Prediction and Reduction. Hillsdale, NJ: Earlbaum, 1991. Wiegmann, D, and Shappell, S. “Human factors analysis of post-accident data: Applying theoretical taxonomies of human error,” The International Journal of Aviation Psychology 7.5 (1997): 67-81. Read More