Ship Collision Risk

- An identification and evaluation of important factors in collisions with offshore installations

Karin af Geijerstam Hanna Svensson

Department of Fire Safety Engineering and Systems Safety Lund University, Sweden Brandteknik och Riskhantering Lunds tekniska hgskola Lunds universitet Report 5275, Lund 2008

Ship Collision Risk

An identification and evaluation of important factors in collisions with offshore installations

Karin af Geijerstam Hanna Svensson

Lund 2008

Title ShipCollisionRiskAnidentificationandevaluationofimportantfactorsincollisionswith offshoreinstallations Authors KarinafGeijerstam HannaSvensson Report5275 ISSN:14023504 ISRN:LUTVDG/TVBB5275SE Numberofpages:151 Keywords Offshoreinstallation,collision,ship,risk,model,humanfactors,organisationalfactors,expert judgement,interview Skord Offshoreinstallation,kollision,fartyg,risk,modell,mnskligafaktorer,organisatoriskafaktorer, expertbedmning,intervju Abstract Theriskforashipcollisionisusuallypredictedtobeoneofthedominatingrisksforanoffshore installation.Thesubjectofthisthesisoriginatedinaneedforcontinuousupdateandreviewof themodelsforassessingthecollisionrisk,sothatthetechnicaldevelopmentandmanagement changesoftodayarereflected.Theriskforcollisionisgovernedbytheactionsoftheship,which dependsonseveralhumanandorganisationalfactorsthatmaybecomplicatedtomeasure.The focusofthisthesisthereforelieswithintheorganisationoftheship,withtheaimtoidentifyand assesscausesandunderlyingfactorsthatcontributetoacollision.Thisisundertakenbyusinga hierarchicalmodelwheretheincludedcomponentsareassessedthroughexpertjudgementvia interviews.Theresultsfromtheinterviewsarecombinedwithresultsfromaliteraturereview andthemostcontributingfactorsinashipcollisionwithanoffshoreinstallationareoutlined. Theresultsshowthatthethreemostcontributingcausestothecollisionriskareiftheofficeron watchisabsent,distractedorasleep. Copyright:BrandteknikochRiskhantering,Lundstekniskahgskola,Lundsuniversitet, Lund2008.
BrandteknikochRiskhantering Lundstekniskahgskola Lundsuniversitet Box118 22100Lund brand@brand.lth.se http://www.brand.lth.se Telefon:0462227360 Telefax:0462224612 DepartmentofFireSafetyEngineering andSystemsSafety LundUniversity P.O.Box118 SE22100Lund Sweden brand@brand.lth.se http://www.brand.lth.se/english Telephone:+46462227360 Fax:+46462224612

Acknowledgements
QuiteafewpeoplehaveplayedasignificantpartduringtheprogressofthisMasterThesis.First ofallwewouldliketothankHenrikHassel,ourmentorattheDepartmentofFireSafety EngineeringandSystemsSafetyatLundUniversity.Hehasprovideduswithvaluableinputand helpfulcommentsalongtheway. WearegratefulforallguidancefrompeoplewithinDetNorskeVeritas(DNV)andespeciallyour mentorHkonFartum.Wereallyappreciatetheopportunitytowriteourthesisinassociation withDNVandbeingabletousetheextensivesourceofcontactswithintheorganisationandthe officefacilities. Inadditiontothepeoplementionedabove,thethesiswouldnothavebeenpossibleifitwasnot fortheparticipationfromalltheinterviewees.Abigthankyouto: TorEinarBerg,EmilAallDahle,JohnDouglas,saEk,ThomasEriksen,FrankLambergNielsen, ArveLerstad,StefanLindberg,MichaelManuel,EgilPedersen,HelgeSamuelsen,TorEgilHopen Saue,StevenSawhill,JensUweSchrder,TorkelSoma,JanErikVinnem,DavidWendel,Carl HenrikWulff,Pettervers. WearealsoveryappreciativefortheinputfromourexaminerRobertJnssonandour opponentsOskarBergqvistandFredrikDjurklou.ManyThanks! KarinafGeijerstam&HannaSvensson Oslo,December2008

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ExecutiveSummary
Anoffshoreoilinstallationisexposedtoseveraltypesofrisksandhazardssuchasexplosions, leakages,fires,fallingobjectsandcollisionsbuttheriskforshipcollisionsisusuallypredictedto beoneofthedominatingforaninstallation.Accordingtomanysourcesofstatistics,the probabilityofcollisionsisnotsignificantbutitdoeshoweverhappenfromtimetotime.The responsibilityforensuringcompliancewithlegislativeconditionsliesontheorganisation conductingpetroleumactivitiesandtheseconditionsareofteninformofariskacceptance criterionforlifesafety. Therearenumerousmodelsdevelopedtoassesstheriskforshipcollisionswithoffshore installations,suchasCOLLIDEandCRASH.Themodelsprimarilyoriginatefromapreviously madeprojectwithassumptions,technicalequipmentandmanagementproceduresonaship thatarenotreflectingtheadvancesintechnologyandoperationsoftoday. Thepurposeofthisthesisistoanalysewhyacollisionwithanoffshoreinstallationoccur, howeverwithoutanyattentiontotheconsequencesofcollisions.Theshipisthefocalpoint, consideringitsimportantroleandhowitisphysicallyabletoavoidcollidingwithanoffshore installationbychangingitscourse.Itisnotedthatagreatlevelofcomplexitylieswithinthe organisationofships;involvinghumans,technicalequipmentanddecisionmakingatseveral levelsoftheorganisationalstructure.Theareaofgrasping,assessingandquantifyinghuman andorganisationalfactorsanditsimpactonaccidentscenariosischallenging,butnecessarydue totherecognisedsubstantialimpactinaccidents.Anotherdilemmainassessmentsofactions andhumanerrorsishowhumansarenotpredictableandthataccidentsoftenoccurasseveral stepslinkedtogetherinachainofevents. Aprinciplewithinthisthesisisanapplicationofthesystemapproachwhenworkingtowardsa structurethatoverviewsacollisionscenario.Byusingasuccessscenarioapproach,an identificationofcomponentsinacollisionwasestablishedbyadoptingtheoriesandfindings fromliterature,accidentstatistics,riskanalysismodelsandhazardsidentificationsthrough workshops.Theprocessresultedinastructuralmodelwiththreedifferentlevelsincluding scenarios,primarycausesandunderlyingfactors.Byapplyingthismodel,anoutlineofthechain ofeventswascreatedwithseveralcomponentsthattogethermayresultinacollision.The identifiedcomponentswereevaluatedbyusingexpertjudgementsduringinterviewstogether withconclusionsfromresearch. Partoftheresultsfromtheevaluationwasthatthemostcontributingscenariotothecollision riskappearstobealackofawarenessontheship,followedbyhandlingerrorsandshipspecific technicalproblems.Themostinfluentialprimarycausestolackofawarenessare;theofficeron watchbeingasleep,distractedorabsent.Theresultsmaybeusedasabackgroundtofurther researchconcerningcollisionrisks,sothatathoroughupdateoftheriskanalysismodelscanbe completed.Thethesisalsoindicateshowimportantitistoreviewriskanalysismodels continuouslywithregardstochangesinorganisations,equipmentandenvironmental conditions.Theconclusionscanfurthermoreprovideinputtowheresignificanthazardslie withinthemaritimeindustry,tobeadoptedinriskanalysesorworkplacesafetyassessments. Anenhancedappreciationoftheuncertaintiesinvolvedinassessmentofhumanand organisationalfactorsmayalsobeachieved.

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Sammanfattning(SummaryinSwedish)
Enoffshoreinstallationutsttsfrfleraolikatyperavriskerochfarorsomt.ex.explosioner, lckage,brnder,fallandeobjektochkollisionervaravriskenfrkollisionoftaberknasvaraen avdestrsta.Enligtstatistikfrnflerakllorrdocksannolikhetenattenkollisionintrffarinte signifikantmendethndernddochd.Organisationensomansvararfroffshore installationenskasetillattregelverkfljsvilketoftainnebrattriskacceptanskriterierfr personskerhetskauppfyllas. Detfinnsfleramodellersomutvecklatsfrattberknariskenfrfartygskollisionermedoffshore installationervaravtvexempelrCOLLIDEochCRASH.Modellernartillstordelbaseradep etttidigaregjortforskningsprojektdrantaganden,tekniskutrustningochrutinerinom organisationenpettfartyginteterspeglarutvecklingensomskettinomdessaomrdenfram tillidag. Syftetmedexamensarbetetrattanalyseravarfrkollisionermedoljeplattformarintrffar, dockutanattgvidareinpkonsekvensernaavenkollision.Fokusliggerpfartygetsagerande eftersomdettaharmjlighetattundvikaenkollisiongenomattndrakurs.Organisationenp ochkringettfartygrkompliceradochinvolverarmnniskor,tekniskutrustningoch beslutsfattandepfleraolikaniver.Attfrst,vrderaochkvantifieramnskligaoch organisatoriskafaktorersamtderaspverkanpolyckorrenutmaningmenocksndvndigt ddennapverkanansesvarastor.Mnniskorrintefrutsgbaraocholyckorberoroftapen kedjaavhndelservilketytterligarefrsvrarenvrdering. Denvergripandestruktureniettkollisionsscenarioharutvecklatsmedutgngspunktien systemsyn.Genomattutgfrnettsuccessscenarioikombinationmedinformationfrn litteratur,olycksstatisk,riskanalysmodellerochfaroidentifieringgenomworkshopsharolika komponenterienkollisionidentifierats.Dettaresulteradeienmodellmeddetreniverna; scenarier,primraorsakerochunderliggandefaktorer.Genomattanvndamodellenskapades enversiktligbildavdekomponentersomtillsammansbidrartillenkollision.Deidentifierade komponenternavrderadesgenomintervjuermedexperterikombinationmedresultatfrn litteraturskning. Resultatenvisarblandannatattbristpuppmrksamhet/medvetenhetverkarvaradetmest bidragandescenariottillriskenfrkollision.Direktfelhandlandeochtekniskafelpfartygetkan ocksvarabidragandemenisammautstrckning.Bristenpuppmrksamhet/medvetenhet beroroftastpattvakthavandebeflharsomnat,rdistraheradellerrfrnvarandefrn bryggan. Riskanalysmodellernafrkollisionermellanfartygochoffshoreinstallationerkanuppdateras genomattresultatenanvndssombasfrvidareforskninginomkollisionsrisker.Resultaten visarocksphurviktigtdetrattuppdaterariskanalysmodellerregelbundeteftersomdetsker frndringariorganisationer,utrustningochdenomgivandemiljn.Frutomdettakan resultatenvenanvndasinomriskanalyserochskerhetsarbeteinomsjfartengenomattvisa vardestrstaproblemenfinns.Frhoppningsviskanocksfrstelsenfroskerheteri allmnhetka,specielltnrdetgllerbedmningavmnskligaochorganisatoriskafaktorer.

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TABLE OF CONTENTS
ACKNOWLEDGEMENTS EXECUTIVE SUMMARY SAMMANFATTNING (SUMMARY IN SWEDISH) 1 INTRODUCTION 1.1 1.1.1 1.2 1.3 1.4 1.5 1.6 2 BACKGROUND Association with DNV PROBLEM DEFINITION PURPOSE RESEARCH QUESTIONS DELIMITATIONS DISPOSITION I III V 1 1 2 2 3 4 4 5 7 7 8 8 8 9 11 11 11 12 14 15 17 17 19 19 21 22 25 25 25 26 27 28 28 28 28 28 29 29 29 31 31 31 32 33

METHOD 2.1 SCIENTIFIC PERSPECTIVE 2.2 WORK PROCESS 2.2.1 Decision of purpose and research questions 2.2.2 Literature and contacts 2.2.3 Evaluation and measurement of factors

HUMAN AND ORGANISATIONAL FACTORS 3.1 3.2 3.3 3.4 3.5 INTRODUCTION DIFFERENT VIEWS CATEGORISATION AND DEFINITIONS OF FACTORS DEFINITIONS MEASURING HUMAN AND ORGANISATIONAL FACTORS

INTERACTION BETWEEN THE MARITIME AND OFFSHORE INDUSTRIES 4.1 4.2 4.2.1 4.3 4.4 MARITIME TRAFFIC SETTING THE SCENE THE OIL AND GAS INDUSTRY Legislation STATISTICS OF INCIDENTS IN THE OFFSHORE INDUSTRY UNCERTAINTIES IN ACCIDENT DATA

COLLISION RISK ANALYSIS 5.1 5.2 5.2.1 5.2.2 5.2.3 5.2.4 5.3 5.3.1 5.3.2 5.3.3 5.3.4 5.4 HOW TO PERFORM A MARITIME RISK ASSESSMENT EXISTING COLLISION RISK MODELS Components in a collision risk analysis Probability of a collision Vessel types Type of collision CIRCUMSTANCES WITH AN IMPACT ON COLLISION RISK Characteristics of the installation Location of an offshore installation Manned or unmanned installation Shipping traffic REFLECTIONS

THE AS-PLANNED MODE A SUCCESS SCENARIO 6.1 6.2 6.3 6.4 ON APPROACH TOWARDS AN OFFSHORE INSTALLATION DEFINING COLLISION COURSE COLLISION AVOIDANCE REFLECTION

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IDENTIFICATION OF FACTORS IN COLLISIONS 7.1 7.1.1 7.1.2 7.2 7.2.1 7.3 7.4 FOUR SCENARIOS CONTRIBUTING TO THE COLLISION RISK Interaction between scenarios Selection of scenarios to assess LACK OF AWARENESS Primary causes HANDLING ERROR UNDERLYING FACTORS

35 36 37 37 38 38 40 40 43 43 44 45 46 47 48 49 50 51 52 53 54 55 56 56 57 59 59 62 62 65 65 65 66 67 67 70 73 85 87 89 91 103

EVALUATION OF FACTORS IN COLLISIONS 8.1 8.2 8.3 8.4 8.4.1 8.4.2 8.4.3 8.4.4 8.4.5 8.4.6 8.4.7 8.4.8 8.5 8.6 8.7 8.7.1 INTERVIEWS METHOD FOR ASSESSING THE RESULTS SCENARIOS LACK OF AWARENESS Failure related to navigation equipment/process External communication failure Substance abuse Asleep Illness Personal injury Distracted Absent HANDLING ERROR FACTORS ADDED DURING THE INTERVIEWS SUMMARY OF RESULTS Comparison to RABL project

DISCUSSION 9.1 9.2 9.3 INTERVIEWS AND RESULTS HUMAN AND ORGANISATIONAL FACTORS MEASURING THE IMPACTS THE LITERATURE REVIEW

10

CONCLUSION 10.1 10.2 10.3 REACHING THE PURPOSE ANSWERING THE RESEARCH QUESTIONS FUTURE WORK

11

REFERENCES 11.1 11.2 LITERATURE ELECTRONIC REFERENCES

APPENDIX A INTERVIEW GUIDE APPENDIX B EXPERT GROUP APPENDIX C EXPLANATIONS APPENDIX D DEFINITIONS OF CONCEPTS APPENDIX E RESULTS: SCENARIOS AND PRIMARY CAUSES APPENDIX F RESULTS: UNDERLYING FACTORS

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Introduction

Thischapterprovidesthebackgroundofthethesis,outlinesthepurposeandresearchquestions anddefinedelimitations. ThismasterthesisistheconcludingpartoftheMasterofScienceProgrammeinRisk ManagementandFireSafetyEngineeringatLundUniversity,Sweden.Thethesishasbeen writteninassociationwiththeDepartmentofFireSafetyEngineeringandSystemsSafetyin LundandDetNorskeVeritas(DNV)inOslo.Theprojecthasbeendevelopedduringaperiodof 20weeks.

1.1 Background
TheninthofJuly2007oneofthemostseriousincidentsoftheyearoccurredwhenthevessel BourbonSurfcollidedwiththeoffshoreinstallationGrane.Thesituationwasclosetoresultin catastrophicconsequencesfortheinstallationandthenumberoffailurescenarioslinked togetherpriortothecollisionwasremarkable. ThePetroleumSafetyAuthority(PSA)hasrarelybeenpresentedwithascenarioincludingsucha considerablenumberoffailuresatthelevelofseriousnessasweredescribedbytheshipping companyBourbonOffshoreinOctober2007: Boththecaptainandthemasterleftthebridgeatacriticaltimewhentheshipwason itswaytowardsGraneandthevesselcontinuedatautopilotwithoutanywatchkeeping. Thewaypointoftheshipwassetdirectlyattheoffshoreinstallation. Therewasnocontactbetweenthevesselandtheinstallationduringtheapproach,even thoughtheprescriptioncallsoutforthis. Thescheduleforenteringthesafetyzonewasnotfilledout. Thecaptainmisinterpretedthespeedofthevesselandthedistancetotheinstallation, hencethespeedofthevesselexceededtherestrictions. Theresponsibilitiesandtherolesbetweenthecaptainandthemasterwereunclear,the communicationwasquestionableandthecaptainwasnotincontrolofthevesselina criticalphase. (FreelytranslatedfromPSA,2008b) Asdescribedintheaccidentscenarioabove,collisionsbetweenshipsandoffshoreinstallations dooccureventhoughtherehavebeenamazingimprovementswithinthemaritimesector consideringtechnicalequipment,trainingandmanagementprocedures(Wang&Zhang,2000; Ltzhft&Dekker,2002).So,whydocollisionsstilloccur?Agreatlevelofcomplexitylieswithin shiporganisations,asystemwhichinvolveshumans,technicalequipmentanddecisionmaking inseveraldifferentpartsoftheorganisationalstructure.Thereiswithoutdoubtaneedfor identifyingtheunderlyingreasonsofacollision,sothatagreaterunderstandingofwhy collisionsoccurcanbeachievedandfutureaccidentsavoided. Theconsequencesofacollisiondependoncharacteristicssuchasthetypeofvessel,thespeed, whereontheinstallationtheshiphitsetc.Thecollisioncaninaworstcaseleadtoatotal collapseoftheoffshoreinstallationresultinginfatalities,environmentaldamagesandhigh economiccosts.

 Whendiscussingoffshoreinstallationswithinthisthesis,severaltypesofobjectsinvolvedin petroleumactivitiesareincluded.Fixedplatforms,floatinginstallations,semisubmersibles, jackupsandfloatingproduction,storage&offloading(FPSO)unitswillallbetakenaccountofin theexpressionoffshoreinstallation. Anoffshoreinstallationisexposedtomanytypesofrisksandhazards,suchasexplosions, leakages,fires,fallingobjectsandcollisions(Harstad,1991).Statisticsshowthatapproximately 10percentoftheannualdamagecostforanoffshoreinstallationisrelatedtocollisions(DNV Technica,1995).Ananalysisofincidentrecords(19752001)oftheUnitedKingdomContinental Shelf(UKCS)showsthatthemeanincidentcollisionfrequencyis0.24peryearforcollisions (HSE,2003).Themostfrequenttypeofcollisioninvolvessupplyvesselsthataredesignatedto reachanoffshoreinstallation,butforsomereasoncollidewiththeinstallation.Theseincidents generallyhaveminorconsequencesduetodecreasedspeedetc.butsomerareeventshave occurredwithconsiderableconsequences(HSE,2003).Othervesseltypesthatposeariskare forexamplemerchantships,fishingboats,standbyvesselsandnavyvessels,outofwhich merchantshipsarelikelytocauseconsiderableconsequencesduetocharacteristicssuchassize andspeed. Theriskforshipcollisionsisusuallyestimatedtobeoneofthedominatingrisksforanoffshore installation(HSE,2003).Whetherthisdependsontheactualriskbeinggoverningorthemodels forassessingcollisionrisksnotreflectingrealitywellenoughisleftunsaid.However,without commentingthestatementfurther,thisshowsagreatrelevanceoftheareaofresearch.There isalsoaneedtoupdatethemodelstoreflectthetechnicaldevelopmentandmanagement changesoftoday,whenconsideringthatmanyofthebaseassumptionsofthemodelsoriginate fromthe1980s.

1.1.1 AssociationwithDNV
DNVisregularlyworkingwithclientsfromtheoffshoreindustry,e.g.performingrisk assessmentsofnewdevelopmentsofoilandgasinstallationsorassessingchangesthatare requiringanupdatedriskassessment,tocorrectlyreflecttheexistingriskpicture. ThereareseveraldifferentresearchprojectswithinDNVwithanaimtofurtherdevelopthe modelsusedforanalysingcollisionrisks.Theprojectsarespanningfromextensiveconsequence modellingtoestablishmentofvalidshipdataandstatistics.Thesubjectofthisthesisoriginated inaneedwithinDNVforcontinuousupdateandreviewofthemodelsusedwhenassessingthe collisionriskforanoffshoreinstallation.

1.2 Problemdefinition
Firstofall,thefocusofthisthesismainlylieswithintheboundariesoftheshipandnotthe installationduetowheretheprimarypossibilitytoavoidacollisionexists.Aboveall,itisthe shipthatisphysicallyabletoavoidcollidingwithanoffshoreinstallationbychangingitscourse. Anonfixedoffshoreinstallationmaybecapableofchanginglocation,butthisisinmostcases suchatimelyandhighriskoperationthatmustbeinitiatedataveryearlystageandmeansa significantproductionloss.Thismaythereforenotbealikelymeasuretotake.Afullevacuation ofanoffshoreinstallationisconsideredtolastapproximately30minutes(PSA,2008a).Priorto this,thecrewhastoobtainawarenessofapotentialcollisionriskandinitiateevacuation.Along

durationofthisphasedependsonfactorssuchasthedifficultytoidentifyavesselasariskata longdistance,highshipdensityetc.Theriskforshipcollisionsisgenerallyperceivedassmall amongstemployeesatoffshoreinstallations,whencomparedtootherhazardssuchasleakages, explosionsandfires(PSA,2008a).Thisviewmayprolongthetimebeforeawarenessisreached. Also,torelocateanoffshoreinstallationdoesnotnecessarilymeanriskavoidance,considering thattheshiphypotheticallycouldchangeitscourseinthesamedirection. Oneofthemostcomplicatedareastomeasureandquantifyishumanandorganisationalfactors anditsimpactonaccidentscenariosisknowntobesubstantial(refertoSection3.1).The collisionriskmodelsdogenerallynotseemtoconsidererrorswithorganisationalandhuman backgroundinsuchacomprehensivemannernecessarytoprovidereliableapplicability. Anothermattertoqueryisdiscoveredwhenlookingintotheinputdatausedwhenconducting ananalysis.Numerousinputsconsistofexpertjudgementsbasedonassumptions,technical equipmentandmanagementproceduresthatwererelevantforthetimeofthejudgement. Therehavebeengradualchangessincethemodelswerecreatedandanupdateistherefore necessary,tomoreaccuratelyreflectthecurrentconditions. Itisshowninaccidentdatabasesthataverylimitednumberofcollisionswithoffshore installationshaveoccurredworldwide(e.g.HSE,2003).Therearethereforemanydifficulties withestimatingtheprobabilityofacollisionwhenonlyusingstatisticaldataasthefoundation, giventhefewaccidentsthathaveoccurred. Bearinginmindthereasoningabove,therearesomesignificantweaknesseswiththeexisting methodsthatareusedtoassesscollisionrisk.Morebackgroundinformationtotheproblem definitionwillbeprovidedinChapters26whichalsogivesmorecontexttothedelimitations.

1.3 Purpose
Theoverallpurposeofthisthesisistoevaluatefactorsthatareaffectingtheriskforacollision betweenashipandanoffshoreinstallation.Thiswillcontributetoabetterunderstandingof whichfactorsshouldbeincludedinacollisionriskanalysisandhowimportantthesefactorsare. Theresultsfromthisstudyshouldbepossibletouseforcompaniesandorganisationsthatdeal withcollisionriskanalyses.Theresultsshouldalsoprovideguidanceandsupportriskcontrol measuresthataretobeundertaken. Theprincipaltargetgroupofthisthesisispeopleworkingwithcollisionriskanalysisinthe offshoreindustryandinthemaritimesector.

1.4 Researchquestions
Theresearchquestionsthatneedtoberesolvedtoobtainthepurposeofthisthesisare:

Whataretheprimarycausesandunderlyingfactorsbehindashipcollisionwith anoffshoreinstallation? Towhatextentdotheseidentifiedprimarycausesandunderlyingfactors contributetotheriskforacollision? Howcanthisdeeperunderstandingofcollisionsbeused,bothintegratedwhen assessingcollisionriskandgenerallyinthemaritimesector?

1.5 Delimitations
Severaldelimitationshavetobemadeduetothelimitedtimeavailableofthemasterthesis. Onlycollisionsbetweenshipsandoffshoreinstallationswillbeexamined,notcollisionswith otherkindsofinstallationsorcollisionsbetweentwoships.Thethesiswilllookcloserinto modelsthatareusedtopredictthefrequencyforthecollisionriskandwillnotdiscussthe consequencesbecausehowthemethodstoassessfrequencyandconsequenceforacollision generallyareseparated.Therearealsoseveralsourcesofresearchthatdealswiththestructural impairmentsubsequentacollision.Asdescribedintheproblemdefinitionabove,anassumption consideringthepossibilityoftheoffshoreinstallationrelocatingtoavoidacollisionis disregarded.Intentionalcollisionssuchasterrorismwhereavesselaimstocollidewithan offshoreinstallationareonlybrieflydiscussed.Similarly,directtechnicalproblemsthatmay causeacollision,e.g.steeringfailure,areonlyconciselytouchedupon.Thestudyexcludes collisionsbetweenoffshorevesselsandtheirdedicatedoffshoreinstallationsandalsocollisions withsubmarines.Theorganisation,proceduresandpatternsofmovementofbothoffshore vesselsandsubmarinesadverselydivergesfromotherpassingvesselsandthisthesisis thereforenotapplicabletothesevesseltypes.

1.6 Disposition
Thethesisisdividedintofourpartstoeasilygiveanoverviewofthescopeofworkandalsoto facilitateifareaderhasaninterestinaspecificsection.Severalchaptersareconcludedwith reflections,whichconsistofthethoughtsoftheauthorsifnothingelseismentioned. Part1compriseschapters12andprovidesabackground,expressesthepurposeofthethesis andsummarisestheresearchquestions.Inaddition,themethodologyusedinthethesisis outlinedandrelatedtoscientificsettings. Part2containschapters36whereimportantconceptsandtheoriesaredescribedfollowedby amorespecificintroductiontothemaritimeandoffshoreindustriesandtoriskassessment withintheoffshoresector. Part3consistsofchapters78andpresentstheidentificationandassessmentofidentified componentsinacollisionscenariotogetherwithasummaryoftheresultsfromexpert judgements. Part4includeschapters910withadiscussionoftheresults,conclusionsand recommendationsforfuturework.

Method

Thischapterdescribessomeofthethoughtsbehindthechoiceofmethodandgivesabrief summaryoftheworkprocessofthethesis.Thetextiscomplementedbyanillustrationthat showstheinteractionsbetweenthedifferentpartsoftheworkprocess(refertoFigure1,p.10).

2.1 Scientificperspective
Tomakesurethatresearchcanbeusefulandbeneficialtoothers,itisveryimportanttobe scientific.Ifscientificmethodsandwaystoexpressresultsareapplied,validationwillbe possibleandtheresultscanthereforebeappliedinothercontexts,hencefacilitate communicationbetweenpeople(Backman,2008). Toachievescientificresearch,itisnecessarytopursuereliability,validityandobjectivity (Ejvegrd,2008).Validityconsidersifwhatissupposedtobemeasuredreallyismeasured. Reliabilitydescribeshowreliablethewayofmeasuringis,e.g.therepeatabilityofthemethod. Lowreliabilityalwaysleadstolowvalidity.Objectivitytakesintoaccounthowneutralprojects areandifallviewsoftheproblemareconsidered.(TheUniversityofGothenburg,2008) Therearethreestatementsthatrefereesofscientificarticlesuseandthatcontributetothe achievementofvalidity,reliabilityandobjectivity.Itshouldbepossibleforreadersofaresearch reportto: Repeattheexamination Evaluatemethods,observationsandresults Understandtheintellectualprocess (LuleUniversityofTechnology,2008) Thesestatementsarekeptinmindduringthedevelopmentofthethesiswhichhopefullyhas resultedinatransparentprojectthatiseasytofollow,understandandevaluate. Itispossibletomeasurevalidityandreliabilityinnumericalwaysifquantitativemethodsare used(TheUniversityofGothenburg,2008).Anendeavourtoachievevalidityispossiblein qualitativestudies,butitishoweverunlikelythatthevalidityofaqualitativemeasuring instrumentwillbeascategoricallylaiddownasaquantitativeinstrument(TheUniversityof Mlardalen,2008).Thevalidityinqualitativestudiesisratherfocusedonhowworkis accomplishedandtheeffortputintoitthanthemethodused(Golafshani,2003). Themethodofthisthesisisclassifiedasquantitative,butwithaqualitativeapproach.Whenit comestotheassessmentoffactors,questionnaires,scalesandnumericalmethodsareused, whichtraditionallyaresignsofaquantitativemethod(Backman,2008).Thepurposeishowever morefocusedoncontributingtoafundamentalunderstandingofthemostimportantfactorsin acollisionthantryingtoevaluateprobabilitiesofthese,whichmakestheapproachmore qualitative.Inadditiontothis,thebasisoftheassessmentisanevaluationofcausesand underlyingfactorsundertakenthroughliteraturereviewsanddiscussions,alsonormallyseenas qualitativemethods(Backman,2008).

2.2 Workprocess
Thissectiondescribestheworkprocessanddiscussesboththewaytowardsadefinitionofthe purposeandthephasesthatledtocompletionoftheproject.

2.2.1 Decisionofpurposeandresearchquestions
Theoverallpurposewasfromthebeginningtoevaluateandupdatetheexistingmodelsthatare usedtoassesstheriskforcollisionsbetweenshipsandoffshoreinstallations.Duetothelarge extentofthatpurpose,delimitationshadtobemade.Acomparativelylargeamountoftime duringthefirstweekswasspentevaluatingthemodelsforcollisionriskthatareusedatDNV,so thatamorespecificpurposecouldbeoutlined.Afterthereviewofthemodels,afocusonthe actionsoftheshipinacollisionscenariowasdecided,mainlyforthereasonofthecrucialrole theshipplaysinacollisionandthenecessitytoupdatethispartofthemodel.

2.2.2 Literatureandcontacts
Literatureandcontactsareessentialpartsofthework.Readingofliteraturehasbeenanon goingprocessfromstartandalmosttotheend,ofcoursewithdifferentfocusareasduringthe progressofthethesis. Theliteraturereviewstartedwitharatherunspecifiedsearchforrelevantinformation. Keywordswhensearchingforliteraturewereforexample:offshore,ship,collision,riskanalysis, QRA,HRA,humanerror,organisationalfactorsandoilplatform.Thegoalwastoreachadeeper understandingofthesubjectandbeabletomakedelimitationsandcometoadecisionon researchquestions. SomeoftheriskanalysesrecentlyundertakenbyDNVwerestudied,whichhelpedtoidentify importantassumptionsandlimitationsthatareincludedinacollisionriskanalysis.Italsogave anunderstandingforhowtheanalysesareperformedtoday. Duetotheglobalnatureofshipping,researchwithintheareaisspreadallovertheworld.The sourcesofinformationaremanyanddivided,bothgeographicallyandbetweendifferenttypes oforganisations.Thiscontributestodifficultieswhentryingtogetanoverviewbutalsoprovides numerousindependentsourcesanddiverseviewsofthearea. Theinformationaboutsafetymanagement,organisationalfactorsandhumanerrorsisalmost neverending,especiallywhenitcomestotheoreticalapproachesandhowtodividefactorsinto separategroups.Primarilyliteraturecloselylinkedtothemaritimesectorwasselected.Existing researchdoesnotoftendiscusscollisionrisksforoffshoreinstallations,butmorefrequently focusesoncollisionsbetweentwoships,shipsandwindfarmsorotherkindsofaccidentssuch asgroundings. Exceptfromthearticles,reportsandbooksfoundthroughdifferentsearchengines,alotof usefulinformationwasreceivedfromcontactswithinDNV.Universitieswithrelevanteducation programmesandwithorganisationsthatworkwithinthemaritimeandoffshoresectorshave alsobeensourcesofinformation.

2.2.3 Evaluationandmeasurementoffactors
Fromtheliteraturereviewincombinationwithworkshopsandbrainstorming,aselectionof causesandunderlyingfactorsthatcontributetotheriskforcollisionscouldbecompleted.Inthe workshops,ahierarchicalmodelwasusedasastartingpointwithacollisionasthetopevent. Onthebasisofthemodelitwaspossibletoworkoutalogicalconnectionbetweenthe identifiedscenarios,primarycausesandunderlyingfactors.Amorethoroughdescriptionofthis processcanbefoundinSection7.1.1.Whenthestructurehadbeensetup,itwaspresentedto peopleworkinginthemaritimesectoratDNV. Theevaluationoffactorswasdoneinassistancewithexpertsthroughinterviews.Theinterview guidewastestedbyoneriskanalystwithintheoffshoresector,oneriskanalystwithinsafety andonepsychologistworkingwithhumanfactors.Thiswasdonetoachieveamaterialthatwas workableandcomprehensible. Thereareseveralbenefitswithusingexertjudgement,consideringthepossibilitiestoembrace newknowledgeandassessareasthataredifficulttoanalysebyonlyusingstatistics.Expert judgementshavebeenusedinseveralprojectswithinthearea(Technica,1987;HSE1999; Soma,1999). Theinitialplanwastoassessthefirsttwolevelsofthestructuralmodel,i.e.thescenariosand primarycausesthatcanleadtoacollision,withashortquestionnaireandvaluetheunderlying factorsthroughinterviews.Thereasontowhyaquestionnairewaschosenfortheprimary causesbutnotfortheunderlyingfactorswasmainlybecausetheprimarycausesarequiteeasy tounderstandwithoutexplanations.Theunderlyingfactorsaremorecomplicatedtoexplainin ashortandconsistentway.Byrankingtheprimarycausesinaquestionnaireandnotonlyin interviews,theadvantageofmanyrespondentsfortheprimarycausescouldhavebeen achieved.Thequestionnairewassenttoshipcaptainsandlastyearstudentsatmaritime collegesbutduetolowresponsefrequency,thequestionnairewasnotusedwhencompiling theresults.Tomakesurethattheresultswouldbevalid,theinitialaimwastoreceive approximately100answers,howeveronly40questionnaireswerereturnedintheend. Scenarios,primarycausesandunderlyingfactorswereinsteadevaluatedthroughinterviews. Theinterviewswerefollowinganinterviewguidewithalayoutasaquestionnaire(referto AppendixA).Theselectionofparticipantsininterviewsisofgreatimportance,especiallywhen thenumberofrespondentsislimited.Alistofparticipantsininterviewscanbefoundin AppendixB. Theresultsfromtheinterviewswerebroughttogetherandthencomparedwithprevious researchfoundthroughtheliteraturereview.Conclusionscouldbedrawnfromtheanalysisand recommendationsforfutureworkweremade.

Figure1:Anillustrationandoverviewoftheworkprocesswithrespecttoitsdistributionovertime.Thearrowsshowtheflowofinformationbetweenthe differentphases.

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Humanandorganisationalfactors

Thischapterprovidesthebasisforourviewonhumanandorganisationalfactors.Definitionsof conceptsthatareregardedasimportantfortheunderstandingofthisthesiswillalsobegiven.

3.1 Introduction
Evenbeforethe19thcentury,humanerrorwasidentifiedasoneoftheprimaryfactors contributingtocasualtiesatsea.TheresearchabouthumanfactorsincreasedwiththeWorld WarIIandthepositiveresultsprovidedtheimpetusforfurtherresearchintheareaofmaritime humanfactors.Sincethen,therehasbeensubstantialdevelopmentandhumanfactorsare currentlyintegratedintheregulationsfromtheInternationalMaritimeOrganisation(IMO) throughforexampletheISMcodeandtheSTCWconvention.(Grechetal,2008) Today,researchaboutthesubjectisorhasbeenconductedbyforexampleIMO,theHealthand SafetyExecutive(HSE)intheUKanduniversities(e.g.NorwegianUniversityofScienceand TechnologyandLundUniversity).AccidentdatabasesandreportsfromforexampletheSwedish AccidentInvestigationBoardalsotendtoprovidemoredetailedinformationaboutcausesof accidentsthanbefore. Humanfactorsareveryoftenmentionedasthemostcommoncausetoaccidents,butits contributionvariesindifferentsourcesfrom46%to85%oftheaccidents(Baker&Seah,2004). Theholisticviewtogetherwithdefinitionsofhumanfactorsandhumanerrorsplayavitalrole withregardstohowthesecanbeusedinresearch,preventivemeasuresetc.Thedefinitionsare thoughveryseldommentionedinresearcharticlesandaccidentreports.Thislackofascientific definitionofthehumanfactormakesitdifficulttointerpretthefindings(MarineProfile,2008).

3.2 Differentviews
Therearetwobasicwaystolookathumanerrors;thepersonalapproachandthesystem approach.Thepersonalapproachfocusesonunsafeactsasresultsfromdeviantmoral processes.Thesystemapproachregardshumanerrorsasconsequencesratherthancausesand thathumanerrorsmainlyhaveanorigininsystemicfactors.Abasicstatementofthesystem approachishowhumanconditionsareimpossibletochange,buttheconditionsunderwhich humansworkcanbealtered.Defencesandbarriersarekeyelementsintheapproach.(Reason, 2000) Thesystemapproachisusedasabasisfortheevaluationofcausesandunderlyingfactorstothe collisionriskinthisthesis.Thesystemapproachhasbeenchosen,mainlybecauseofabeliefin theapproachbutalsobecausethisistheoutstandinglydominatingapproachintheliterature.It doeshoweverseemlikethepersonalapproachismoreoftenappliedinpracticethanintheory. Reason(2000)illustratesthesystemapproachwithaslicedSwisscheesewheretheholesinthe cheeserepresentfailures(Figure2).Foranaccidenttooccur,failuresusuallyneedtohappenat differentlevelsandtogetherbelinkedasachainofeventsendingintheincident.Thepresence ofaholeinonebarrierdoesnormallynotcauseanaccident,eachbarrierservesasadefenceor apreventivemeasure.

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Figure2:TheSwisscheesemodel(Reason,2000).

Theholesinthebarriersarisefortworeasons:latentconditionsandactivefailures.Latent conditionsarethosethatdonotimmediatelydegradetheoperationofasystembutcanleadto anaccidentifcombinedwithotherevents,forexampleactivehumanerrors(Embrey,1992). Activefailuresareunsafeactscommittedbypeoplewhoareindirectcontactwithasystem.The activefailureshaveanimmediateandusuallyshortlivedimpactontheintegrityofadefence. Ananalogycanbemadewhereactivefailuresaredescribedtobelikemosquitoes. Theycanbeswattedonebyone,buttheystillkeepcoming.Thebestremediesaretocreate moreeffectivedefencesandtodraintheswampsinwhichtheybreed.Theswamps,inthiscase, representtheeverpresentlatentconditions. (Reason,2000) Latentconditionscanbeidentifiedanddealtwithbeforeanadverseeventoccurs,whileactive failuresoftenaremoredifficulttoforesee. Itisveryimportanttorealisethathumansnotonlycontributetofailuresbutarealsohandlinga lotofproblematicsituations.Afeasiblesolutionishardlytoreplaceallhumanswithtechnical equipment;humansarestillmoreadaptivetodifferentenvironmentsandsituationswith creativitywhenitcomestosolvingproblems.

3.3 Categorisationanddefinitionsoffactors
Thesystemapproachmeansthatnotonlythehumanasanindividualisaffectingthepossibility forafailurethatiscategorisedasahumanerrorinforexampleanaccidentreport.Human errorsarealsoinfluencedbythesurroundingsthroughlegislation,organisationalculture, environment,designetc. Theconnectionsbetweenthesedifferentelementshavebeenillustratedasasociotechnical system,forexamplebyKoesterthroughTheSeptigonModel(Figure3).Thesociotechnical systemmodelaimstofocusontherelationshipbetweenpeopleandtechnology.Grechetal. (2008)meanthatitisobviousthatorganisationsinthemaritimedomainareconsistentwiththe sociotechnicalsystemsperspectiveandthatshipscanbeanalysedasacombinationof technology(thevessel,engine,equipment,instrumentsetc.)andasocialsystem(thecrew,their culture,norms,habits,custom,practicesetc.).

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Figure3:TheSeptigonModelbyThomasKoester(Grechetal.2008).

Anotherillustrationoftheconnectionbetweendifferentelementshasbeenpreparedby Embrey(1992).ThisgenericmodeliscalledMACHINE(ModelofAccidentcausationusing HierarchicalInfluenceNetwork)andshowshowthedirectcausesofallaccidentsare combinationsofhumanerrors,hardwarefailuresandexternalevents(Figure4).

Figure4:TheMACHINEmodelreflectstherelationshipbetweenhumans,technologyandenvironmental elements(Embrey,1992).

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Thesetwomodelsarejustasmallselectionofthetheoriesfoundintheliterature.Thereare severaldifferentcategorisationsandgroupingsofhumanandorganisationalfactorsthatallaim toclarifytheconnectionsbetweenhumansandthesurroundingenvironment. Mostresearchprojectsfocusonanarrowarea,maybejustonespecificcontributingfactor,and arethereforenotforcedtodealwiththeproblemofcategorisationinthesamewayasprojects thatspanoveralargerextent.Thecorrelationbetweenfactorscansometimesmakeitdifficult todecidetheoriginofafailure.Thebordersbetweendifferentcategoriesorelements,e.g. humanfactors,organisationalfactorsandtechnicalfactors,arefarfromfixedanditisnot alwaysobviouswhichcategoryaspecificfactorbelongsto.

3.4 Definitions
Asmentionedbefore,theconcepthumanfactorisveryseldomdefinedinliterature,which increasesthelikelihoodthatdifferentinterpretationsoftheconceptareused.Thisproblemis closelyconnectedtothediscussionaboveaboutcategorisation.Ifsomeonefailsusingthe technicalequipment,istheproblemtechnicalorhuman?Doesthefailuredependonthedesign oftheequipmentorbecausetheuserdoesnotknowwhatbuttontopress? Therearenoblackorwhiteanswerswhendealingwithhumanandorganisationalerrors,rather afieldwithdifferentshadesofgrey.Thecausesofafailurecanbemanyandmostofthemare, asshowninFigure4,connectedtoeachother.Inonewayoranother,humansarealwaysthe causeofafailurebecausetheydesigntechnicalequipmentandformorganisations.Butthere needtobeadistinctionsomewhere,whereshouldthelinebedrawn? Conceptswithinthisthesisaredefinedasfollows.Thedefinitionsarenotcomprehensivebut theywillhopefullygivesomeguidance. HumanfactorThescientificdisciplineofunderstandingtheinteractionsamonghumansand otherelementsofasystemandalsotheprofessionthatappliestheory,principles,dataand methodstodesigninordertooptimisehumanwellbeingandoverallsystemperformance(IEA, 2008).Humanfactorissometimesusedsynonymouslywithergonomicseventhough ergonomicsisasubsetofhumanfactors(Grechetal,2008). HumanerrorAninappropriateorundesirablehumandecisionorbehaviourthatleadsto unwantedoutcomesorhassignificantpotentialforsuchanoutcome(Grechetal,2008). Dekker(2002)viewshumanerroronthebasisofthreefactorsthatallcontributetothe definition: Humanerrorisasymptomofproblemsdeeperinsidethesystem. Humanerrorissystematicallyconnectedtofeaturesofpeoplestools,tasksand operatingenvironment. Humanerrorisnottheconclusionofaninvestigation,itisthestartingpoint. Theexpressionhumanerrorisusedinsituationswhenthereasonisprimarilyrelatedto humanbehaviour.Underlyingfactorstotheprimarycausescanbeorganisational,humanor technicalbuttheprimarycauseisstilltheactsofanindividual.

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OrganisationalfactorAfactorconnectedtoacorporateresponsibilityreflectedbyateamora groupofindividuals,consciouslyornot. TechnicalfailureAfailurethatisnotaffecteddirectlybyhumansinthespecificsituation.This canforexamplebeaproductionfailurethatarisesduringtheusageofequipmentbutnot relatedtotheuser.

3.5 Measuringhumanandorganisationalfactors
Humanandorganisationalfactorsarenoteasytomeasureandquantifybecauseoftheirvery nature.Theyarelivingelementsandaretoalargeextentbaseduponsubjectivethoughtsand ideas. Therearedifficultiesanduncertaintiesinvolvedwhenassessinghumanandorganisational factorsinaquantitativeway.Itshouldalsobetakenintoconsiderationifthereevenisa purposeofquantification.Itcanbemisleadingtoquantifyfactorsthatarechallengingto estimate,especiallywhenthevaluesaregoingtobeusedinabiggerperspectiveandmaybe evenwithoutacompletedefinitionandexplanation. Thedifferentmethodsavailableformeasuringhumanandorganisationalfactorsaremanyand almostimpossibletooverview.Mostmethodsareadjustedtothepurposeofthespecific survey.ExamplesofmethodsusedareTHERP,HEARTandSLIM(Grozdanovi&Stojiljkovi, 2006).Dataandstatisticsusedinthemethodsareusuallybasedonexpertjudgementor statisticsfromaccidentsandnearmisses. Eventhoughthereisagreatcomplexityintryingtoquantifyhumanandorganisationalfactors, ignoringthetopicisnotafeasibleway.Humanandorganisationalfactorsmustbetakeninto considerationsomehowandtheimpactshouldbereflectedinriskanalysesthatconcern systemsinvolvinghumans.

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16

Interactionbetweenthemaritimeandoffshoreindustries

Thischapteraimstobrieflytouchuponthemaritimeandoffshoresectorsincludingapplicable legislation.Followingthisisapartaboutincidentswithinshippingandthelastsectionisa discussionofthedilemmawithusingaccidentstatisticswhenassessingthecollisionriskbetween shipsandoffshoreinstallations.

4.1 Maritimetrafficsettingthescene
Shippingandseafaringisoneoftheoldestindustriesintheworldandalsoveryimportantby carrying97percentoftheworldtrade(Wang&Zhang,2000).Theindustryisinternationalandit iscommonwithcrewsofvariousnationalitiesincludingdifferentlanguages. Allshipshaveaflagstate,whichisaregionalpolicymakingauthoritywithineachcountrythat upholdstheinternationallegislation(Maritime&CoastGuardAgency,2006).SeealsoSection 4.2.1thatpresentslegislativerequirements. Therearevarioustypesofshipswithintheindustryandmaritimeworkcanbedefinedasany kindofworkperformedonboardanykindofvessel(Grechetal,2008).Fivemaritimeworktasks canbedefined: Navigation:routeplanning,trackkeepingandcollisionavoidance. Propulsion:theresponsibilityfortheintegrityoftheshipspropulsionsystemandassociated auxiliaries. Cargohandling:loading,keepingthecargo(includingpassengers)ingoodcondition,and unloading. Vesselmaintenance:keepingtheship,itsequipment(e.g.theauxiliaryequipment)andthecrew inoperationalcondition. Shipmanagement:allocationoftasksandresponsibilities,controlandsupervision,and communication. (Bertranc,2000) Aswithineverytypeofbusinessarea,therearevastdifferencesinorganisationalculturesinthe companiesoftheshippingindustry.Therealsoexistsalotofresearchconcerningsafetyculture andorganisationalcultureinthemaritimeindustries(PSA,2008a;Kristiansen&Soma,1999; Hvold,2007).

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 Assummarisedabove,oneoftheessential componentswithinshippingisnavigation. Navigationalaccuracyislimitedandwind/waves maygivedeviationofseveralnauticalmiles.GPS (GlobalPositioningSystem)isverycommonon allboatsexceptforsmallervessels(USCoast Guard,2008).AIS(AutomaticIdentification System)hasbeenenforcedbytheInternational MaritimeOrganisation(IMO)andisrequiredfor allvesselsthatmayposearisktooffshore installations.Theseareexamplesofthegreat developmentandseveralnewaidsthatbenefit theshippingindustry.Thesystemsimproveboth thenavigationalaccuracyandthepossibilityof easieraccessingcontactinformationofvessels, henceincreasingthelikelihoodofsuccessful warninginacollisionscenario. Figure5showsshiptrafficintheScandinavian area,gatheredfromAISdata.Thefigure Figure5:AnoverviewofshiptrafficinScandinavia, describestheregularshippingpatternsinthe recordedwithAIS(DNV,2008). watersoftheNorwegianContinentalShelf, shownasshadedareasoutsidethecoastlines. Everycompanyisobligedtoensurethatthemaster,officersandratingsdonotworkmore hoursthanissafeinrelationtotheperformanceofdutiesandthesafetyoftheship(IMO, 1999).Thereshouldforexamplealwaysbetwopeopleonthewatchduringnighttimeandin badweather(IMO,1995). Thetypeandsizeofashipisreflectedinthestructureoftheorganisation,bothinthecompany andonthevesselitself,byaffectinghowthewatchesaredivided,manninglevelsetc.Alarge passengershipwillpresumablyhaveatleasttwopeopleonthebridgewhilesmallfishing vesselsoftenhaveminimumcrewlevelsthataresupposedtobothmanagewatchkeepingon thebridgeandperformtasksondeck.Themanninglevelofavesselwouldmostlikelyaffectthe typeofwatchsystemthatisapplied.Thesizeoftheshippingcompanyandtheorganisational structureaffectstheorganisationalculture,acceptanceandhowwellproceduresare implemented.Shipsalsohavedifferentpatternsofmovement.Shipsinregulartrafficare expectedtofollowhistoricalshippingrouteswhilefishingboatsfollowthemotionsoftheir catch. AllvesselsmustbestandbyontheVHF(VeryHighFrequency)channel16.Thisopenand internationalwayofcommunicationisrestrictedtorelevantandsafetyrelatedcommunication (SwedishMaritimeAdministration,2008a).Irrelevantcommunicationisforbidden,butmay unfortunatelybecommon.

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Authorities TheNorwegianMaritimeDirectorate(NMD),knownasSjfartsdirektoratetinNorway, influencestheNorwegianstandsonshippingmattersandlegislationinaninternational perspective.ThedirectoratehasjurisdictionovershipsregisteredinNorwayandforeignships arrivinginNorwegianports.Thedirectoratesmaingoalsaretopreventaccidentsandto achieveahighlevelofsafetyforlives,health,vesselsandtheenvironment.(NMD,2008) TheInternationalMaritimeOrganisationisthemaritimeorganisationwithintheUnitedNations, withthekeytasktodevelopandmaintainacomprehensiveregulatoryframeworkforshipping globally.TheIMOsetstheinternationalstandardsthatlateronarereflectedinthenational legislation.Thisincludessafety,environmentalconcerns,legalmatters,technicalcooperation, maritimesecurityandtheefficiencyofshipping.TheIMOprovidesconventionssuchasSOLAS, MARPOLandtheISMcodethatestablishestheminimumlevelofsafetyonaship.Thereisalso aninternationalstandardfortraining,certificationandwatchkeepingforseafarers(STCW). (IMO,2008)

4.2 Theoilandgasindustry
TheoilandgasindustrystartedinNorway inthelate1960swiththediscoveryofthe Ekofiskarea(NPD,2008a).Figure6 Figure6illustratesthelocationand densityoftheoilandgasfieldsinthe Norwegiancontinentalshelf. ThepetroleumindustryinNorwayinvolves productioninformofbothoilandgasand isnowthedominatingbusinessareain Norwaybyprovidingapproximatelyathird ofthenationalincome.Thereare57fields ofproductionintheNorwegian ContinentalShelfin2008.Norwayis presentlythefifthlargestoilexporting countryandthe11thlargestproducerin theworld.(NPD,2008a) Alloffshoreinstallationsaresurrounded byasafetyzonethatextends500metres fromanypartoftheinstallation.Shipsare notallowedtoenterthezone.(HSE,2008) Figure6:Locationoftheoffshoreinstallations2006
(NPD,2008b)

4.2.1 Legislation
Thelegislativeframeworkprovidestheconditionsforlayoutandlocationofoffshore installationsandrequiresriskanalysestobeperformedsothatacertainlevelofsafetycanbe ensured.Therehasbeengreatdevelopmentandadjustmenttothesurroundingconditionsin theoffshoreindustry.Norwayhas,togetherwiththeUK,beentheproceedingcountrywith

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regardstolegislationandnew,innovativeideas.Theauthoritieshaveprogressivelychangedthe legislationtowardsbeinggoalorientedandperformancebased,whencomparedtotheprevious morespecificandprescriptiverequirements(Aven&Pitblado,1998;Smith,1995;FriisHansen &Simonsen,2002). Authorities ThemainauthoritythatprovideslegislativeconditionsforpetroleumactivitiesintheNorwegian ContinentalShelfisthePetroleumSafetyAuthority(PSA),whichisreferredtoas Petroleumtilsynet(Ptil)inNorwegian.PSAisthegovernmentalbodyfortechnicaland operationalsafetyincludingemergencypreparednessandfortheworkingenvironment(PSA, 2008c). InadditiontotheinternationalandNorwegianjurisdiction,theauthoritiesintheUKalsoplayan importantroleduetoitsgeographicallocation.TheHealthandSafetyExecutive(HSE)isthe governmentalbodyintheUnitedKingdomthataimstoprotectpeopleagainstriskstohealthor safety,arisingoutofworkactivities.Thisisachievedthroughresearch,informationandadvice, promotingtraining,inspection,investigationandenforcement.(HSE,2008) Overviewofhistoricalbackground Thelegislationrestrictingtheoilandgasproductionindustryhasitsstartingpointin quantitativeriskassessment(QRA)thatoriginatedintheprobabilisticriskassessments developedinthenuclearindustryintheUSA(Vinnem,2007). QRAwasintroducedintheoffshoreindustryinNorwayinthelate1970s.Thiswasfollowedby guidelinesforsafetyevaluationofplatformconceptualdesignin1981,requiringthataQRAwas completedforeachinstallation.Thedocumentpresentedafixedriskacceptancecriterionfor lifesafetythatwassetto104perplatformyearasthelegitimatefrequencyofaccidents(Aven& Vinnem,2005).Followingthisdevelopment,NorwaywastheonlycountryrequiringaQRAuntil itbecamemandatoryintheUKaswellin1988,followingthePiperAlphaincident. Existinglegislation Since2004thePetroleumSafetyAuthority(PSA)hasissuedfiveregulationsthatcontrolsafety ofdesignandoperationofoffshoreinstallations: 1. Regulationsrelatingtohealth,environmentandsafetyinthepetroleumactivities(the Frameworkregulations) 2. Regulationsrelatingtomanagementinthepetroleumactivities(theManagement regulations) 3. Regulationsrelatingtodesignandoutfittingoffacilitiesetc.inthepetroleumactivities (theFacilitiesregulations) 4. Regulationsrelatingtoconductofactivitiesinthepetroleumactivities(theActivities regulations) 5. Regulationsrelatingtomaterialandinformationinthepetroleumactivities(the Informationdutyregulations) (PSA,2008d)

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 Inadditiontotheregulationsdescribedabove,theNMDRiskAnalysisRegulationsrequirethata riskanalysisiscompletedforallmobileunits.Thisappliestoallvesselsthatareregisteredwithin theNorwegianregisterofships. ThelegislativeframeworksarenowsimilarintheUKandNorway.However,onenoteworthy differenceishowtheriskanalysesintheUKonlyareappliedtoassesslifesafetyandnot environmentalandassetrisks. Riskacceptancecriteria Therearetwomaincategoriesofriskacceptancecriteriarelatedtopersonnelriskthatare commonlyusedintheNorwegianandUKcontinentalshelves.Firstly,thereareabsolutevalues thatstatethatthelikelihoodofacertainconsequenceshallnotexceedafixednumber,suchas theacceptancecriterionof104aspreviouslymentioned.Secondly,statisticalexpectednumbers offatalitiesper100millionexposedhours(i.e.theFARvalue)isappliedwithintheindustry (Aven&Pitblado,1998). Usingdefiniteriskcriteriathatarepredeterminedcanresultinassessmentshavingthewrong focusandpurelyaimtomeetthecriteriaratherthanachievingoverallgoodandviabledesign solutions(Aven&Vinnem,2005).Itispossiblethathavingspecificriskacceptancecriteriamay leadtonumbercrunchingintheareasthatareconsideredeasilyquantifiedwhereas significantareassuchashumanfactorsaretreatedmorevaguelyduetothedifficultiesin accuratequantification.Butthesetypesofproblemsmayalsoexistifriskacceptancecriteriaare definedafterariskanalysisiscompleted. Practice Thereisaclearoutlineofrolesconcerningsafemanagementwithintheoffshoreindustry.The keyprincipleofthesafetyregimeinNorwayisthattheentireresponsibilityforensuring compliancewithlegislativeconditionsisontheorganisationconductingpetroleumactivities (Aven&Vinnem,2005).Inadditiontothis,theauthoritiessupervisethatthemanagement systemsareprovidingasatisfactorysafetyenvironment(Aven&Pitblado,1998).Incombination withthelegislativerequirements,therecanalsobespecificcompanyrequirementswhich necessitateanevenhigherlevelofsafetyinthedesignofanoffshoreinstallation.

4.3 Statisticsofincidentsintheoffshoreindustry
ThePetroleumSafetyAuthority(PSA)publishesyearlyreportswithincidentstatistics.Figure7 belowshowsthenumberofincidentswithshipsonacollisioncourseinrelationtothenumber ofinstallationswithsurveillancefromStatoilHydroTrafficControl.Thestationprovides surveillanceservicesto85%ofalltheoffshoreinstallationsontheNorwegianContinentalShelf (TorEgilHopenSaue,20081103).Ascanbeseeninthefigure,thenumberofvesselson collisioncoursewithaninstallationseemstohaveadecreasingtrendbutariskdoeshowever stillexist.

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Figure7:Numberofshipsoncollisioncourseinrelationtothenumberofoffshoreinstallationswith surveillancefromSandslilandbasedstation(PSA,2008a).

Therehavebeen6incidentsworldwideduringthetimeperiod1980to2007ofsuchasevere consequencethattheresultbecameatotallossoftheoffshoreinstallation(Vinnem,2007).Out ofthesesix,oneincidentoccurredintheNorthSea.Incidentsofmediumconsequenceare morecommon,evenifthisdoesnothappenveryoften.Inthetimeperiodbetween2000and 2007,threeaccidentshavetakenplaceintheNorthSea(PSA,2008a). Thereasonsbehindcollisionsvarywidelybutacommonprincipleforallincidentsseemstobea seriesofeventsthattogethercontributetotheconsequencecollision.TheMaritimeAccident InvestigationBranch(MAIB)summarisesomeofthemostcommonreasonsbehindcollisionsas: overrelianceonequipment,inadequatetraining,poornavigationalwatchkeepingpractices, sharedwatchkeeping,notgoodseamanship,inactionetc.(MAIB,2008)Acommonconclusion withinMAIBfromaccidentinvestigationsisthathumanerroristheprimarycausebehind collisions(MAIB,2004).

4.4 Uncertaintiesinaccidentdata
Therearequiteafewdifferentdatabaseswhereincidentsarereported;examplesarethe MarineIncidentDatabase(MarineAccidentInvestigationBranch,UK),theShip/platform collisionincidentdatabase(HealthandSafetyExecutive,UK)andtheWorldOffshoreAccident Databank(DetNorskeVeritas).Oneofthemajordifficultieswithcomparisonsofdataand statisticsfromdifferentdatabasesisthedivergenceindefinitionsandconcepts.Therecanbe dissimilarunderstandingsofwhatahumanerrormeansandthedefinitionsarecrucialwhen comparingdata.Thereisnostandardisedaccidentreportingsysteminthemaritimedomain, whichcreatesaproblemwhentryingtofindcausalfactorsfromaccidentdata(Hetherington, 2006).Chapter3ofthisthesisgivesdefinitionsoftheconcepthumanerrorandotheressential explanationswithinthearea.Tobeabletodrawreliableandvalidconclusionsfrom investigations,theyneedtobebasedonthesame(oratleasttransparentandcomparable) assumptionsandmethods.Itisalsoverydifficulttocompareincidentstatisticsifmethodologies anddefinitionsarenotdescribedatall. Anotherproblemisthetypesofaccidentsthatarereported.Itislikelythatnominorincidents areincludedinthestatistics.Itwouldbeveryusefulifnearmissesandsmallaccidentswere

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reportedinaccidentstatistics,toencourageaproactiveconceptinsafetymanagementrather thanthefrequentreactivemeasuresthataretakensubsequenttoaccidents. Aspreviouslymentioned,aproblemariseswhenusingstatisticaldataasthesoleinputto collisionrisksassessments,duetothelowaccidentrates.Veryfewincidentshaveoccurredand thereforethedatacanbequestionedwithregardstoitsreliabilityandwhetherconclusionscan bederivedfromthelimitedexperiences.Asuitablemethodtosomewhatgetawayfromthis problemisthereforetocombineaccidentstatisticswithexpertjudgementsandlogicalmodels.

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24

Collisionriskanalysis

Thischapteraimstogiveanoverviewofthemodelsandmethodsthatareusedwhenassessing theriskforashipcollision.Thefocusisonthelikelihoodthatacollisionoccursandthemodels thatdealwithconsequencesarethereforenottouchedupon. Severaldifferentriskanalysesarecompletedwhenanewplatformisbuiltormodified.Risk analysesareundertakenfordifferenteventssuchasfires,leakagesandcollisionsthatcanlead tolossofamainfunction,forexamplethecontrolroom,theevacuationpossibilityorthe structuralbearingcapacityoftheinstallation.AsoutlinedinSection1.3,thisthesisislooking closerintotheriskanalysisforcollisions.Theresultfromthecollisionriskanalysiswill,together withtheresultsfromtheotherriskanalyses,giveapictureofthetotalriskfortheoffshore installation.

5.1 Howtoperformamaritimeriskassessment
ItisdescribedbyIMOthatagenericmodelforcollisionriskshallnotbeviewedinisolation,but ratherasacollectionofsystems,includingorganisational,management,operational,human, electronicandhardwareaspects.Thesystemsandfunctionsshouldbebrokendowntoan appropriatelevelandaspectsofinteractionoffunctionsandsystems.Theextentoftheir variabilityshouldalsobeaddressed.Thehumanelementisregardedasoneofthemost contributoryaspectstothecausationofaccidentsandmustbeincorporatedinanassessment. Expertjudgmentisanimportantpartofanassessmentthatprovidesproactivethoughtsand ideasandisnecessarywherelimiteddataexists.(IMO,2007) Duringanidentificationofpossiblehazards,itisnecessarytocombinebothcreativeand analyticaltechniqueswiththeaimtoidentifyallrelevanthazards.Structuredgroupreviewswith expertsinthevariousappropriateaspectssuchasshipdesign,operationsandmanagement shouldbeundertakenfollowedbyarankingofhazardsandscenarioswithregardstotheir contributiontoanaccident.(IMO,2007)

5.2 Existingcollisionriskmodels
Mostoftheriskmodelsforestimatingcollisionfrequenciesaresplitintotwosteps.Tobegin withthepotentialcollisionriskisdeterminedwithoutconsideringanyriskmitigationoptions,as rootedinanapproachfrom1974(FriisHansen&Simonsen,2002).Thefollowingstepisthento assesstheeffectsfromaversivemanoeuvresandhowthesereducetheriskforacollision. Globally,thereareacoupleofdifferentmodelsthatareusedtoassesstheriskforcollisions betweenvesselsandoffshoreinstallationsandasummaryofthemainmodelscanbefoundin Table1below.

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 Model COLLIDE SOCRA CRASH COLWT COLLRISK DYMITRI Organisation DovreSafetec MaritimeResearchInstitute DetNorskeVeritas GermanisherLoyd AnatecUKLtd BritishMaritimeTechnologyLimited

Table1:Overviewofmodelsthatareusedtoassessshipcollisionrisk(SSPA,2008).

Themodelsareingeneralprettysimilarandthecommonapproachistoestimatethenumberof possiblecollisionsandmultiplythiswithanestimatedfractionofwhenacollisionoccurs.The causationfactorconsiderstheprobabilitythatacollisionwillnotbedetectedandavoided.The modelsarebasedontheassumptionthatthecollisionfrequencyisproportionaltothequantity ofshipspassinganoffshoreinstallation.Thishashoweverneverbeenprovedduetolackofdata (DNV,1998).ThemodelsCOLLIDEandCRASHseemtobethemodelsmostfrequentlyused withintheNorwegianContinentalShelfandarethereforefocusedonthroughoutthischapter. BothofthesemodelsaremainlyusingtheoriesfromtheRiskAssessmentofBuoyancyLoss Project(RABL)from1987(DNV,1998;ThomasEriksen,20081104)andthemodelsare thereforeconsideredtoberathersimilar. InCOLLIDEandCRASH,thenumberofpossiblecollisionsisassessedbyusinginformationof shippinglanesinareaswherethetrafficisrestrictedtosuch,e.g.intheUKorbyusinghistoric shippingdataasine.g.Norwaywheretherearenospecifiedlanes.Thetrafficisusually consideredtobeGaussiandistributedasanattempttoincludethevesselsthathappentotravel outsidetheshippinglanesorarenotfollowingtheroutesofthehistoricaldata.Historic shippingdatacanbefoundinAIS(AutomaticIdentificationSystem)orinmoresimplisticdata,of whichAISdataisamoresophisticatedandanincreasinglycommonmethod.

5.2.1 Componentsinacollisionriskanalysis
Twoconditionsneedtooccursimultaneouslyforacollisiontobeafact;avesseloncollision courseandcollisionavoidancemeasuresnotsuccessfullyundertaken.Thewayofassessingthe firstcomponentisdescribedabove.Thesecondcomponentisgenerallybrokendowninto differentparts(refertoChapter6): 1. Failureinplanningorfailureinexecutingtheplancorrectly. 2. Watchkeepingfailure(notadequatewatchorradarfailureinbadvisibility). 3. Platform,standbyvesselandlandbasedsurveillancestationsmustfailtoalertthe vessel. Thecomponentpassageplanning(1)isregardedtodependonhowlonganinstallationhas beeninplaceandhoweffectivelyinformationaboutthishasbeendistributed.Thecomponent ismodelledinaneventtreeinCOLLIDE.CRASHusesfixedplannabilityfactorsfordifferenttypes ofvesselsandinstallationtypesandanempiricalfunctiondependentontimesincetheplatform wasinstalled.(DNV,1998)

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Theelementwatchkeeping(2)onthevesselvariesslightlyinCRASHandCOLLIDE.Thereasons behindafailureinwatchkeepingareidentifiedintheRABLprojectas: Noreactionbythewatchkeeperofthebridgedueto: Absentfrombridge Presentbutabsorbed Presentbutincapacitated Presentbutasleepfromfatigue Presentbutincapacitatedfromalcohol Ineffectiveradaruse(badweatheronly) (Technica,1987) Verylimitedstatisticaldataonwatchkeepingfailureexistandthecomponentistherefore quantifiedbyacombinationoffaulttreesandexpertjudgements,wheretheprobabilitiesofthe detailedscenariosareatleastpartlybasedonjudgements.Themodelsseparatetheconditions intwoscenarios,goodorbadvisibility,butthisdoesonlyaffecttheprobabilityforthereason ineffectiveradaruse.Theremainingfivefailuremodeshavedifferentvaluesdependingon typeofship(supply,standbyandthreedifferentsizesofmerchantships).Itisalsoassumedthat thereasonbehindthefailurehastolastforaminimumof20minutes.Therankingofthe reasonsforawatchkeepingfailure,fromhighesttolowestprobability,is:asleep,absent, absorbed,incapacitatedfromalcoholandincapacitated.Theofficeronwatchbeingasleepis viewedasthesignificantlymostimportantfactor.Therankingjustdescribedisbasedonan averagefailurefrequencyforthemerchantshipsofthreedifferentsizesexcludingsupplyand standbyvessels.(Technica,1987) Platforminitiatedrecovery(3)isconsideredtodependonthetimeavailabletoperformany collisionavoidanceactions.Thisfactoristakentohaveafixedvaluethatisinfluencedbythe organisationcharacteristicsoftheoffshoreinstallation.

5.2.2 Probabilityofacollision
Thequantificationofcollisionfrequencyisasimplemultiplicationoftheindividualcomponents thataredescribedabove.ThemodelusedinCRASHisshownbelowandthemodelinCOLLIDEis verysimilar:

FCP = N Fd P1 P2 P3
FCP= N= Fd= P1= P2= P3= frequencyofpoweredpassingvesselscollisions. totaltrafficinthelane. proportionofvesselsthatareinthepartofthelanedirectedtowardstheplatform. probabilitythatthepassageplanningstageisnotcarriedoutcorrectly. probabilitythatthevesselsuffersawatchkeepingfailure. probabilitythattheplatformorstandbyvesselfailstoalerttheshipintimeto preventacollision.

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5.2.3 Vesseltypes
Themodelsaregenerallybrokenupintobeingspecifictothevesseltypeandanalysed separately.Differentmodelsarethereforeusedtoanalysethepotentialcollisionsofpassing merchantvessel(i.e.cargochips,cruiseshipsetc),fishingboats,offshorerelatedtrafficand navytraffic.AsdescribedinSection1.5,thisthesisdoesnotconsidertheriskforcollisions betweenoffshorevesselsandtheirdedicatedoffshoreinstallationsorsubmarinesand installations.ThisleavesallothertypesofshipsthatmaybepresentintheNorwegian ContinentalShelfsuchasmerchantvessels,cruiseships,fishingshipsandsupplyboats(i.e. duringthetraveltowards/awayfromotheroffshoreinstallations).

5.2.4 Typeofcollision
Anotherdistinctionisacategorisationincollisionscenarios;poweredcollision,driftingcollision, collisiononapproachtoaninstallationandcollisionalongsideanoffshoreinstallation.The collisionscenariosarerelatedtothetypeofvesselandthefirsttwocollisionscenariosare applicabletoallvesseltypes,whereasthelattertwoonlyapplytooffshorerelatedtraffic.This thesisishowevermainlyfocusedonpoweredcollisions.Acollisionscenarioischaracterisedas poweredwhenthereasonbehindtheincidentisnotconsideredasdirectlytechnicale.g.engine breakdown,whichmaydevelopintoadriftingcollision(refertoSection7.1).Thismeansthata poweredcollisioncanbecausedbyforexamplelackofsituationalawarenessorfailurein conductingcollisionavoidancemeasures.

5.3 Circumstanceswithanimpactoncollisionrisk
Severalcharacteristicsthatarespecifictoaninstallationinfluencetheriskforashipcollision. Thesecircumstancesmustbetakenintoaccountwhencompletingacollisionriskanalysis.

5.3.1 Characteristicsoftheinstallation
Alargeinstallationmaybeeasiertoidentify,eithervisuallyorviaradar,butthesizealsomean anincreaseoftheareawhereacollisioncanhappen. Mobileinstallationsareabletochangelocationwhichcanbeawaytoavoidacollision,but beingmobilecouldalsoincreasetheriskforacollisionifthenewpositionisunknowntoships. Historicalcollisionexperienceshowsthattheriskforacollisionworldwideis1.5timeshigherfor amobileinstallationthanforafixed(DNV,1998). Collisionavoidancemeasurescanvarybetweeninstallations.Atypeofwarningsystemsis standbyvessels(SBVs),butthesearesometimessharedbetweeninstallationsandsomeare without.AsmentionedinSection4.3,StatoilHydroissupervisingmanyoftheoffshore installationsontheNorwegianContinentalShelf.Someoftheothersareeitherunguardedor areprovidedwithsurveillancefromanotherstation.

5.3.2 Locationofanoffshoreinstallation
Thelocationandhencethefrequentshippingroutesdeterminethetrafficdensitysurrounding aninstallation.Alocationnearhightrafficroutesisconsideredtoincreasetheriskforacollision (refertoSection5.4).Inadditiontothis,theweatherconditionsandhowthisinfluencestherisk foracollisionwillvarywiththelocation.

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 Accidentstatisticsshowthattwooutofthreecollisionsoccurredwithinstallationsthatwere isolated,i.e.farawayfromotherinstallations(DNV,1998).Although,whenconsideringthe positiveeffectsoftheStatoilHydroTrafficCentreandthewarningthestationprovides,therisk forcollisionshouldpresentlynotbesignificantlyhigherforanisolatedinstallation(giventhat theinstallationisprovidedwithsurveillance).

5.3.3 Mannedorunmannedinstallation
Withoutpermanentpersonnel,recoveryandwarningofanapproachingvesselviaanSBVwill notbeinitiated,asforamannedinstallation.Thegeneralactivityaroundamannedinstallation willalsoincreasetheawarenessandalertnessofthewatchkeeperaboardavessel(Vinnem, 2007).Theriskposedtoanunmannedinstallationcouldalsobehigherduringnighttime,dueto e.g.afailurewiththepowersupplyresultingintheinstallationbeingunlitandthereforenot easytolocaliseforanapproachingvessel.

5.3.4 Shippingtraffic
TherearenoshippinglanesintheNorwegianwaters,butthereareareaswherethetraffic densityishigherthaningeneral.Shipsthatareregularlyoperatingintheareaarelikelytohave normalroutesthatarefollowedbuttherecanbechangesintheseaswell,duetoe.g.severe weatherconditions.(DNV,1998)

5.4 Reflections
Oneoftheweaknesseswiththeshipcollisionmodelsdescribedabovelieswithinthe componentwatchkeepingfailure,sometimesalsoreferredtoasshipinitiatedrecovery.This componentisbasedontheproceedingsfromaproject(Technica,1987)thatwascompleted morethantwentyyearsagoandmanyoftheassumptionsthatwereapplicablethenarenot accuratetoday,withregardstothetechnologyandmanagementprocedures.Toexemplify,it canbementionedhowmodellingofthenavigationprocesswasestablishedpriortowhen technicalequipmentsuchassatellitebasednavigationsystemsandtheuseofAISbecame commonpractice. Withregardstopassageplanningandnavigationalprocedures,manyvesselshavebeenknown touseinstallationsaswaypointsfornavigationandreferencesoflocations.Thishasbeena recognisedhazardforalongtime,consideringthatadirectcoursetowardsaninstallation followedbye.g.lackofattentioncanendupinacollision.Thisunsafebehaviourseemstohave decreasedduetopreventiveworksuchasinformationtoseafarers(TorEgilHopenSaue,2008 1103).

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Theasplannedmodeasuccessscenario

Thischapterpresentstheconceptsuccessscenarioandhowthisisappliedasafoundationwhen assessingshipcollisionswithoffshoreinstallations. Inthisthesis,asuccessscenarioisthebasisforidentifyingfailurescenariosthatcanleadtoa collision,sincetheseareconsideredtobedeviationsfromthesuccessfulpath.Asuccess scenariocanbedescribedasthenormalmodeortheasplannedscenario(Kaplan,1997). Beforediscussingsuccessscenarioswithregardstocollisionavoidance,itmustbementioned thatthelinkbetweenvesselsandoffshoreinstallationsisacomplexsystemwhichincludes severalparametersandhumanandorganisationalinvolvementinmanyaspects.Manyofthe factorsandcomponentsarealsocorrelatedanditisverydifficulttopresentasimplisticmodel oftheinterfacebetweenvesselsandoffshoreinstallations.Also,asuccessscenarioisinthis casenotonesinglechainofevents,ratherseveraldifferentchainsthatallsharethesamefinal consequence,i.e.thatacollisiondoesnotoccur.

6.1 Onapproachtowardsanoffshoreinstallation
Beforeashipleavesport,anadvanceplanningoftherouteistobeundertakentofacilitate travelinasafeandcosteffectivemanner.Theplanningshouldincorporateinformationone.g. weatherconditionsandlocationofoffshoreinstallations.Theprocedureneedstoconsider updatedmapsandchartstoidentifyallobstacles.Thereareanumberofdifferentwaysfora vesseltobecomeawareanoffshoreinstallation;directlyvisualbylookingoutfromthebridge, byusinge.g.ECDIS(ElectronicChartDisplayInformationSystem),byusingradarandby communicationwithothervessels,theinstallationorlandbasedsurveillancestations. Theproceedingscanbeconsideredasnormaluntilthevesselissoclosetotheinstallationthat itisseenashazardousandatthispointsomesortofcollisionavoidancemeasureisusually undertaken.Whatisregardedasabnormallyclosediffersbetweentheperspectiveofavessel andaninstallation,consideringwherethemainabilityofactionslies.Theriskishencelikelyto beperceivedassignificantlyhigherbypeopleontheinstallation,whencomparedtopeopleon thevessel(PSA,2008a).

6.2 Definingcollisioncourse
Generallyitcanbesaidthatachainofeventsoccurinacollision.Firstly,avesselisonacollision courseandsecondly,thevesseldoesnotchangecourseawayfromtheoffshoreinstallation.A shiponastraightcoursetowardsaninstallationisnotnecessarilyacriticalconditionitselfand actuallyanormaloccurrenceintheNorthSeaduetothehighdensityofinstallationsandships. Atsomepointandsomedistance,everyshipisonacoursetowardsaninstallationbutthisdoes howevernotnecessarilyleadtoacollision.

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Therearedifferentdefinitionsofacollisioncourse.ThePetroleumSafetyAuthority(2008a)uses thefollowingexplanations: 1. Whenthecourseofavesselistowardsthesafetyzoneofaninstallationandthe installationhasnotbeenabletocontactthevessel25minutesbeforeapotential collision. 2. Whenthestandbyvesselhasbeenmobilisedtoapproachtheincomingvesselthisis regardedasavesseloncollisioncourse,withoutrespecttothetimebeforeapotential collisionorthedistancethevesselmightpasstheinstallationwith. ThelandbasedsurveillancestationinSandslioperatedbyStatoilHydrogenerallyworksbythe definitionthatavesselisoncollisioncourseifitdoesnotanswercallswhenitis50minutes awayfromthesafetyzoneofaninstallation,withregardstocourseandspeed(TorEgilHopen Saue,20081103).

6.3 Collisionavoidance
Theworkprocedureofthesurveillancestationwithregardstotimebeforeanexpectedcollision isasfollows: 6058minutesanalarmonthelandbasedstationisactivated. 54minutesanattempttocontactthevesselviasatellitephone,VHF,mobilephone andDSC(DigitalSelectiveCalling). 50minutesifcontactwiththeapproachingvesselisnotachieved,theoffshore installationisnotified. Someoffshoreinstallationsrequiremoretimeforcollisionavoidanceandevacuation proceduresandtheactionsarethereforeinitiated90minutesbeforeanexpectedcollision.(Tor EgilHopenSaue,20081103) ItiscommonthatoffshoreinstallationsintheNorthSeahavearadarcollisionwarningsystem. Thesystemautomaticallyprovidesawarningifavesselisonacoursethatpassesclosetothe installation,whichoftenissettoalert45minutesbeforecontact(Vinnem,2007).Thisenables thecrewoftheinstallationtoidentifyavesselonacollisioncourseatanearlystage,resultingin moretimetocarryoutcollisionavoidancemeasureshenceincreasingthelikelihoodof performingtheseactionssuccessfully. Onalarm,theSBVisgiventhecourseandpositionoftheapproachingvesselandstartsmoving towardsit,whiletryingtocontactthevesselonVHF.Ifthereisnoreplyonthepursuittoradio contact,theSBVapproachesthevesselandtriestonotifybysounds,lights,pyrotechnicsetc. Thismaybeproblematicduetotheshorttimeavailable,therelativelylowspeedofanSBVand difficultyinmakingcontactwithavesselandespeciallythosesufferingawatchkeepingfailure. ApossibleactionisthattheSBVcouldtrytodeflectthecourseofthevesselbyusingphysical contact,butconsideringhowunsafethisactioncouldbeitisseenasratherunlikely.

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Theactionsoftheapproachingvesselandthecollisionavoidancemeasuresoftheoffshore installationarestronglycorrelated.Thereasontowhyasituationoccurswithavesselon approachtowardsaninstallationisinfluencinghowandiftheactionstakenbytheinstallation aresuccessful(Haugen,1991).Thiscanbeexemplifiedbyhowe.g.awatchkeepingfailureona vesselthatiscausedbytheofficerofwatchbeingdistractedisfarmorelikelytobepositively affectedbycollisionavoidancemeasuresthancomparedtoiftheofficerisabsent. Theprobabilityofacollisioniscorrelatedtothedistancetotheshipandtherisklevelgrows exponentiallyasperFigure8below.Thisduetohowsuccessofcollisionavoidancemeasures decreaseswiththedistance.

Figure8:Descriptionofhowthelevelofriskisaffectedbythedistancebetweenavesselandanoffshore installation(Vinnem,2007).

6.4 Reflection
Acommonprincipleinthelinkofactionsdescribedaboveishowthereareseveraldifferent levelswhereafailurecanarise.Morethanonefailuremusttakeplaceatthesametimefora collisiontobeafact.AparallelcanbedrawntoReasonsSwissCheeseModel(referto Chapter3)withseveralbarriersbetweenahazardandaconsequenceandhowanaccident generallydependsonacombinationofevents.Barriersinacollisionscenarioaree.g.watch keepingontheshipandcommunicationfromtheoffshoreinstallationasillustratedinFigure9 below.Thefigurepurelyaimstoprovideaconceptualillustrationofthechainofactionsandcan notbeconsideredtobefullychronologicalorafulldescriptionofacollisionscenario.

Figure9:Illustrationofdifferentlevelsoffailuresthatcancauseacollision(Reason2000,adoptedbythe authorsofthisthesis).

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34

Identificationoffactorsincollisions

Thischapterpresentsthecomponentsinacollisionscenariobyusingastructuralmodelwith scenarios,primarycausesandunderlyingfactors. Thepurposeofthethesisistoidentifyallfactorsthatmaycontributetotheriskforship collisionsandanewmodelwasthereforedeveloped.Bythisanewperspectiveisachieved, whichmaynothavebeenpossibleifthemodelsdescribedinChapter5wereused.The identificationandevaluationoffactorswasperformedinseveralsteps.Firstly,scenariosthat cancauseacollisionweredeterminedfromliteraturereviews,accidentstatistics,riskanalysis modelsandhazardsidentificationsthroughworkshops(refertoSection2.2).Secondly,all factorsthatcontributetoaccidentsweregatheredandcategorisedinfourscenariogroups.The aimwasbothtoassessfactorsthathavebeenidentifiedinearlierstudiesandtrytofindnew factorsthatcontributetothecollisionrisk.

Externalinfluencessuchasthesurroundingsocietyandlegislationwerenottakenintoaccount whenidentifyingfactors,onlyelementswithintheorganisationofashipwereconsideredwhen discussingtheriskforacollision. Thefactorsaredividedintoprimarycausesandunderlyingfactors.Primarycausesareactions thatdirectlyleadtoascenarioandaredependentuponunderlyingfactors.Thescenariosand primarycausescanbeseenasactivefailures,whiletheunderlyingfactorscanbecomparedto latentcondition(refertoSection3.2).Theunderlyingfactorsforaspecificprimarycausewillnot beregardedascontributingtothecollisionriskiftheprimarycauseisnotimportantforthe scenario.Inthesamewaywilltheprimarycausebeseenaslessimportantifitsoverlying scenarioisnotcontributingtothecollisionrisk. Itissometimesappropriatetoexplainascenariobybothprimarycausesandunderlyingfactors. Otherscenariosarecomplicatedtodescribeinspecificprimarycausesandarethereforedirectly outlinedbyunderlyingfactors,duetothelargeamountofpossibleeventsandhenceadifficulty tocategorisethese. AsseeninFigure10,scenarios,causesandfactorsthatmaycauseacollisionarestructuredina hierarchicalmodelcreatedbytheauthorsofthisthesis,withfourlevelswherecollisionisthe topevent.

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Figure10:Ahierarchicalmodelthatshowstheconnectionbetweenacollisionandthescenarios,primary causesandunderlyingfactors.

Theunderlyingfactorsarepresentedseparatelywithinthisthesisandcategorisedintogroupsas inmostotherresearchprojects,e.g.agroupoforganisationalfactors.Thefactorsmaybemore orlesscorrelatedwitheachother,whichmakesitchallengingtofullyseparatetheminto categories(refertoSection3.3).Byreferringtothedefinitionsofeachfactor(refertoAppendix D)andalwayskeepingtheminmindwhenreadingthisthesis,therewillhopefullynotbeany majordifficultiesinunderstandingthefactorsandtheircontext. Asummaryofallintroducedscenarios,primarycausesandunderlyingfactorscanbefoundlast inthischapter(Figure12,p.41).

7.1 Fourscenarioscontributingtothecollisionrisk
Theoverlyingcategorisationinfourscenarios representsthefirstlevelbelowtheoutcomecollision andcanbedescribedasgroupsofreasonstowhy collisionsoccur,whereallscenarioscontributetothe collisionrisk. Theycanseparatelybetheprimaryreasonfora collisionbutcanalsooccurduringthesamechainof eventsthatleadtoanaccident. Fourscenariosareidentifiedandassessedinthisthesis: Intentionalfailure Technicalproblems Lackofawareness Handlingerror Intentionalfailureisasituationwhensomebodyonashipaimstocollidewithaninstallation, e.g.anactofterror,whichmeansthatthescenarionotcanbeclassifiedasanaccident. Intentionalfailureisveryseldommentionedinliteratureandnocollisionswithoffshore

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installationshaveeverbeenreportedduetothistypeofactions.Thereisalotofsecrecywithin organisationsaboutthreatsandemergencypreparedness. Technicalproblemsinvolvefailureswithsteeringequipment,machineryetc.thatmayhindera shipfromchangingcourseawayfromaninstallation.Theofficeronwatchisinthisscenario awareofthecollisioncourseandthepotentialdangerbutcannotdoanythingaboutit.Ifthis scenariowouldresultinacollisionitcouldbecomparedtotheconceptdriftingcollision(refer toSection5.2.4).Dataaboutthiskindoffailurescanbefoundinaccidentreportsortechnical equipmentreliabilitydata(refertoSection7.1.2)anditisoftenrathercleariftheprimary reasonforanaccidentisatechnicalproblem. Lackofawarenessisdescribedaswhentheofficeronthebridgeforsomereasonisnotawareof theoffshoreinstallation,thecollisioncourseorthepositionoftheshipitself.Thismeansthatno actionstoavoidacollisionareundertakenontheship.Lackofawarenessincludesforexample thattheofficeronwatchisdistractedorasleep.Thisscenarioisawellknownproblemamongst peopleworkingwithinthemaritimesectorandisoftenreferredtoinliteratureandaccident reports,evenifotherconceptssometimesareused. Handlingerrorarisesfromasituationwheretheofficeronwatchisawareofanoffshore installationbutforsomereasonfailstoavoidcollision.Thismeansthattheofficeronwatch possessessituationalawareness,butthereisafailurewhenundertakingcollisionavoidance measures.Anexamplecanbeifashipischangingcourseawayfromaninstallationbutnot enoughtoavoidanaccident.Theconcepthandlingerrordoesnotseemtobediscussedwhen assessingthecollisionrisk,butfailuresthatcanbelongtothiscategoryarehowevermentioned inaccidentreports.Thescenariohasalsobeendiscussedandsupportedduringworkshops.

7.1.1 Interactionbetweenscenarios
Asalreadymentioned,thecausesbehindeachscenariocanbeinfluencedbydifferent underlyingfactors.Atechnicalproblemcouldforexampledependoninsufficientmaintenance whichmaybeclassifiedasanorganisationalfactor.Thescenarioscanalsobecorrelatedwith eachother.Onescenariocaninitiateasituationwhereasanotherscenarioistheprimaryreason forthecollision.Forexamplecanatechnicalfailure,suchasablackout,leadtoanawareness failurewhichthenistheprimaryreasonforthecollision. AsdiscussedinChapter5.2.1wherethecollisionriskmodelsaredescribed,theoutcomeofa scenarioisnotonlydependentontheactionsofaship.Handlingerrorandlackofawareness canbepreventedthroughexternalcommunicationfromlandbasedstationsand/ortheoffshore installation.Externalcommunicationwillprobablynotaffectanintentionalfailureortechnical problem.

7.1.2 Selectionofscenariostoassess
Inthenextsectionsthescenarioslackofawarenessandhandlingerrorarefurtherevaluated. Thethesisisnotlookingcloserintointentionalfailuresbecauseoftheassumednegligible likelihood,thedifficultieswithconfidentialityandproblemswitheffectivepreventivemeasures aspreviouslymentioned.

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Technicalproblemstendtobeareappearingcausetocollisionsandmaritimeaccidents,butits contributionvariesbetweendifferentsources.Informationfromsomestatisticaldocumentsis summarisedbelowtogivecontexttohowoftentechnicalproblemscontributetomaritime accidents: 4%ofallnearmissesbetweenshipsandplatformswererelatedtosteering failureand20%ofallnearmissesbetweenshipsandplatformsinUKwaters wererelatedtoenginefailure(HSE,2003) 5%ofallcollisionsinCanadianwaters(Baker&McCafferty,2005) 5%ofallcollisionsinUKwaters(Baker&McCafferty,2005) 6%ofallcollisionsinAustralianwaters(Baker&McCafferty,2005) Inviewofthepreviousbriefdiscussion,adecisiontonotfurtherassessdirecttechnical problemsismadebecauseofhowthereexistsmoredataandstatisticswithintheareaof technicalreliabilitythanwhencomparedtohumanreliabilitydata. Awarenessfailureandhandlingerrorseemtobemorecomplexandinvolvehumanand organisationalfactorsthatarenoteasytofinddataorstatisticsabout.Thesetypeoffailuresare alsoquitevaguelydescribedintheexistingmodelsforcollisionriskanalysis,whyitisimportant toevaluatethemfurther.

7.2 Lackofawareness
Alackofawarenessmayresultinanaccident,dependingonwhen(orif)awarenessisachieved again.Thelongerthedistanceisbetweenthevesselandtheoffshoreinstallation,themore likelyitisthattheofficeronwatchregainsawarenessbeforeacollisiontakeplace.Afew minutesofunawarenesswillprobablynotresultinacollision.Inthisthesis,lackofawareness thatcanresultinacollisionisconsideredandthereforeincorporatesdurationtosomeextent.A comparisoncanbemadetotheRABLprojectwhereitistakenintoaccountthatawatch keepingfailuremustlastfor20minutestocauseanaccident(Technica,1987). Eightprimarycausesbehindtheconditionlackofawarenesshavebeenacknowledgedinthis thesis.Thescenariowatchkeepingfailure,whichisusedinthecollisionriskmodelstoday(e.g. CRASH),mainlyconsistsofthesamekindoffailuresthatareadoptedinthisthesisasprimary causes.

7.2.1 Primarycauses
Theprimarycausesthatareidentifiedtolie behindlackofawarenessareillustratedinFigure 11below,followedbyexplanationsofthe causes.Severalsourcesrecognisetheprimary causesbelowasreasonstowhyalackof awarenessoccur(e.g.HSE,1999;Technica, 1987).Therearethoughsomedifferenceswithin theconceptlackofawarenessbetweenthetwo sourcesofliterature.Informationfromthe documentshasbeenusedasabasistogether

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withreflectionsfromtheauthorsofthethesisof whatisconsideredtoaffectthelikelihoodfor thescenariolackofawareness.Additionstothe existingtheoriesare:

Failurerelatedtonavigationalequipment Externalcommunication

Figure11:Thescenariolackofawarenessandtheprimarycausesbehindthisscenario.

Afailurerelatedtonavigationalequipmentincludeseverythingregardingthenavigation process.Thereforefailureswhenusingtheequipment,actualtechnicalmalfunctionsandlacking devicesetc.areconsidered. Anexternalcommunicationfailureisrelatedtoproblemswiththetechnicalcommunication system,anerrorinreceivingorinterpretinginformationandlackofcommunication.This situationisthereforeconsideredtobeatwowaycommunication,wherethefailureoccursat theship.Thisprimarycausedoesonlyconsiderincomingcommunicationfromothervessels, installationsorlandbasedstationsandnotthecommunicationthatoccursinternallyonthe vessel. Lackofawarenessduetosubstanceabuseconsidersiftheofficeronwatchispresentonthe bridgebutundertheinfluenceofsomesortofsubstancesuchasalcohol,drugsormedication, whichdecreasesthecapabilitiesoftheperson. Anotherreasontowhyanofficeronwatchlacksawarenessofasituationmaybeduetothe personbeingasleeponthebridge. Asuddenillnessofthepersonbeingresponsibleofwatchkeepingcanresultinalackof awareness.Thiscanbelinkedtoforexampleaheartattack,astrokeoranepilepticattack. Anotherprimarycauseisidentifiedtobeifapersonalinjuryoccurstotheofficeronwatchthat preventsthepersonfrombeingfullyawareofthesituation.Thiscategoryincludespersonal injuriesforinstancefalls,headinjuriesetc. Distractioncanoriginateintheofficeronwatchperformingothertaskssimultaneouslywith watchkeepingsuchaspaperworkandphonecallsorthatmanypeoplearepresentonthe bridge.

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Ifthewatchkeeperisabsentfromthebridgeduringthewatch,thisinevitablyresultsinlackof awareness.

7.3 Handlingerror
Handlingerrorisnotdiscussedinthemodelsforship collisionanalysis(DNV,1998;Technica,1987).Inthis thesistheconceptisadoptedandahandlingerroris directlybrokendownintounderlyingfactors,incontrary tothescenariolackofawarenesswhichfirstisdivided intoprimarycauses.Thisisbecauseofthemany differentkindsofhandlingerrorsthatcanbeidentified andtheproblemtocategorisethese.Ifahandlingerror doesoccur,itisverylikelytoresultinanaccident.Ifthe installationisidentifiedatalatestagethisalso influencestheexecutionandsuccessoftheactionsto avoidacollision.

7.4 Underlyingfactors

Anoverviewoftheinteractionsbetweenunderlying factorsandprimarycausesarevisualisedinFigure12. Presentedbelowarealltheunderlyingfactorsthatare identifiedtocontributetothecollisionrisk,tooneextent oranother.Thefactorsaresortedalphabeticallywithin eachgroup,notinrelationtothecontributionofthe factor.Manyoftheunderlyingfactorsareconsideredto playaroleinmorethanonescenario,whereassomeof thefactorsaremorelikelytobespecifictoonescenario. Factorsrelatedto Equipmentrelatedfactors Blackout handling
Failurerelatedtonavigation equipment Inadequatetechnical equipment Maintenance Technicalfailureof communicationequipment Technicalfailureof navigationequipment Familiarisationwithship characteristics Failuretoensurefitnessat handover Lackofcommunication Misunderstanding Notfollowingguidance Notusingindependent referenceequipment Overrelianceontechnical equipment Personalstress Wishfulthinking

Organisationalfactors
Bridgeprocedures Healthmanagement/culture withintheorganisation Layoutofthebridge Organisationalculture Reportingandfollowup Timeintothewatch Typeofwatchsystem Workloadtoohigh Workloadtoolow Workpressure

Externalfactors
Durationofjourney Extremeeventonship Levelofothervesselactivity Timeofday Weather

Personalcharacteristics
Ageandgeneralhealth Competence Fatigue Language Perceptionofnegative effectsfromsubstances

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Figure12:Anillustrationofhowtheidentifiedscenarios,causesandfactorsarelinked.

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42

Evaluationoffactorsincollisions

Thischapterpresentstheanalysisofthethesis,whichincludestheresultsfrominterviewsand workshopscombinedwithstatisticsfromliterature. Bycombiningresultsfromexpertjudgementswithaccidentstatisticsandresearch,asolid backgroundtounderstandingthereasonsbehindcollisionsshouldbeachieved.The presentationofresultsalsoincludesreflectionsfromtheauthorsofthisthesis. Interviewswereundertakentolookfurtherintotheprimarycausesandtheunderlyingfactors. Arankingofthefactorswasmadeinthestudywhichincludedapossibilitytoaddotherfactors. Theinterviewswereperformedasopendialogueswithaninterviewguideasabasis(foundin AppendixA).Thisgaveanopportunitytofreelydiscusseverythingbroughttomind,todefine conceptsandexplainuncertaintieswithquantitativecomparableresultsasanoutcome.

8.1 Interviews
Expertjudgementsweregatheredviainterviewswith19peoplewithexperiencefrome.g.sea faring,collisionriskanalysisandmaritimehumanfactorsresearch.Afulllistofrespondentsis foundinAppendixB.Duetothetimeavailableforthisthesisandtheamountofcoordination andtravelnecessarytocarryouttheinterviews,itwouldnothavebeenpossibletoaddmore participantstothestudy.Theinterviewslasted11.5hoursandwasalwaysperformedbyboth authorsofthisthesis.Ofthe19interviews,5werecompletedovertelephoneandtheremaining 14inperson.Therespondentswerehandedtheinterviewguidetogetherwithalistof definitionsacoupleofdaysbeforetheinterview. Thequestionswerealllaidoutinasimilarmanner,byinquiringthecontributionofeach scenario/primarycause/underlyingfactorwithregardstotheoverlyingconcept;i.e.thelevel aboveinthestructuralmodel.Anexampleofaquestionisgivenbelow: Consideringcollisionsbetweenshipsandoffshoreinstallations,towhatextentdo youthinkthefollowingscenarioscontribute? a) Technicalfailure b) Lackofawarenessonship c) Handlingerrorincollisionavoidance d) Intentionalfailure e) Other,pleasespecify Afivestepscalewasusedtomakesurethatsomedivergencebetweentheresultscouldbe achieved,whichwouldnothavebeenlikelyifathreestepscalewasused.Also,providingtoo manyoptions(e.g.ascalewithtenlevels)couldhavecreateddilemmasinwhatanswerto choose. Allscenarios,causesandfactorsweredefined,eitherinthequestionnaireitselforina documentwithallconceptsthatwereadoptedintheinterviews(refertoAppendixD).Ascan beseeninthequestionabove,therewasapossibilitytoaddotherfactorswhichseveralofthe

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respondentstooktheopportunitytodoandthesefactorsarealsobrieflydiscussedinthe followingsections.

8.2 Methodforassessingtheresults
ThischapterfollowsthehierarchicalstructurefromChapter7andthereforebeginswiththe scenarios,followedbyprimarycausesandunderlyingfactors. Itshouldbenotedthattheanswersfromtheinterviewsarequiteoftenwidespreadandthatit thereforecanbedifficulttodrawgeneralconclusions.Theresultsfromtheinterviews,i.e.the answersillustratedinadiagram,arefoundinappendixEandF.Itisimportanttolookatthe diagramspresentedforeachfactortofullyunderstandtheopinionsoftheinterview participants.Thepurposeofthediagramsistovisualisetheanswersandconsequentlyprovide transparencytotheassessmentprocess.Theresultsfromtheinterviewscannotbeseenas statisticaltruththatcanbeassessedbymeans,averagesetc.duetohowthesamplesize wouldbeinvalidforthistypeofassessment.Instead,tendenciesandtrendsinthecontribution ofeachfactorareidentified.Theresultsfromtheinterviewsarepresentedindiagramswiththe numberofrespondentsontheyaxisandthedistributionoftheanswers,i.e.thecontributionof eachscenario/primarycause/underlyingfactor,onthexaxis. Theresultsfromtheinterviewsshowedthatamajorityoftheunderlyingfactorshadrather cleartendencieswithregardstotheircontribution,whilesomehadmoreofadivergenceand arethereforeproblematictodrawconclusionsfrom.Thelatterarecategorisedasvaguefactors andmustnotberegardedaslessimportantthanthefactorswheremoreapparenttendencies arefound.Theunderlyingfactorsmaybeveryimportantandsignificantlycontributetothe collisionriskortheycanbetheopposite,i.e.nothaveanycontributionatall,butthisthesishas howevernotbeenabletoshowtheseindications.Additionalstudiesneedtobemadetocome toanyconclusionsoftheimpactofthevaguefactors. Onlyasmallselectionoftheliteratureisreferredtointheevaluation,duetohowmuch informationthatwasfound.Informationabouttheprimarycausesisintegratedinthefollowing sectionwhereasstatisticsconcerningtheunderlyingfactorsispresentedinAppendixFin relationtoeachdiagram. Factorsaddedbytheexpertsduringinterviewsthatcannotberelatedtotheinitialscenariosor causescanbefoundlastinthissection.Theaddedfactorsarenotincludedinthegraphical presentationsoftheresults. Afewrespondentsdidnotanswerallthequestions.Therearethreeanswersmissing,resulting inthreequestionshaving18answersinsteadof19.Becauseofthewaytheresultswere interpreted,thisshouldnotadverselyaffecttheconclusions.

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8.3 Scenarios
Thefirstquestionintheinterviewsconcernedtowhat extentthefourdifferentscenariostechnicalproblem,lack ofawarenessonship,handlingerrorincollisionavoidance andintentionalfailurearecontributingtotheriskfora collisionbetweenashipandanoffshoreinstallation.The purposebehindthisquestionwasmainlytovalidatethe previouslymadeassumption,namelythatthescenarios lackofawarenessandhandlingerrorwerechosentofocus on. Themostcontributingscenariotothecollisionriskseemstobelackofawareness,which14 respondentsregardashavingsignificantorverysignificantcontribution.Technicalproblemand handlingerrorareassessedtohavelittleormediumcontributionbymostrespondents.There arealsosomehigherrankingsfortechnicalproblemsandbothhigherandlowerrankingsfor handlingerrors.Therespondentsperceivedintentionalfailureasaveryunlikelycontributorto theriskforcollisions,16outof19haveanswerednocontributionandtheother3answered littlecontribution.TheresultsareshowninFigure13.Itwasalsomentionedthatlackof awarenessisnotascommonasithasbeenbecauseofhighersafetyrequirementstoday(Helge Samuelsen,20081104).Severalrespondentspointedoutthatthereshouldnotbeany problemstochangecourseandavoidacollisionwithaninstallation,whichmakeshandlingerror ratherunlikely.

18 16 14 12 no contribution litlle contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Technical failure

Lack of awareness

Handling error

Intentional failure

Figure13:Diagramshowingtowhatextentthescenarioscontributetotheriskforacollision.

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8.4 Lackofawareness
Question2oftheinterviewsconsideredtheprimary causestolackofawareness,i.e.failurerelatedto navigationalequipment,externalcommunicationfailure, distraction,absencefrombridgeandincapacitationdueto substanceabuse,sleeporillness. TheeightprimarycausesthathavebeenidentifiedinSection7.2.1andtheircontributiontolack ofawarenessarepresentedinFigure14belowandfurtherinSections8.4.1to8.4.8. Addedprimarycauses Somerespondentsimpliedthatunclearrolesandresponsibilitiescanbeacontributingfactorto awarenessfailure.Theinternalcommunicationonthebridgeandindistinctrolesmaycreate misunderstandingsaboutwhoisincommand.Thiscouldresultinthatnoonetakes responsibilityfornavigationandthereforeunawareness.
18 no contribution litlle contribution medium contribution significant contribution very significant contribution

16

14

12

Responses

10

0
Navigational equipment External communication Substance abuse Asleep Illness Personal injury Distracted Absent

Figure14:Diagramshowingtowhatextenttherespondentsconsideredtheprimarycausescontributeto thescenariolackofawareness.

Asummaryoftheunderlyingfactorsandtheirimpactispresentedinrelationtoeachprimary cause.Besideeachsectionisafigurethatshowstheprimarycauseandtheunderlyingfactors.If aprimarycauseoranunderlyingfactorisshadedthefactorisseenaslessimportant.The

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underlyingfactorsthatdidnotshowanycleartendenciesareshowninbrackets.Theunderlying factorsaresortedwithregardstotheirimportance.

8.4.1 Failurerelatedtonavigationequipment/process
Theanswersfromtheinterviewsarespreadfromlittletosignificantcontributionwitha tendencytowardslittlecontribution.Failuresrelatedtonavigationequipment/processarenot mentionedveryofteninaccidentreportsorotherliterature.Inastudyofincidentdatafrom 19912001,navigationwasdeterminedtocauseapproximately8%ofallaccidents(Baker& Seah,2005).Byregardingtheresults,thenavigationprocesscouldhavesomecontributiontoa collisionscenario.However,forthisprimarycausetoresultinacollisionitislikelythatother barriersneedtofail.Thesebarrierscanforexamplebeafailuretokeepaproperlookout throughthewindow,nowarningfromthetrafficsurveillancestationortheinstallation,afailure inreceivingcommunicationetc.Allinall,anavigationfailureishencenotconsideredtohavea significantimpactonthecollisionrisk.
Underlyingfactors Notusingindependent referenceequipment Notfollowingguidance Weather Technicalfailureof navigationalequipment Maintenance Resultsfrominterviews Significantcontribution Resultsfrom literaturestudies Nospecificdata

Mediumtosignificant contribution Aroundmedium contribution Averagecontributionbut maybenotlikelydueto redundancy Littleormedium contribution

Maybea contribution Uncleartendencies

Medium contribution

Smallcontribution

Inadequatetechnical Smalltomedium Fewreferences, equipment contribution smallcontribution Vaguetrends Blackout,levelofothervesselactivity,competence Summaryofimportantfactors Notusingindependentreferenceequipment,notfollowingguidance,weather conditionsandtechnicalfailureofthenavigationequipment.

Addedfactors

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8.4.2 Externalcommunicationfailure
Theopinionsconcerningtowhatextentexternalcommunicationisaprimarycausetothe scenariolackofawarenessaredividedbetweentherespondentsanditisdifficulttosay anythinggeneralaboutit.Amajoritymeanthatitscontributionislittleormediumbutthereare alsoseveralrankingsasverysignificant.Manyrespondentsclaimedthattheimportanceof externalcommunicationmaybemoresubstantialwhendiscussingcollisionsbetweentwoships thaninasituationwithashipandanoffshoreinstallation,whichalsoisreflectedinthe literature. Grechetal.(2008)notethatverbalcommunicationcanbedifficultinnoisyenvironmentsand thatitalsocanbeproblematicwhenusingtechnicalcommunicationdeviceswithpoorsound quality.Inabreakdownofcommunicationrelatedaccidents22.4%wereduetolanguage problems,18.4%wereduetotechnicalproblemsand59.2%wereconsideredproblematic communications.(McCafferty&McSweeney,2003) Thediscrepancywithregardstohowimportantexternalcommunicationisperceivedamong respondentsandalsowhencomparedtoliterature,resultedinthatthecontributionofthe factorcannotbevalidlyevaluated.Evenifitwasdifficulttooutlinethesignificanceof communicationfailuresincollisionsbetweenvesselsandinstallations,theunderlyingfactorsto errorsincommunicationhavebeenpossibletosummarise.
Underlyingfactors Lackofcommunication Language Misunderstanding Resultsfrominterviews Significantcontribution Equaldistribution,strong tendencytowards significant Equaldistribution, tendencyagainst significant Mediumorsignificant contribution Notanimportant contribution Lowcontribution Resultsfrom literaturestudies Medium Significant

Nodata

Notfollowingguidance Medium contribution Blackout Low Technicalfailureof Medium communicationequipment Vaguetrends Competence Summaryofimportantfactors Lackofcommunication,language,misunderstandingandnotfollowingguidance.

Addedfactors Informationoverloadwasalsoseenasacausalfactortoexternalcommunicationfailure.When listeningtotheVHFradioinareaswithhightrafficdensity,therecanbepeopletalkingalmost constantlyandthiswouldmakeitverydifficulttorecognisevitalcommunication.

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8.4.3 Substanceabuse
Amajorityoftherespondentsranksubstanceabuseashavinglittlecontributiontolackof awarenessandonepersonanswersnocontribution.Although,threepersonsviewthe contributiontothecollisionriskassignificantorverysignificant. Lang(2000)writesthatthereisverylittlerecentevidenceofhumansfailingatseadueto alcoholandthatalcoholasprimarycausetohumanfailurehaslargelydisappeared,mainlydue toverystrictrulesonboardmanyships.ThisopinionisconfirmedbyGrechetal.(2008)who ascribethisdiminishthegreaterknowledgeabouttheeffectsofalcohol,morewidespread testingandalcoholpolicies.Itwasalsoconfirmedbysomeoftherespondentswhodescribed alcoholuseasadecreasingproblem.Therearethoughothersubstancesthanalcohol,two respondentsspecificallymentioneddrugsandmedicineabuse(JensUweSchrder,20081113; StefanLindberg,20081114).Theseareproblemsthatareseldommentionedinliteraturebut Lang(2000)meanthatthereiscircumstantialevidencetoindicatethatdrugsplayapartinsome accidents. Takingintoaccountthediscussionabove,itisregardedthatanawarenessfailureisunlikelyto becausedbyanofficeronwatchbeingincapacitatedduetosubstanceabuse.Ifontheother handthisprimarycausewouldtakeplace,theunderlyingfactorsseenascontributoryareas follows:
Underlyingfactors Resultsfrominterviews Resultsfrom literaturestudies Significant contribution Smallmedium

Organisationalculture Significantcontribution Workpressure Significant Personalstress Significantcontribution Medium contribution Failuretoensurefitnessat Mediumtosignificant Smallmedium handover Perceptionofnegativeeffects Mediumtosignificant Nodata ofsubstances Competence Lowcontribution Nodata Vaguetrends Summaryofimportantfactors Organisationalculture,workpressureandpersonalstress,failuretoensure fitnessathandoverandperceptionofnegativeeffectsofsubstances

Addedfactors Participantsmentionedthattheworkingenvironment/teamworkonboardaship,medication andaddictionmightplayapartinanofficeronwatchbeingincapacitatedbysubstanceabuse.It canbeagreedonthattheworkingenvironmentcouldbeainfluentialfactortowhyapersonis usingsubstancesandthatthisperhapsisnotincludedineitherofthefactorsorganisational culture,personalstressorhighworkload.Problemswithmedicationandaddictionwould hopefullybepickedupduringmedicalcheckups,testsoridentifiedotherwise.

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8.4.4 Asleep
Theanswersfromtheinterviewsarealmostevenlydistributedbetweenlittle,medium, significantandverysignificantcontributionbutwithasmallpeakatsignificantcontribution.It wasmentionedinaninterviewthattheofficeronwatchbeingasleepislikelytobemore commonatshipswithcrewofminimumlevels(CarlHenricWulff,20081110).Sleepasa causationfactorisprobablyunderestimatedinaccidentreportsbecauseofdifficultiesin measuring(Swedishmaritimeadministration,2008).Indicatorsoffatigueareoftendifficultor impossibletoidentifyfollowinganaccident(Grechetal,2008).Inananonymousstudywith Swedishseafarers,73%admittedhavingfallenasleeponceorseveraltimesduringtheirwatch (Ltzhft&Kiviloog,2003).Withregardstothefindings,sleepisviewedasanessentialreason towhycollisionshappen.
Underlyingfactor Typeofwatchsystem Timeofday Workloadtoohigh Resultsfrominterviews Significanttovery significant Significantcontribution Mediumtovery significantcontribution Resultsfrom literaturestudies Significant

Significant Medium

Timeintothewatch mediumtosignificant Medium Failuretoensurefitnessat Smallcontribution Nodata handover Vaguetrends Workloadtoolow,organisationalculture,durationofjourneyandover relianceontechnicalequipment. Summaryofimportantfactors Typeofwatchsystem,timeofday,workloadtoohighandtimeintothe watch.

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8.4.5 Illness
Anillnessisgenerallyperceivedbytherespondentsasasmallcontributortothescenariolackof awareness.Almost85%haveanswerednoorlittlecontribution.Itwasmentionedthatthere arequitestrictrulesformedicalcheckupsatseawhichshouldresultinagoodhealthstandard. Theliteraturepartlygivesadifferentview.Casesofmoreseverediseasesonshipsarefewer todaythanpreviouslybutshipsarestillenvironmentswhereminorillnessescanbepassedon easily.Oftentheconsequencesarerelativelysmall,butitwouldstillhaveanimpactontask performance(Grechetal,2008).Researchshowsalargeriskfortheshortandlongtermhealth ofthoseworkinginshiftsystems(Ltzhftetal,2007).Lackofawarenessduetoanillness whichlatercouldcauseacollisionishoweverseenasascenariowithverylimitedinfluence, whenkeepinge.g.therigoroushealthmanagementproceduresandthesmalllikelihoodfora severeillnessinmind.
Underlyingfactor Ageandgeneralhealth Resultsfrominterviews Mediumtovery significantcontribution. Resultsfrom literaturestudies Nodata

Vaguetrends Healthmanagement/culturewithinorganisation Summaryofimportantfactors Ageandgeneralhealth.

Addedfactors Seasicknessandinflexiblesystemsarementionedasunderlyingfactorstounawarenessdueto illness.Thereisalsoadilemmawiththeinflexiblesystemsonboardships,whichoftenare withoutredundancyifapersongetsill.

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8.4.6 Personalinjury
Anaccidentthatcausesapersonalinjuryisrankedasafactorwithlowcontributiontolackof awarenessbyalmostallrespondents.Someofthecommentariesduringinterviewswerehow unlikelythisisandthatthebridgeisarathersafeenvironment.Nospecificinformationhas beenfoundwheretheofficeronwatchhasbeenincapacitatedduetoapersonalinjury,but injuriesarementionedinrelationtoworkatdeck.Oneoftheexpertsparticipatinginan interviewmentionedanexperiencewithanofficeronwatchfallingatthebridgeandbreaking hisneckwhichyetshowsthatitcouldhappen.Although,apersonalinjuryonthebridgethat resultsinlackofawarenessisconsideredtohavealmostnegligibleimpactontheriskfora collision.Whenassessingtheunderlyingfactorstoapersonalinjury,theweatherconditionis rankedasthemostimportantfactorfollowedbytimeofday,whereasthelayoutofthebridgeis notsignificant.
Underlyingfactor Weather Timeofday Timeintothewatch Resultsfrominterviews Significantcontributor Mediumtosignificant Resultsfrom literaturestudies Nodata

Nodata

Smalltomedium Smallcontribution contribution Workloadtoohigh Aroundmedium Smallcontribution contribution Layoutofthebridge Small Small Vaguetrends Durationofjourney,reportingandfollowupandnotfollowingguidance. Summaryofimportantfactors Weather,timeofday,timeintothewatch,workloadtoohigh.

Addedfactors Whendiscussingthefactorreportandfollowupofaccidentsandnearmissesduringthe interviewsanditsimpactonpersonalinjuries,notmanyrespondentsunderstoodthefactor. Followinganexplanation,someoftherespondentsrecognisedthecontribution,butthefactor seemstobebetterknownwithintheriskmanagementareathaningeneral. Anotherpointofviewwasthattheorganisationalculturehasanimpactontheprimarycause personalinjury.Thismightbeacontributoryfactor,butcomparedtootherfactorssuchas heavyweatherandtimeofday,theorganisationculturedoesprobablynothaveasignificant impactoninjuries.

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8.4.7 Distracted
Theresultsfromtheexpertjudgmentshowthatdistractionhasacontributionthatisspread betweenlittleandsignificantcontribution,withamajorityleaningtowardsasignificant influence.Distractionorinattentionisregardedasaprobleminseveralresearchprojects,but noprojectsthatsearchdeeperintotheproblemhavebeenfound.Areviewofaccidentsin Canadianwaters19811992establishesthat20outof273accidentswererelatedtodistraction (7%).Inaresearchprojectaboutsafetymeasuresinattentionisperceivedtocause14%ofall situationswheretheofficeronwatchlostthenavigationalcontrol(Kristiansen&Soma,1999). Anexamplementionedduringinterviewswashowtheofficeronwatchcanbeworkingwith othertasksandsimplyforgetsabouttheinstrumentsandtolookout(Pettervers,200811 04).Anotherexampleisalarmsconnectedtothebridgewhichcandrawattentionawayfrom watchkeeping(DavidWendel,20081107;TorEgilHopenSaue,20081103).Withregardsto theresultsfromtheinterviews,remarksandfindingsinliterature,thesituationofanofficeron watchbeingdistractedisconsideredtoplayasignificantroleinalackofawarenessscenario.
Underlyingfactor Workloadtoohigh Overrelianceontechnical equipment Organisationalculture Resultfrom interviews Mediumto significant contribution Mediumto significant contribution Mediumto significant contribution Medium contribution Resultfromliterature studies Significantcontribution

Significantcontribution

Significantcontribution

Notfollowingguidance Mayhaveacontribution Personalstress Significant Significantcontribution contribution Levelofothervesselactivity Medium Littlecontribution contribution Nospecificdata Worktoolow Littletomedium contribution Vaguetrends Extremeeventontheship,layoutofthebridgeandbridgeprocedures Summaryofimportantfactors Highworkload,overrelianceontechnicalequipment,organisationalculture, notfollowingguidance,personalstress,levelofothervesselactivity

Addedfactors Threeadditionalunderlyingfactorswereconsideredtohaveanimpactonanofficeronwatch beingdistracted;nonnavigationalrelatedcommunication,e.g.withpeopleonthebridge, onboardactivitiesonsmallerships,suchasfishing,andconversationsontheradio.Allofthese threefactorsareacknowledgedasimportanttowhydistractiontakesplace.

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8.4.8 Absent
Accordingtotherespondents,absencecanbeconsideredasamajorproblemwhendiscussing lackofawareness.12participantsregardthecontributionofthefactorassignificantorvery significant,while7meanthattheimpactismediumorlower.Manyrespondentsmentioned thatabsenceshouldjustnothappen.AccidentreportsfromtheSwedishmaritime administrationshowsthatitcanhappen(SwedishMaritimeAdministration,2008),eventhough itisonlymentionedasacontributingfactorinoneof139accidentreports.Inaresearchreport, 3%ofthesituationswheretheofficeronwatchloosethenavigationalcontrolmaybecaused bytheofficerbeingabsent(Kristiansen&Soma,1999).Anabsentwatchkeeperisseenas havingsignificantinvolvementinthescenariolackofawareness,mainlyduetotheresultsofthe interviewsbutalsoconsideringdiscussionsinliterature(e.g.HSE,1999).
Resultsfrom Resultfromliterature interviews studies Organisationalculture Verysignificant Significantcontribution contribution Overrelianceontechnical Mediumto Significantcontribution equipment significant contribution Timeintothewatch Little Nospecificdata contribution Layoutofthebridge Little Nospecificdata contribution Vaguetrends Competence Summaryofimportantfactors Organisationalcultureandoverrelianceontechnicalequipment. Underlyingfactors

Addedfactors Havingonboardactivitieswasalsoregardedtoimpactonanofficeronwatchbeingabsentfrom thebridge.

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8.5 Handlingerror
AspreviouslydescribedinSection7.3,thescenariohandling errorisdirectlyconnectedtounderlyingfactorsandnotfirst dividedintoprimarycauses. Thescenariohandlingerroranditscontributiontothe collisionriskwasdescribedinSection8.3.
Underlyingfactors Notfollowingguidance Unclearrolesand responsibility Resultfrom interviews Mediumto significant contribution Mediumto significant contribution Resultsfromliterature studies Averagecontribution

Nospecificdata

Mediumtovery Averagecontribution significant contribution Lackofcommunication Average Averagecontribution contribution Mediumto Littlecontribution Familiarisationofship significant characteristics contribution Workpressure Significant Significantcontribution contribution Overrelianceontechnical Mediumto Significantcontribution equipment significant contribution Maintenance Littletomedium Littlecontribution contribution Vaguetrends Blackout,wishfulthinking,language,misunderstanding,competence Summaryofimportantfactors Notfollowingguidance,unclearrolesandresponsibility,fatigue,lackof communication,familiarisationwithshipcharacteristics,overrelianceon technicalequipment.

Fatigue

Addedfactors

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8.6 Factorsaddedduringtheinterviews
Inadditiontothefactorsidentifiedbytheauthors,therespondentshadthepossibilitytoadd otherfactorsineachquestion.Mostoftheaddedfactorsarementionedinrelationtospecific primarycausesabove,whereastheonesthatarenotrelatedtoonespecificcausearediscussed below. Themanmachineinterface Oneadditionalfactorthatmaycontributetoexternalcommunicationfailuresanderrorsrelated tonavigationalequipmentwasthemanmachineinterface.Thedesignofequipmentandhow informationissharedbetweentheuserandthemachinecanaffecttheprobabilityforfailures becauseofhowthislimitstheusage.Thesetypesofissuesmaybeseenasincludedinthefactor inadequateequipment. Personalactionsorchoice Personalactionsorchoicewasaddedasbeingcontributorytoanofficeronwatchbeingasleep andabsent.Therespondentsmeantthatapersonaldecisioncanresultintheunawareness. Fromtheperspectiveoftheauthorsandthesystemapproach(refertoSection3.2),thereare veryfewdecisionsthatcanbeclassifiedasapersonalchoice,consideringhowasufficientlevel ofeducation,riskperception/acceptanceandmaybeevenmoralsshouldbearesponsibilityof theorganisation.Thisfactorshouldthereforebeincludedinthefactororganisationalculture. Weather Somerespondentsconsideredthattheweatherhasaninfluenceonotherprimarycausesthan mainlyinjuriesandnavigation,forexampleanofficerbeingasleep.Badweather(precipitation, wavesetc.)islikelytoincreasethealertnessonthebridgebutwillalsomakeitmoredifficultto navigateandcreateatiringenvironment.Inthatsense,weatherconditionswouldbeafactorin somebodyfallingasleep.

8.7 Summaryofresults
AllresultsfromthediscussionabovearesummarisedinFigure15below.Thefigureisbasedon thehierarchicalmodelfromChapter7butisadjustedtoreflecttheresults.Scenarios,primary causesandunderlyingfactorsthatnotplayanimportantrolewithregardstotheresultsare faded.Causesandfactorswhichhavenotshownanycleartendenciesareplacedwithin brackets.Theunderlyingfactorsarerankedaftertheirimportanceaccordingtotheresults,with themostcontributingfactorfirst. Thefactorsandcausesthatwereidentifiedandaddedbytheparticipantsduringtheinterviews haveallbeenacknowledgedbyonepersoneach.Duetothis,thesefactorsandcauseshavenot beenanalysedfurthereventhoughitispossiblethatthefactorsmayhaveasignificantimpact onthecollisionrisk.AlsorefertoSection9.1. Anunderlyingfactorthatisrepresentedinseveralprimarycausescouldbemoreimportantthan onethatonlyisconnectedtooneprimarycause.Howeverthisalsodependsonhowimportant thespecificprimarycauseis.Theunderlyingfactorwillberegardedasinsignificantifthe primarycausedoesnotaffectthecollisionrisktoagreatextent.

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Someunderlyingfactorswereidentifiedtoplayanimportantroleinseveralprimarycausesand arethereforeconsideredtobesignificantareaswhenimprovementsandriskmitigationareto beundertaken.Examplesoftheseareasareproblemswithnotfollowingguidanceandanover relianceontechnicalequipment,whichappearstobewellknownhazards.Areoccurringfocus areashouldalsobetheorganisationalcultureonaship,e.g.acceptanceandunderstandingof actionsandbehaviors.

8.7.1 ComparisontoRABLproject
WhencomparingourresultswiththestudyintheRABLprojectthesamethreemostimportant causesforlackofawareness(orwatchkeepingfailureasreferredtointheRABLproject)are found;asleep,absentandabsorbed.TheRABLprojectshowsthatofficeronwatchbeingasleep hasaprobabilityaround100timeshigherthanabsentanddistraction.Inthisthesisitwasfound thatsleep,absenceanddistractionhaveequalcontributiontothescenariolackofawareness. TherearesomedifferencesbetweenthisthesisandtheRABLprojectwhyalltheresultsnotare comparable.TheRABLprojectwasfocusedonevaluatingdataforriskanalysisanddidnot discussreasonstowhythedifferentcausesoccur,i.e.theunderlyingfactors.Different assessmentshavebeendoneintheRABLprojectdependingonthetypeofship,e.g.merchant shipsandfishingvessels.TheRABLprojectvariedbetweenusingonetofourexpertsinthe assessments,whichseemslikeasmallselectionifreliablevaluesaregoingtobeachieved.

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Figure15:Themodelofscenarios,causesandfactorsupdatedwithregardstotheresults.

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Discussion

Thischapterpresentsadiscussionofuncertaintiesinthemethodandtheanalysis,including benefitsandstrengths. Ithasbeendifficulttofindarecognisedmethodforcombiningalimitednumberoffrequency dataandpreviouslymadeexpertjudgementswithresultsfromanewstudy.Astructuralmodel hasthereforebeenusedasabase,withapursuittofindinformationfromotherareaswhenthe areaofresearchrelatedtooffshorecollisionsislacking.Itislikelythatthereisnotagreatdeal ofinformationaboutoffshoreshipcollisionsduetotheriskbeingsmallwhencomparedto othertypesofshipcollisions. Therehasbeenanattemptduringthewholeworkprocess,namelythatthefinalthesiswill achievethreestatements:thattheexaminationisrepeatable,thatthemethodsand observationscanbeevaluatedandthattheintellectualprocesscanbeunderstood.Thishas beenachievedbydescribinghowtheinterviewswereperformedandwhichquestionswere asked.Allanswersarepresentedwithinthethesistogetherwithstatisticsfromwhere conclusionsweredrawn.Thisshouldgiveatransparentprojectthatispossibletovalidate. ThegeographicalareawheretheconclusionsfromthisthesisareapplicableismainlytheNorth SeabutpossiblyalsootherareaswithregulationsandconditionssimilartothoseoftheNorth Sea.Theworkisnotspecifictotheoffshoreindustrybutrathertotheshippingindustryin general.

9.1 Interviewsandresults
Therewasasmallsetbacktotheoriginalplanwhenavalidsampleofquestionnairerespondents wasnotachieved.Thismayforexampledependontherespondentslackoftimeorthatpeople ingeneralaremorewillingtoanswerquestionnaireswhenconfrontedinperson.Inhindsight, thiswasthoughprobablythebestoutcomeconsideringthemanyadvantagesofinterviews.The interviewsgaveanopportunitytoexplainthehierarchicalmodel,todefineconceptsandtoask therespondentsquestions. Manyconclusionscanbedrawnfromtheresultswithregardstothecontributionofthecauses andfactorsforthecollisionrisk.Itmightalthoughbepossiblethattheopinionsofthe respondentsarenotreflectedinsuchawaythatwasinitiallyplanned. Subjectivity Subjectivityisalwaysaproblemininterviews.Resultsaredependentonhowresearchers completingaprojectandexpertgroupsinterpretinformation.Therearesubjectivevalues involvedduringinterviewsandalsoafterwardswhenthegatheredinformationisassessed. Thereisalsoapossibilitythatrespondentswanttoprotecttheircolleaguesandthereputation oftheirprofessionandthereforenotalwaysanswerthequestionstruthfully.Bycomparing informationfromdifferentsources,currentlyusedmodelsandexpertjudgementtheresults havebeengivenvaliditybyusingtriangulation.

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Differentbackgrounds Ourwishwasthattheexperienceoftheparticipantswouldprovidetheabilitytolookata collisionobjectivelyandthusidentifypossiblehazardsandriskcontributingfactors.Someofthe participantswereabletoapplyamoreopensetofmindwhereasotherswerelessflexible.It wasalsonotedthattheparticipantshaddifferentframesofreference.Therespondentscame fromdifferentbackgroundsandsomeofthemhadneverworkedonboardashipinthespecific areawhileothershadneverperformedriskanalyses.Thishasanimpactonforexample whethertherespondentsansweredwiththespecificgeographicalareainmindorhadamore globalfocus. Humanshavethereasonableexpectationthattherecurrencesofthepastprovideafairguide tothelikelihoodsofthefuture(Reason,1988) Asremarkedinthequoteabove,itwasnoticedthatafewoftherespondentsmainlyrelatedto ownexperienceswhenansweringquestions,withouttryingtohaveamoregenericfocus.If somethinghadhappenedtothem,theyweremorelikelytoratethiscauseorfactorashigh. However,byconsideringtheselectionofintervieweeswithdifferentbackgrounds,thatallin somewayareconnectedtothemaritimeoroffshoresectors,webelievethatthesomeofthe uncertaintiesincorporatedintheexpertjudgementwoulddiminish.Thenumberofexpertsis substantial,withrepresentationfromactivecaptains,formercaptainsworkinginotherareas, peoplewithineducationinthemaritimesectorandresearchersetc. Differentinterpretations Duringthecompletionofinterviews,itbecameobviousthatsomeoftheinquiresweredifficult tounderstandandthattheinterpretationofthequestionscanvarydependingonthe respondentsframeofreferences. Explanationsofconceptswouldnotguaranteethattheparticipantsofthestudyhadthesame viewsastheauthors,butitwoulddefinitelyincreasethelikelihood.Wetriedtobeconsistent andexplainconceptsduringtheinterviews,sothatthequestionswereapproachedfromthe sameperspectiveandthisshouldsignificantlyhaveimprovedtheresults.Nevertheless,the explanationswerenotalwaysadopted,maybebecauseofthedifficultiestomakeaperson totallyembraceanewsetofmind.Itcouldalsobepossiblethattheparticipantsanswered questionswithoutaskingforclarifications.Theresultsmighthavebeenclearerifthe respondentshadcompletelysharedtheviewsofallthedefinitionsandwerefamiliarwiththe structuralmodel. Diversitiesinresults Diversitybetweenanswerscanbeasignofseveralthings.Itcouldberelatedtodifficultiesin understandingthequestions,diverseinterpretationsofthequestionsorsimplyreflectvarying opinions.Anexampleofthisisaquestionregardinghighworkloadasanunderlyingfactorto anofficeronwatchbeingdistracted.Onewaytoreadthequestionisiftheworkloadistoo high,towhatextentwouldthiscontributetotheofficerbeingdistracted?.Ourintentionwas thatthequestionshouldbeinterpretedasconsideringanofficeronwatchbeingdistracted,to whatextenthasahighworkloadcontributedtothatdistraction?.Thisproblembecame

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apparentduringsomeoftheinterviewsanditwasunfortunatelydifficulttoimpacton. Sometimesitfeltliketherespondenthadabottomupperspectiveratherthanatopdownview wherethecollisionistheoverlyingstartingpoint. Atendencywithregardstotheunderlyingfactorsisthatfewextremevalueswereusedduring therankings.Respondentsseemedtopreferlittlecontributiontosignificantcontribution(i.e.2, 3or4)iftheywereunsure,especially3mediumcontribution.Somerespondentspointedout thetendencytonotchooseextremevalues,i.e.nocontributionandverysignificant contribution. Theresultsaremorethanonceevenlydistributed,whichmakesitdifficulttooutlineanydistinct conclusions.Besidesthat,itislikelythattheresultsfromtheexpertstudyareinfluencedbythe difficultyinachievingacategorisationthatisperceivedastotallyobvious.Howtheunderlying factorswerecomplicatedtodivideintogroupsmayalsohavebeenreflectedintherespondents answers.Buttheevendistributioncanalsobeasignofanuncertainfactorwhichisan importantconclusionitself. Factorsaddedduringtheinterviews Thefactorsaddedbyparticipantsintheinterviewscanbeusefulinfuturestudies.Itwasnoticed thatmanyrespondentsfounditdifficulttoaddownfactorsaftertherankingofthe predetermined.Wehadprobablyobtainedmorefactorsiftherespondentshadtheopportunity toreasonindependently,butwiththelikelyconsequenceofincomparableresults.Asolutionto thiscouldhavebeentoconductaworkshopwithallexpertsinsteadofinterviews,butthiswas notpossiblebecauseofdifficultyincoordinatingthis. Correlations Theanswersmightalsohavebeenaffectedbycorrelationbetweenvariousfactors.Itisnot alwayseasytoknowwherecertainproblemsbelong,whichcanbeexemplifiedbythefactors languageandcompetence.Languagecanbeseenasacomponentincompetence(education, skills),buthowwouldthequestionaboutcontributiontocommunicationbeansweredifthere aredifficultiesininterpretations?Asignificantpartofcompetencemayinvolvelanguage whereasthelanguageskillsalsomaybeexcludedandassessedseparately.Thisisaproblem thatisinevitable,itisimpossibletoclarifyallconceptstoanextentthatallpeopleinterpret theminthesameway. CorrelationisalsoaproblemwhenitcomestothecategorisationmadeinSection7.4where onespecificfactorcanbelongtomorethanonecategory.Examplesarefamiliarisationwithship characteristicsandoverrelianceontechnicalequipmentwhicharecategorisedasfactors relatedtohandlingbutthatalsocouldbecategorisedunderorganisationalfactors.Becauseof theuncertaintieswiththecategorisationnoconclusionsofthedifferentcategoriesaredrawn. Thetwotypesofcorrelationscanleadtothecontributionoffactorsbeingoverorunder valuated.

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9.2 Humanandorganisationalfactorsmeasuringtheimpacts
Onecommonproblemwithmeasuringhumanandorganisationalfactorsistheareaitself.Itis oftenverydifficulttograspconceptsandunderstandwhatpartsthatarecorrelatedwithor impactingonothers.Itmaybechallengingtoagreeonwhathumanandorganisationalfactors meanandthereisoftenadiscrepancyindefinitions,withaconsequenceofpredicamentswhen resultsfromdifferentprojectsaretobecompared. Anotherdilemmawithtryingtoquantifyactionsandhumanerrorsishowhumansarenot predictableandthataccidentsoftenoccurinseveralstepsinachainofevents.Thiscanresultin problemswhentryingtoquantifyfailuresandfactors.Itcanbehardtocollectempiricaldata fromtheindustry,asthereoftenisinadequateinformationavailable.Eventhoughthereare severalmaritimeaccidentdatabases,thedatacontainedisonlymarginallyrelevanttohuman andorganisationalfactors.Underlyingfactorsareseldommentionedinaccidentreports, consideringthattheyaregenerallynotanalysedtothatlevelofdetailbutareprobablyapartof allaccidents. Itmaysometimesbebettertousequalitativediscussionstoassesstheimpactofhumanand organisationalfactorsthanquantitative,consideringhowthiswouldallowformoreofa discussionaroundtheareainlieuofavoidingit.Thereisadangerwithapplyingfixedvaluesin riskanalyses,withoutunderstandingandreflectingoverwhatliesbehindthem.Aqualitative discussioncanthereforegivemoreofanunderstandingofthearea.Webelievethatitisbetter totrytopenetratetheareathanavoidingameasurementofhumanandorganisationalfactors, consideringthatmanysourcesmeanthattheimpactofhumanerrorsissignificantinaccidents.

9.3 Theliteraturereview
Therehasbeenastrivetowardsfindingliteraturethatisapplicableforourpurposebutmost researcharedealingwiththeshippingindustryandinteractionswithinitorwiththeoffshore industrybutnotthecollisionrisk.Wehavedrawnconclusionsfromresearchregardingcollisions betweentwoshipsandgroundings.Informationhasbeenappliedwithcarefulnessandthe authorsarewellawareoftheproblemsanduncertaintiesthismightmean.Itmusthoweverbe keptinmindthattherealsoisagreatadvantagewithadoptingmethodsandinformationfrom otherareasconsideringthatthiscanprovidenewknowledge. Statisticaldata Itischallengingtopredictscenariosandaccidentsthatdonotoccurveryoftenbyjustlookingat statisticsandincidentfrequencies,consideringthatthismightnotgiveapictureoftheactual risk.Iffewaccidentshaveoccurred,likeinthecasewithoffshorecollisions,thiscouldindicatea toolowfrequency.Itcouldalsobepossiblethattheriskispredictedasmoresignificantwhen lookingathistoricaldata,asmoreaccidentscouldhaveoccurredpreviouslythannowadays.A changeovertimecoulddependonadvancesintechnology,suchastrafficsurveillancestations. Onefindingduringtheliteraturereviewwasthebigdivergencebetweenaccidentdatabases. Thesourcesseemtohavetheirownwaytodescribeandcategorisedata,whichresultsinbig disadvantageswhencomparingstatistics.Causestoaccidentsarealsoofgreatimportancefor preventivemeasuresundertaken.Ifreasonsbehindaccidentsarenotaddressedproperly,it couldresultinriskmitigatingmeasuresthatareinadequate.Nearmissesareofgreat

62

importance,especiallywithintheoffshoreindustrywheretheexperiencesfromcollisionsis relativelysmall.Accidentdatabasesaregenerallynotrelatedtotrafficpatterns.Changesin trafficdensity,routesortypeofshipscanaffecttheriskforanaccidentandthisisimportantto keepinmindwhenusingaccidentdata.

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64

10 Conclusion
Thischapterdescribeshowthepurposeofthethesiswasfulfilled,followedbyanswersofthe researchquestions.Thoughtsandideasforfutureworkthatareperceivedasimportantarealso outlined.

10.1 Reachingthepurpose
Thepurposeofthisthesiswastoachieveabetterunderstandingofwhyacollisionbetweena shipandanoffshoreinstallationoccurandtoidentifythemostinfluentialfactorsintheaccident development.Thisisachievedbycreatingahierarchicalmodelofacollision,includingscenarios, primarycausesandunderlyingfactors.Itwasherebypossibletograspthechainofeventswith severalfactorsthattogethercontributetoaprimarycause,whichbyslippingthroughnumerous layersofriskmitigatingbarriersmayresultinacollision.

10.2 Answeringtheresearchquestions
Theresearchquestionsansweredduringtheworkwiththethesisare: Whataretheprimarycausesandunderlyingfactorsbehindashipcollisionwithan offshoreinstallation? Thelevelsofcausesandfactorsinacollisionwereidentifiedfromtheliteraturereview combinedwithsmallworkshops.Thestudyisaltogetherbasedonthehierarchicalmodel delineatedduringthedevelopmentofthisthesis.ThemodelcanbefoundinFigure12 (p.41)andshowsallidentifiedscenarios,causesandunderlyingfactors. Towhatextentdotheseidentifiedprimarycausesandunderlyingfactorscontributeto thecollisionrisk? Thescenariowithmostcontributiontothecollisionriskisrecognisedtobeawareness failurewithasleep,absenceanddistractionasthemostcontributingcauses.The conclusionsfollowingtheinterviewsandinformationfromresearchareillustratedinFigure 15(p.58),wherethemostcontributorycausesandfactorsarepointedout.Itisalsopossible toseefactorsthatareregardedasnotimportant. Howcanthisdeeperunderstandingofcollisionsbeused,bothintegratedwhenassessing collisionriskandgenerallyinthemaritimesector? Conclusionsfromthisthesiscanbeappliedinoffshorecollisionriskanalyseswherethe resultstogetherwithfurtherresearchcancontributetoanupdateofexistingcollisionrisk models.Thisprojectalsoshowsthatitisimportanttoupdatethecollisionriskmodelswith regardstonewtechnicalequipment,organisationalchangesetc.

65

Themaritimeindustrycanbenefitfromthisresearchwhentryingtoidentifyhazardsine.g.risk analysesandworkplacesafetyassessments.Thisprojectcanalsobeusedtobetterunderstand humanandorganisationalfactorsincludinguncertainties,especiallyindisciplinesthatnormally areveryquantitative.

10.3 Futurework
Tomakesurethattheresultscanbeusefulinforexampleriskanalyses,somefurtherwork needstobedone. Additionalresearchshouldbeundertakenintheareaoftheidentifiedmajor contributoryfactors.Thesecanbefurtherassessedhenceleadingtomoreaccurate reflectionoftherisk. Thereisaneedforconsistencyindiscussinghumanandorganisationalfactors,which especiallyisidentifiedtobenecessarywithinaccidentinvestigationsanddefinitionsof factors. Moredetailshouldbeprovidedinaccidentdatabases,togiveabetterunderstandingof howdifferentfactorscontributetoanaccident.Afocusonnearmissesandadeeper discussionofunderlyingfactorscouldhelpfacilitatemoreproactiveworkwithhazards andrisks.

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11 References

11.1 Literature
Alvik,S.(2000),Theperceptionofsafetymanagementwithinshippingcompanies,TheRoyal institutionofnavalarchitects,RINAinternationalconferenceLondon2729September,United Kingdom. Atwell,C.,Pourzanjani,M.,Pearce,D.(1996),Userrequirementsfornewnavigationsystems, Theinternationalconferenceonpreventingcollisionatsea,Collision96,HillTaylorDickinson seminaronmaritimecollision. Aven,T.&Pitblado,R.(1998)OnriskassessmentinthepetroleumactivitiesontheNorwegian andUKcontinentalshelves.ReliabilityEngineering&SystemSafety,Issue61,pp.2129. AvenT.&VinnemJE.(2005)Ontheuseofriskacceptancecriteriaintheoffshoreoilandgas industry,ReliabilityEngineering&SystemSafety,Issue90,pp.1524. Backman,J.(2008),Rapporterochuppsatser,Studentlitteratur,Pozkal,Poland.(inSwedish) Baker,C.C.&McCafferty,D.B.(2005),Accidentdatabasereviewofhumanelementconcerns: whatdotheresultsmeanforclassification?,ABS(AmericanBureauofshipping)technicalpapers 2005,USA. Baker,C.C.&Seah,A.K.(2004),MaritimeAccidentsandHumanPerformance:theStatistical Trail,ABS(AmericanBureauofshipping)technicalpapers2005,USA. Bertranc(2000),Finalconsolidatedprogressreport,Brussels,Belgium. BrownA.&Haugene,B.(1998),Assessingtheimpactofhumanandorganisationalfactorson theriskoftankergrounding,8thInternationalOffshoreandPolarEngineeringConference,Paper NoISOPE98HKP03,May1998. Bryant,D.T.(1991),Thehumanelementinshippingcasualties,Departmentoftransport,Marine Directorate,UnitedKingdom. Dekker,S.(2002),Thereinventionofhumanerror,TechnicalReport200201, LundUniversitySchoolofAviation,Ljungbyhed,Sweden. DelaCampaPortela,R.,RodrguezGmez,B.A.,Lpez,M.,RiveroMartnez,B.(2006)Studyin Applicationofnaturallanguageprocessinginmaritimecommunications,JournalofMaritime Research,Vol.3,No.3,pp.1936. DNVTechnica(1995),UpdateoftheUKCSRiskOverviewOTH94458,HealthandSafety ExecutiveOffshoreTechnologyReport. DNV(1998),AppendixXRiskAnalysisofCollisions.AGuidetoOffshoreQRA,Oslo,Norway.

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 Ejvegrd,R.(2008),Vetenskapligmetod,Studentlitteratur,Lund,Sweden.(inSwedish) Embrey,D.E.(1992),Incorporatingmanagementandorganisationalfactorsintoprobabilistic safetyassessment,ReliabilityEngineeringandSystemSafety,Vol.38,pp.199208. FriisHansen,P.&SimonsenB.C.(2002)GRACAT:softwareforgroundingandcollisionrisk analysis,MarineStructures,Vol.15,pp.383401. Golafshani,N.(2003),Understandingreliabilityandvalidityinqualitativeresearch,The Qualitativereport,Vol.8,No.4,2003. Grech,M.,Horberry,T.,Koester,T.(2008),Humanfactorsinthemaritimedomain,CRCPress. NewYork,USA. Grozdanovi,M.&Stojiljkovi,E.(2006)Frameworkforhumanerrorquantification,Philosophy, SociologyandPsychology,Vol.5,Issue1,pp.131144. Harstad,E.(1991),Safetyasanintegratedpartofplatformdesign,Paperpresentedatthe1st InternationalConferenceonHealth,SafetyandEnvironment,TheHague,1014November1991. Haugen,S.(1991),Probabilityevaluationoffrequencyofcollisionbetweenshipsandoffshore platforms,Ph.D.Thesis,NorwegianUniversityofScienceandTechnology. Hetherington,C.,Flin,R.,Mearns,K.(2006),Safetyinshipping:Thehumanelement,Journalof safetyresearch,No.37,pp.401411. HSE(1999),EffectiveCollisionRiskManagementforoffshoreinstallations,Offshoretechnology report,OTO1999052,HealthandSafetyExecutive,UnitedKingdom. HSE(2003),Ship/platformcollisionincidentdatabase,PreparedbySercoAssurance.Research Report053,HealthandSafetyExecutiveUnitedKingdom. Hvold,J.I.(2007),FromSafetyCulturetoSafetyOrientationDevelopingatooltomeasure safetyinshipping,DoctoralthesisNorwegianUniversityofScienceandTechnology,Trondheim Norway. IMO(1995),InternationalConventiononStandardsofTraining,CertificationandWatchkeeping forSeafarers,InternationalMaritimeOrganisation. IMO(1999),Principlesofsafemanning,ResolutionA.890(21),InternationalMaritime Organisation. IMO(2007),FormalSafetyAssessment.ConsolidatedtextoftheGuidelinesforFormalSafety AssessmentforuseintheIMOrulemakingprocess.MaritimeSafetyCommittee,International MaritimeOrganisation. Kaplan,S.(1997),ThewordsofRiskAnalysis,RiskAnalysis,Vol.17,Issue4,pp.407417.

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 Kristiansen,S.&Soma,T.(1999),EffectivenessofSafetyMeasuresinMaritimeOperations, Norwegianuniversityofscienceandtechnology,divisionofmarinesystemsdesign,Trondheim, Norway. Lang,J.(2000),AnAccidentinvestigatorsperspective,ThemarineAccidentInvestigation Branch,TheRoyalinstitutionofnavalarchitects,RINAinternationalconference2729 september,London,UnitedKingdom. Ltzhft,M.&DekkerS.(2002),OnyourwatchAutomationonthebridge,Journalof navigation,Vol.55,Issue1,pp.8396. Ltzhft,M.&Kiviloog,L.(2003),Sjfartsdagen2003:Kommenteradevoteringsresultat, ngfartygsbeflhavaresllskapetiStockholm(inSwedish). Ltzhft,M.,Thorslund,B.,Kircher,A.,Gillberg,M.(2007),FatigueatSeaAfieldstudyin Swedishshipping,VTIreport586A,Linkping. MAIB(2004),Bridgewatchkeepingsafetystudy,Marineaccidentinvestigationbranch,safety study1/2004,UnitedKingdom. Maritime&CoastGuardAgency(2006),OrganizationalStructures:TheInfluenceofInternaland ExternalStructuresonSafetyManagementPerformance,AreviewpreparedbyGreenstreet Berman,ResearchProject547,UnitedKingdom. McCafferty,D.B.&McSweeney,K.P.(2003),HumanFactorsEngineeringandCulturalCalibration forVesselandOffshoreInstallationDesign,ABSTechnicalpapers2003,AmericanBureauof Shipping. McCallum,M.C.,Raby,M.,Rothblum,A.M.(1996),Proceduresforinvestigatingandreporting humanfactorsandfatiguecontributionstomarinecasualties,U.S.Departmentof Transportation,U.S.CoastGuardReportNoCGD0997. Nationalresearchcouncil(1990),CrewSizeandMaritimeSafety,NationalAcademyPress, WashingtonDC,USA. Nielsen,D&Jungnickel,D.(2003)MaritimeAccidentInvestigationandTemporalDeterminants ofMaritimeAccidents:ACaseStudyofEastGermanRecords,WMUJournalofMaritimeAffairs Vol.2,Issue1,pp.4959. NPD(2008a),FaktaNorskPetroleumverksemd,OilandEnergyDepartment&Norwegian PetroleumDirectorate,Stavanger,Norway.(inNorwegian) Patraiko,D.(2006),Fatigueonboard.Raisingawareness:TheNauticalInstituteReportingPlan. Seaways,March2006. PSA(2008a),RisikoniviPetroleumvirksomhetenNorsksokkel2007,PetroleumSafety Authority,Stavanger,Norway.(inNorwegian)

69

 PSA(2008b),SikkerhetStatusogSignaler20072008,PetroleumSafetyAuthority,Stavanger, Oslo.(inNorwegian) Philips,R.(2000),Sleep,watchkeepingandaccidents:acontentanalysisofincidentatsea reports,TransportationResearchPartF3,pp.229240. Reason,J.(1988),Cognitiveaidsinprocessenvironments:prosthesesortools?InE.Hollnagel,G etal.Cognitiveengineeringincomplexdynamicworlds,AcademicPress,London,United Kingdom. Reason,J.(2000),Humanerror:modelsandmanagement,Britishmedicaljournal,Vol.320, pp.768770. Smith,A.(2001),Offshorefatigue:Astudyofshipsintheoffshoreoilindustry,paperpresented attheSIRCsecondsymposium,CardiffUniversity. Smith,E.(1995),RiskmanagementintheNorthSeaoffshoreindustry:history,statusand challenges.45thIAFConference,ActaAstronautica,Issue37,pp.513523. SSPA(2008),MethodologyforAssessingRisktoShipTrafficfromOffshoreWindFarms,Vind PilotReport.FundedbyVattenfallABandSwedishEnergyAgency,Sweden. Technica(1987),RiskassessmentofBuoyancyLoss,Shipmoducollisionfrequency,ReportNo3, Trondheim. TSB(1998),Asafetystudyoftheoperationalrelationshipbetweenshipmasters/watchkeeping officersandmarinepilots,TransportationSafetyBoardofCanada(TSB),Reportnumber SM9501A. USCoastGuard(1995),Preventionthroughpeople:Qualityactionteamreport,WashingtonDC. Vinnem,JE.(2007)OffshoreRiskAssessmentPrinciples,ModellingandApplicationsofQRA Studies,Springer,London. Wang,J.&Zhang,S.M.(2000),Managementofhumanerrorinshippingoperations,Professional Safety,Section:Humanfactors,No.10,pp.2328.

11.2 Electronicreferences
HSE(2008a),HealthandSafetyExecutive,http://www.hse.gov.uk/offshore/who.htm, 20081012. HSE(2008b),HealthandSafetyExecutive,http://www.hse.gov.uk/pubns/indg189.pdf, 20081112. IEA(2008),TheInternationalErgonomicsAssociation, http://www.iea.cc/browse.php?contID=what_is_ergonomics,20081023.

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 IMO(2008),InternationalMaritimeOrganisation,http://www.imo.org/,20081012. LuleUniversityLibrary(2008),http://www.luth.se/depts/lib/databaser/artiklar.shtml,200810 09(onlyinSwedish) MAIB(2008),MarineAccidentInvestigationBranch, http://www.maib.gov.uk/publications/safety_digests.cfm,20081121. MarineProfile(2008),http://www.marineprofile.com/,20081118. NMD(2008),NorwegianMaritimeDirectorate, http://www.sjofartsdir.no/en/About_the_Norwegian_Maritime_Directorate,20081021. NPD(2008b),NorwegianPetroleumDirectorate,http://www.npd.no/NR/rdonlyres/82610E1F 99484966B4825573267F346D/13108/Letebor_avsl_2006e.jpg,20081118. PSA(2008c),PetroleumSafetyAuthority,http://www.ptil.no/aboutus/category89.html,2008 1121. PSA(2008d),PetroleumSafetyAuthority,http://www.ptil.no/regulations/category87.html, 20081123 SwedishMaritimeAdministration(2008a), http://www.sjofartsverket.se/templates/SFVXPage____1041.aspx,20081118. SwedishMaritimeAdministration(2008b), http://www.sjofartsverket.se/templates/SFVXPdfView____2965.aspx,20081120. TheUniversityofGothenburg(2008),http://www.infovoice.se/fou/bok/10000035.htm, 20081015. TheUniversityofMlardalen(2008), http://www.eki.mdh.se/personal/mlc01/metod_0_7/Validitetochreliabilitet.html,20081015. UKOOA(2008),TheUnitedKingdomOffshoreOperatorsAssociation, http://www.ukooa.co.uk/issues/piperalpha/v0000864.cfm,20081112. USCoastGuard(2008),http://www.navcen.uscg.gov/,20081118.

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72

AppendixAInterviewGuide
Introduction

The purpose of this interview is to investigate the reasons behind collisions between ships and offshore installations. The interview will identify and rank all underlying factors that can affect a collision. The study excludes collisions between offshore vessels and their dedicated offshore installations. The questionnaire considers all types of ships that may be present in the North Sea, such as merchant vessels, cruise ships, fishing ships and supply boats (i.e. during the travel towards/away from other offshore installations).

The scale ranges from 1 to 5, where the grade 5 means that a cause has very significant contribution whereas 1 means no contribution, according to the scale below.

Scale

1 2 3 4 5

No contribution Little contribution Medium contribution Significant contribution Very significant contribution

We are very thankful for your participation in this study! Regards, Karin af Geijerstam Hanna Svensson

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Background information Age Occupation/rank Experience - Time at sea, brief work description, type of ship or/and - Experience from research or projects concerning e.g. ship collisions, human factors or risk analysis

74

Questions 1. Considering collisions between ships and offshore installations, to what extent do you think that the following scenarios contribute? 1
No contribution

5
Very significant contribution

a.) Technical failure E.g. steering failure or machinery breakdown that prevents the ship from changing course

b.) Lack of awareness on ship The crew is unaware of the offshore installation and the collision course (e.g. due to sleep, absence, distraction) c.) Handling error in collision avoidance The crew is aware of the offshore installation but somehow fails to avoid collision

d.) Intentional failure Somebody on the ship aims to collide with an offshore installation

e.) Other, please specify:

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2. Considering collisions, to what extent do you think the following causes contribute to lack of awareness on ship (the crew is unaware of the offshore installation and the collision course)? 1
No contribution

5
Very significant contribution

Equipment related issues: - Failure related to navigational equipment

(Failure of the equipment or failure when using the equipment)

- External communication failure

(Failure of communication equipment or failure when receiving/interpreting information from an installation, other vessels or land-based stations)

- Other, please specify:

Officer on the watch being: - Incapacitated by substance abuse - Asleep - Incapacitated by illness - Incapacitated by personal injury - Distracted - Absent from bridge - Other, please specify:

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Awareness failure The crew is unaware of the offshore installation and the collision course

In an awareness failure, to what extent do you think that these underlying factors contribute to the following scenarios (3-10)?
3.Officeronwatchispresentbutincapacitatedduetosubstanceabuse:

1
No contribution

5
Very significant contribution

a) Competence

b) Failuretoensurefitness athandover c) Perceptionofnegative effectsfromsubstances d) Organisationalculture e) Workpressure f) Personalstress

g) Other,pleasespecify:

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4.) Officer on watch is present but incapacitated due to a personal injury: 1

No contribution

5
Very significant contribution

a) Layoutofthebridge b) Weather

c) Reportingandfollowup d) Workloadtoohigh e) Timeintothewatch f) Timeofday

g) Durationofjourney

h) Notfollowingguidance i) Other,pleasespecify:

5.) Officer on watch is present but incapacitated due to illness: 1

No contribution

5
Very significant contribution

a) Ageandgeneralhealth

b) Healthmanagement/culturewithin organisation c) Other,pleasespecify:

78

6.) Officer on watch is present but distracted: 1

No contribution

5
Very significant contribution

a) Extremeeventonship

b) Overrelianceontechnicalequipment c) Workloadtoohigh d) Workloadtoolow

e) Levelofothervesselactivity f) Layoutofthebridge

g) Bridgeprocedures

h) Organisationalculture i) j) Notfollowingguidance Personalstress

k) Other,pleasespecify:

79

7.) Officer on watch is present but asleep: 1

No contribution

5
Very significant contribution

a) Workloadtoohigh b) Workloadtoolow

c) Failuretoensurefitness athandover d) Organisationalculture

e) Overrelianceontechnicalequipment f) Timeintothewatch

g) Timeofday

h) Durationofjourney i) j)

Typeofwatchsystem Other,pleasespecify:

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8.) Officer on watch is absent: 1

No contribution

5
Very significant contribution

a) Competence

b) Organisationalculture

c) Overrelianceontechnicalequipment d) Layoutofthebridge e) Timeintothewatch f)

Other,pleasespecify:

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9.) Failure related to navigation equipment: 1

No contribution

5
Very significant contribution

a) Competence

b) Notusingindependent referenceequipment c) Maintenance

d) Levelofothervesselactivity e) Weather f) Blackout

g) Technicalfailureofnavigational equipment h) Inadequatetechnicalequipment i) j) Notfollowingguidance Other,pleasespecify:

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10.) External communication failure: 1

No contribution

5
Very significant contribution

a) Competence b) Language

c) Lackofcommunication d) Technicalfailureof communicationequipment e) Misunderstanding f) Blackout

g) Notfollowingguidance h) Other,pleasespecify:

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Handling error The crew is aware of the offshore installation but somehow fails to avoid collision.

11. In a handling error, to what extent do you think that these underlying factors contribute? 1
No contribution

5
Very significant contribution

a) Competence

b) Overrelianceontechnicalequipment c) Maintenance d) Blackout

e) Familiarisationofshipcharacteristics f) Workpressure

g) Notfollowingguidance h) Wishfulthinking i) j)

Lackofcommunication Language

k) Misunderstanding l)

Unclearrolesandresponsibility

m) Fatigue

n) Other,pleasespecify:

Thankyou!

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AppendixBExpertgroup
Name TorEinar Berg Relevantexperiences PrincipalResearchEngineer Researchanddevelopmentrelatedto: Trainingofseafarers KnowledgetestingSTCW95 EmilAall SafetecNordicAS,Oslo, SeniorSafetyConsultant Dahle Norway DrIng John DNVSeaSkill,Oslo,Norway Consultant Douglas 15yearsatsea 10yearsofhumanriskanalysis saEk AerosolandErgonomics, Researchassociate/PhD UniversityofLund,Lund, Developedanevaluationtoolforsafetyculturein Sweden apassengershippingsetting.Collectedempirical dataonsafetyculturebyapplyingthetool onboardsixvesselsininternationaltraffic (Swedishcrews). Thomas SafetecNordicAS,Oslo, SeniorSafetyConsultant Eriksen Norway 8yearsofworkwithshipcollisionmodels,traffic studiesandriskassessment. MaerskTrainingCentreA/S, MaritimeInstructor Frank Chiefmate/captain Svendborg,Denmark Lamberg 20yearsatseacontainervessels,ferries,sailing Nielsen boats. ProjectManager ArveLerstad ShipManeuveringand Chiefofficeratchemicaltanker SimulatorCentre, Investigationmanagerofcollisionsbetweenships Trondheim,Norway andinstallations19862000 ThesisinshipmaneuveringcapabilitiesatNTNU (1981) Stefan Activecaptain,Malm, Captain Lindberg Sweden Atseafor35years,ofwhich24asacaptain Cargotankers,ferries,cruiseships,carry Michael WorldMaritimeUniversity Universitylecturer,formershipcaptain Manuel (WMU),Malm,Sweden 11yearsatsea,shipcaptainonoceangoingships PhDinriskcontrol,researchinhumanfactorsand maritimecasualtyresearch ProfessorinMarineTechnology(nauticalscience) Egil MarineTechnology, Approximately1yearatsea,includingfishing Pedersen NorwegianUniversityof vesselsandseismicresearchvessels ScienceandTechnology (NTNU),Trondheim,Norway Researchconcerningcollisionavoidance: Approximately4yearsatKobeUniversityandthe NationalMaritimeResearchInstituteinJapan. TorEgil StatoilHydro,Bergen, LeaderStatoilHydroMarin HopenSaue Norway MasterMariner,workingatdifferenttypesofship Organisation ShipandOceanLaboratory MARINTEK,Trondheim, Norway

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Helge Samuelsen

ShipManeuveringand SimulatorCentre, Trondheim,Norway

Steven Sawhill

DNVSeaSkill,Oslo,Norway

JensUwe Schrder

WorldMaritimeUniversity (WMU),Malm,Sweden

TorkelSoma DNVMaritimeSolutions, Oslo,Norway JanErik Preventor,Stavanger, Vinnem Norway

David Wendel

DNVSeaSkill,Oslo,Norway

CarlHenric Wulff Petter vers

Formercaptain,Malm, Sweden ShipManeuveringand SimulatorCentre, Trondheim,Norway

beforeStatoilHydro. DevelopmentoftheStatoilHydroTraffic SurveillanceCenter CaptainandseniorinstructoratSMSC 30yearsatsea,ofwhich12asacaptain.Various typesofships;tankers,drycargo,bulketc. 16yearsexperienceassimulatorinstructoron varioustypesoftrainingincludinghumanfactor training. Participatedinseveralriskanalysesregardingrisk ofcollision ProjectManager 16yearsasacaptainatUSCoastGuardships Research:searchandrescue,emergency responseandemergencypreparation Associateprofessor,lastrankatseawas2nd officer 3yearsatseaoveraperiodof12years,starting fromcadetongeneralcargoships,thenABand then2ndofficer.Experienceongeneralcargo, container,coastalandchemicaltanker. Principalsafetyconsultant PhDconcerningmaritimesafetycultures SpecialistAdvisorRiskManagement M.Sc.inNavalArchitectureandMarine Engineering Dr.ing.inSystemSafetyEngineering;The NorwegianUniversityofScienceandTechnology, Trondheim. ProjectManager/MasterMariner 19yearsofMaritimeexperience Onboardexperiencefromcontainer,tankers,RO RO,highspeed,cruiseships MasterMariner,ashoresince4years Cargoships,hoovercrafts,containers,tankers, rorointheNorthofEurope CaptainandProjectManager 18yearsatsea,ofwhich8asacaptain.Mainlyon largeLNGtankers. 12yearsasinstructorinashiphandlingsimulator 10yearsincommercialcargoandshipping operations(ashore)

86

AppendixCExplanations
AIS AutomaticIdentificationSystem.Abroadcastingsystemthattransmits shipinformatione.g.identity,position,speed,size,cargoetc.AISis generallyrequiredtobefittedaboardallshipsofover300grossandall passengerships.AISisalsorequiredonallshipsengagedininternational voyages.(HSE,2007) ElectronicChartDisplayInformationSystem FloatingProduction,StorageandOffloadingvessel.Afloatingtank systemthatisusedintheoffshoreoilandgasindustrytoload,process andstoretheoilorgasuntilitcanbeoffloadedtoatankerorsent throughapipeline. GlobalPositioningSystem HealthandSafetyExecutive(UK) InternationalSafetyManagementCode.ThepurposeoftheCodeisto provideaninternationalstandardforthesafemanagementand operationofshipsandforpollutionprevention. InternationalConventionforthePreventionofPollutionfromShips Amerchantvesselisashipthattransportscargoandpassengers.Most countriesoftheworldoperatefleetsofmerchantships.However,dueto thehighcostsofoperations,todaythesefleetsareinmanycasessailing undertheflagsofnationsthatspecializeinprovidingmanpowerand servicesatfavorableterms. NorwegianPetroleumDirectorate(OljedirektoratetinNorwegian)isan independentStateadministrationbody

ECDIS FPSO

GPS HSE ISMcode

MARPOL Merchantvessel

NPD

PiperAlphaincident Alargeproductionplatform,startedoperationin1976.Therewasa massiveleakageofgascondensatein1988whichcausedanexplosion thatledtolargeoilfires.Theheatrupturedtheriserofagaspipeline fromanotherinstallation.Thisproducedafurthermassiveexplosionand fireballthatengulfedPiperAlpha.167peopledied,62peoplesurvived within22minutes.(UKOOA,2008)

PSA

PetroleumSafetyAuthority.

87

Safetyzone

Anareaextending500mfromanypartofanoffshoreinstallation.Itisan offencetowardsthePetroleumAct(1987)toenterasafetyzoneexcept underspecialcircumstances.(HSE,2008b) AStandbyvesselorEmergencyResponseRescueVesselprovides warning,controlandrescueservicestoanoffshoreinstallation.Theship e.g.notifiesvesselsthatareoncollisioncourseandalsoassistinan evacuation. Internationalconventionforthesafetyoflifeatsea. Internationalconventiononstandardsoftraining,certificationand watchkeepingforseafarers. Ashipspeciallydesignedtosupplyoffshoreinstallation.Itsprimary tasksaretransportationofgoodsandpersonnel. VeryHighFrequency.Marineradiocommunicationforships.Channel16 isusedastheinternationalcallinganddistresschannel. Acoordinateusedtoidentifyaphysicallocationinnavigation.Ithas previouslybeencommontouseoffshoreinstallationsaswaypoint,but thescenariosseemtobelessusual.

SBV/ERRV

SOLAS STCW

Supplyvessel

VHF

Waypoint

88

AppendixDDefinitionsofconcepts
Concepts Absentfrombridge Ageandgeneralhealth Asleep Blackout Bridgeprocedures Competence Definition Officeronwatchisabsent(i.e.notpresentatbridge). Conditionsspecifictothecharacteristicsofanindividual. Officeronwatchispresentbutasleep Thereisnopowersupply. Inadequatestandardsandproceduresfortheoperations onthebridge. Theabilitytoperformaspecifictask,actionorfunction successfully,whichcanbedevelopedfromtraining, educationandexperience. Officeronwatchispresentbutdistracted Thetimethecrewspendsonthevesselincludingtasks beforedepartureandafterarrival. Failureofcommunicationequipmentorfailure whenreceiving/interpretinginformationfroman installation,othervesselsorlandbasedstations. Aneventthatdrawstheattentionawayfromthenormal proceduresofthebridge,e.g.fire,manoverboard Failurerestrictedtothetechnicalnavigationequipment. Allerrorsrelatedtohumanhandlingareexcluded. Failureoftheequipmentorfailure whenusingtheequipment. Thepersonhandingoverthewatchfailstorecognisethat thenextpersonofthewatchisunfitforthetask. Familiaritywiththecharacteroftheship,suchassize, response,equipmentetc. Aconditionoftirednessthatreducesapersonsabilityto act. Thecrewisawareoftheoffshoreinstallation butsomehowfailstoavoidcollision Thegeneralhealthmanagementwithintheorganisation withregardstotheacceptanceofmedicalconditionsand proceduressuchasmedicalcheckups. Thestandardortypeoftechnicalequipmentdoesnotfulfil itspurposeortheequipmentislacking. Officeronwatchisincapacitatedbyaccident(e.g.personal injury) Officeronwatchisincapacitatedbyillness Officeronwatchisincapacitatedbysubstanceabuse Somebodyontheshipaimstocollide withanoffshoreinstallation Thecrewisunawareoftheoffshore installationandthecollisioncourse (e.g.duetosleep,absence,distraction)

Distracted Durationofjourney Externalcommunicationfailure

Extremeeventonship Failureoftechnicalnavigational equipment Failurerelatedtonavigational equipment/process Failuretoensurefitnessat handover Familiarisationwithship characteristics Fatigue Handlingerrorincollision avoidance Healthmanagement/culture withinorganisation Inadequatetechnicalequipment Incapacitatedbyaccident Incapacitatedbyillness Incapacitatedbysubstanceabuse Intentionalfailure Lackofawarenessonship

89

Lackofcommunication Language Layoutofthebridge Levelofothervesselactivity Maintenance Misunderstanding Notusingindependentreference equipment Notfollowingguidance Overrelianceontechnical equipment Organisationalculture Perceptionofnegativeeffects fromsubstances Personalstress Reportingandfollowup Technicalfailure Technicalfailureof communicationequipment Technicalfailureofnavigation equipment Timeintothewatch Timeofday Typeofwatchsystem

Unclearrolesandresponsibility

Weather Wishfulthinking Workloadtoohigh Workloadtoolow Workpressure

No/notenoughcommunicationinasituation. Barriersthatpreventsorinterfereincommunication. Thedesigndoesnotfullyenabletheproceduresofthe bridge. Thedensityand/ortheactivitiesofthesurrounding vessels. Inadequatemanagementstandardsandprocedureswithin theorganisation. Afailuretounderstandoradisagreement. Availablereferenceequipmentfornavigationisnotbeing used. Notfollowingorders,guidelines,legislationetc. Highleveloftechnicalautomationresultsintheofficeron watchunderestimatinghis/hersroleinmanagingtheship. Commonvaluesandideasthataresharedwithinthe organisation. Thepersonofthewatchdoesnotperceivethatthe substancewillimpedetheirawarenessabilities. Stressnotrelatedtoworkenvironment,e.g.family conditions. Proceduresforreportingofincidentsandnearmissesand howthesearefollowedup. E.g.steeringfailureormachinerybreakdown thatpreventstheshipfromchangingcourse Failurerestrictedtothetechnicalcommunication equipment.Allerrorsrelatedtohumanhandlingare excluded. Failurerestrictedtothenavigationequipment.Allerrors relatedtohumanhandlingareexcluded. Thedurationofthewatches. Dayornight. Thetypeofwatchsystemthatisusedinorganisation,e.g. whatistheproportionbetweenhoursofworkandhours offreetime.Examplesare4/8and6/6systems. (work/free) Thereisamisunderstandingwithregardstowhohasthe responsibilityofthebridge,e.g.duetoinadequatehand overbriefings. Weatherconditionssuchaswaves,precipitationetc. Thepersonofthewatchremainsinactiveandhopesthat thehazardwillbeavoidedwithoutactions. Highamountoftasksthataretobeperformedduringthe watch. Boredomcausedbytoofewtasks. Theworkenvironmentisperceivedtobestressful,e.g.due toeconomicpressureortimepressure.

90

AppendixEResults:scenariosandprimarycauses
Question 1
Considering collisions between ships and offshore installations, to what extent do you think that the following scenarios contribute?

18 16 14 12 no contribution litlle contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Technical problem

Lack of awareness

Handling error

Intentional failure

91

Question 2
Considering collisions, to what extent do you think the following causes contribute to lack of awareness on ship? 18 no contribution litlle contribution medium contribution significant contribution very significant contribution

16

14

12

Responses

10

0
Navigational equipment External communication Substance abuse Asleep Illness Personal injury Distracted Absent

92

Question 3
In an awareness failure, to what extent do you think that these underlying factors contribute to: officer on watch is present but incapacitated due to substance abuse?

18 no contribution litlle contribution medium contribution significant contribution very significant contribution

16

14

12

Responses

10

0
Competence Failure to ensure fitness Perception of negative at handover effects of substance abuse Organisational culture Work pressure Personal stress

93

Question 4
In an awareness failure, to what extent do you think that these underlying factors contribute to: officer on watch is present but incapacitated due to an personal injury? 18 no contribution litlle contribution medium contribution significant contribution very significant contribution

16

14

12

Responses

10

0
Layout of the bridge Weather Reporting and follow up Workload too high Time into the watch Time of day Duration of journey Not following guidance

94

Question 5
In an awareness failure, to what extent do you think that these underlying factors contribute to: officer on watch is present but incapacitated due to illness

18 no contribution litlle contribution medium contribution significant contribution very significant contribution

16

14

12

Responses

10

0
Age and general health Health management/culture

95

Question 6
In an awareness failure, to what extent do you think that these underlying factors contribute to: officer on watch is present but distracted

18 16 14 12 10 8 6 4 2 0
na lc ul tu re da nc e sh ip en t ge es hi gh lo w ity ac tiv ev en to n pr oc ed ur ip m to o to o br id gu i on al Pe rs st re s s

no contribution litlle contribution medium contribution significant contribution very significant contribution

Responses

eq u

W or kl oa d

kl oa d

ve ss

to ft

he

el

te ch ni ca l

Ex tre m

La yo u

of o

rg a

on

ve

rr el ia nc e

Le ve l

96

N ot

fo llo w in g

th er

Br

ni sa tio

id ge

or

Question 7
In an awareness failure, to what extent do you think that these underlying factorscontribute to: officer on watch is present but asleep

18 no contribution litlle contribution medium contribution significant contribution very significant contribution

16

14

12

Responses

10

0
Workload too high Workload too low Failure to ensure fitness at handover Organisational culture Over reliance on technical equipment Time into the watch Time of day Duration of journey Type of watch system

97

Question 8
In an awareness failure, to what extent do you think that these underlying factors contribute to: officer on watch is absent
18

16

no contribution litlle contribution medium contribution

14

significant contribution very significant contribution

12

Responses

10

0 Competence Organisational culture Over reliance on technical equipment Layout of the bridge Time into the watch

98

Question 9
In an awareness failure, to what extent do you think that these underlying factors contribute to: failure related to navigation equipment
18

16

no contribution litlle contribution medium contribution

14

significant contribution very significant contribution

12

Responses

10

0 Competence Not using reference equipment Maintenance Level of other vessel activity Weather Blackout Technical failure navigational equipment Inadequate technical equipment Not following guidance

99

Question 10
In an awareness failure, to what extent do you think that these underlying factors contribute to: external communication failure

18 16 14 12 no contribution litlle contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0
Competence Language Lack of communication Technical failure of communication equipment Misunderstanding Blackout Not following guidance

100

O ve rr el ia n ce C

Responses
10 12 14 16 18

on te ch ni c al eq u ip m en t M te nc e

om pe

Fa m ilia ris at io n of sh i p ch ar ac te t W N ot fo l lo w in g gu id a nc e e pr es su r or k ris t ic s Bl ac ko u e

ai nt en an c

W La ck of co m m un i ca t La ng M U nc le ar r is un d ol es / er s re sp ki ng is hf ul th in

In a handling error, to what extent do you think that these underlying factors contribute?

101
io n ua g ta nd on e in g si bi li t y Fa tig ue

Question 11

no contribution litlle contribution medium contribution significant contribution very significant contribution

102

AppendixFResults:underlyingfactors
Resultsfortheunderlyingfactorsfromtheinterviews,presentedalphabetically.
Age and general health

18 16 14 12 no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Illness

Datafromliteraturereview Therearesomedifferencesamongstoperatorswithregardstohealthrelatedattitudesand behavioursandhencesomewhatvaryingtolerancetowithstandtaskdemands(Gretchetal, 2008).Thereisanabsenceofliteraturethataimstoevaluatetherelationshipbetween seafarershealthandperformance.81%failedtoreachaminimumexerciselevelsrequiredfor goodhealth.(Hetheringtonetal,2006) Nostatisticsthatshowarelationshipbetweenage,generalhealthandinjuriesorsevere illnessesonboardshipshavebeenfound. Commentsduringinterviews Thereareregularmedicalcheckupsinthemaritimeindustryande.g.arequirementthatcrew membersmustnothaveaBMI(BodyMassIndex)thatexceed25(EmilAallDahle,20081111).

103


Blackout

18 16 no contribution 14 12 little contribution medium contribution significant contribution very significant contribution 10 8 6 4 2 0

Responses

Navigation process

External communication

Handling error

Datafromliteraturereview Itcanbenotedthat16%ofthenearmisses19972001wererelatedtoatotalpowerloss(HSE, 2003). Commentsduringinterviews Blackoutisnotaprobablereasonforacommunicationfailurebecauseofredundancyand backupsystems(TorEgilHopenSaue,20081103;EmilAllDahle,20081111).

104


Competence

18 16 no contribution little contribution medium contribution significant contribution very significant contribution

14 12

Responses

10 8

2 0 Substance abuse Absent Navigation process External communication Handling error

Datafromliteraturereview Competenceisanimportantfactorincollisionsbetweentwoshipsandexemplifiedbyhowit contributestoalmost80%oftheaccidentsinstatistics(MAIB,2004).However,itislikelythat thisisrelatedtocollisionsbetweentwoships,consideringhowitwouldbeunlikelythatavessel wouldenterthesafetyzoneofaninstallationandapproachaplatformduetolackof competence. Lackofskillandlackofknowledgearetwoofthemostcontributingfactorstolossesinshipping companies,withamoderatetohighcontributionforabout60%ofthecompanies(Alvik,2000). Wang&Zhang(2000)mentionlackofknowledgeandexperienceastwoleadingcausesof humanerror. Commentsduringinterviews

105


Duration of journey

18 16 14 12

no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Personal injury

Asleep

Datafromliteraturereview Therearefewindicatorsfoundinliteraturethatimplythatthedurationofajourneyhasan impactoncollisions.Itdoeshoweverappearlikefatigueisrelatedtodurationofvoyage, consideringthatmostaccidentscausedbyfatigueoccurduringthefirstweekofajourney (Smith,2001). Commentsduringinterviews Alongvoyagecontributestomoreroutinesandlessinterruptionswhichleadtobetter performance(CarlHenrikWulff,20081110).

106

Extreme event on ship

18 16 14 12

no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8

6 4 2

Distracted

Datafromliteraturereview Commentsduringinterviews Somerespondentsprobablyconsideredhowunlikelyitisthatanextremeeventwouldtake placewhenthevesselisclosetoaninstallation,whileothersdidnothavethisinmind,which resultedinwidelyspreadresults.AscommentedduringaninterviewIfanextremeevent happensontheship,youusuallystopthevesselandotherwisesomebodyelsewouldtakecare ofthingssothatyouwouldntneedtobedistracted(JensUweSchrder,20081113).

107


Failure to ensure fitness at handover

18 16 14 12

no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Substance abuse

Asleep

Datafromliteraturereview Failurewithregardstothewatchhandoffisidentifiedin5of109accidentreportsfromthe AustralianTransportationSafetyBureau(Baker&McCaffrey,2005).Handoverbriefingsarean essentialcomponentofteamworkandcooperation(TSB,1998). Commentsduringinterviews

108


Familiarisation of ship characteristics

18 16 14 12

no contribution little contribution medium contribution significant contribution

Responses

very significant contribution

10 8 6 4 2 0

Handling error

Datafromliteraturereview Alackofshipspecificknowledgeiscitedasaproblemby78%ofmarinerssurveyed(National ResearchCouncil,1990). Commentsduringinterviews Itislikelythatthisfactorisofmoreimportanceinscenarioswithcollisionbetweentwoships, takingintoaccountthatthefeaturesofvesselsarenotsodifferentthatthiswouldresultin unsuccessfulcollisionavoidance.Thisviewissharedbye.g.ArveLerstad(20081104)who statedthatnodeeperunderstandingisnecessarytochangecourseofavesseltoavoida collisionwithanoffshoreinstallation.

109


Fatigue

18 16 14 12 no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Handling error

Datafromliteraturereview Theinfluenceoffatigueinpersonalinjuriesvaries,frombeingafactorof3%to16%instatistics (McCallumetal,1996).Fatigueishoweveramajorconcernforseafarers,anopinionsharedby 64%ofthemembersoftheNauticalInstitutewhichincludes7000peoplefrom110countries (Seaways,2006).Sleep/fatigueisdifficulttomeasurewhichleadstoanunderestimationin accidentreports(SwedishMaritimeAdministration,2008).Operatorfatigueisoften problematicorimpossibletoidentifyfollowinganaccident(Gerchetal,2008). Commentsduringinterviews Apointofviewfromarespondentwasthatmoreriskydecisionsaremadewhenapersonis fatigued,suchasthechoicetoleavethebridge(JensUweSchrder,20081113).

110

Health management/culture within the organisation

18 16 14 12 no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8

6 4 2

Illness

Datafromliteraturereview AccordingtoLang(2000),themanninglevelisoftenminimalwhyeverysinglepersonis importantfortheoperationofashipandaseafarerismoreorlessexpectedtoperformhis/hers dutieswhethertheyarefullyfitornot.Researchfromotherdomainssuchastheoffshoreoil industryindicatesapositiverelationshipbetweenhealthmanagementandsafetyperformance (Hetheringtonetal,2006). Commentsduringinterviews Itwasmentionedduringaninterviewthatyouwillprobablybeonyourwatchevenifyouare ill,becauseofinflexiblesystems(StefanLindberg,20081114).

111


Inadequate technical equipment

18 16 14 12

no contribution little contribution medium contribution significant contribution

Responses

very significant contribution

10 8 6 4 2 0

Navigation process

Datafromliteraturereview AstudymadebyAlvik(2000)thatmeasuresafetymanagementwithinshippingcompanies showsthatinadequatetoolsorequipmenthavecontributedlittletothelossesrelatedtoship accidentswithincompanies.InresearchbyKristiansen&Soma(1999),lessthanadequate bridgeequipmentisbelievedtocause4%ofallsituationswherethereisalossofnavigational control. Commentsduringinterviews Anopinionduringaninterviewwasthatthereshouldbeanadequateleveloftechnical equipment,duetofrequentinspectionsofships(CarlHenrikWulff,20081110).

112


Lack of communication

18 16 14 12 no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

External communication

Handling error

Datafromliteraturereview 47of273accidents(i.e.17%)causedbyhumanerrorswererelatedtolackofcommunication accordingtoresearchaboutaccidentcausation.AreviewofaccidentsinCanadianwaters between1981and1992statesthattherearedifferencesinperceptionsbetweenmastersand pilotsregardingtheneedforexchangeofinfoandtheadequacyoftheinformationbeing exchanged.(TSB,1998) Commentsduringinterviews

113


Language

18 16

no contribution little contribution

14 12

medium contribution significant contribution very significant contribution

Responses

10 8 6

2 0 External communication Handling error

Datafromliteraturereview Severalstudiesconcernlanguageandcommunicationproblemsrelatedtolanguage discrepancies.Hetheringtonetal.(2006)concludethatonlyonethirdofallshipshavesingle nationalitycrew,whichpotentiallymaycreatelanguageissues.Itisalsonotedhow20%ofall pilotsmeanthatlanguagebarriersoftenmakeitdifficulttocommunicate(TSB,1998).Atwellet al.(1996)havereviewedlanguageproblemsinshiptoshipsituationswhenusingVHF.Of300 activemariners,22%answeredthattheyalwaysexperiencelanguageproblems,19%oftenand 27%never. Commentsduringinterviews

114


Layout of the bridge

18 16 14 12

no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Personal injury

Distracted

Absent

Datafromliteraturereview Anexampleofproblemsrelatedtolayoutcanbefoundinanaccidentreport(Swedishmaritime administration,2008)wheretheofficeronwatchwasunabletolookoutfromthenavigation patch.DesignofvesselsiscommonlybasedonEuropeanorNorthAmericandesignstandards anddata,whilemanyseafarerscurrentlycomefromSoutheastAsia,whichcouldcausea hazardduetodifferencesinanthropometrics(McCafferty&McSweeney,2003). Commentsduringinterviews Layoutisprobablymoreimportantforshipswithspecialfunctionsthanformerchantships(Arve Lerstad,20081104).

115

Level of other vessel activity

18 16 14 12

no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Distracted

Navigation process

Datafromliteraturereview ItisshowninareviewofaccidentsinCanadianwaters(TSB,1998)that9outof273accidents wererelatedtoothervessels(3%). Commentsduringinterviews

116

Maintenance

18 16 14 12

no contribution little contribution medium contribution significant contribution

Responses

10 8 6 4 2 0

Navigation process

Handling error

Datafromliteraturereview Maintenancerelatedhumanerrorsarethecasualreasonin16%ofaccidentsreportedtoATSB, TSBandMAIB(Baker&McCafferty,2005).Poormaintenanceofshipscanleadtodangerous workenvironments,lackofworkingbackupsystemsandcrewfatiguefromtheneedtomake emergencyrepairs(Bryant,1991;NationalResearchCouncil,1990;USCoastGuard,1995). Commentsduringinterviews Itiscommonthatserviceoftechnicalequipmentisnotperformedbecauseofdelaysindelivers etc(StefanLindberg,20081114).

117

Misunderstanding

18 16 14 12 no contribution little contribution medium contribution significant contribution

Responses

10 8 6 4 2 0

External communication

Handling error

Datafromliteraturereview Severalstudiesshowthataccidentsoccurduetomisunderstandings(TSB,1998). Commentsduringinterviews

118

Not following guidance

18 16 no contribution little contribution 14 12 medium contribution significant contribution very significant contribution

Responses

10

8 6

2 0 Personal injury Distracted Navigation process External communication Handling error

Datafromliteraturereview Failuresrelatedtonotfollowingguidancearenotmentionedinliterature,butomissionis howeverdiscussed.AnincidentreviewperformedbytheAmericanBureauofShippingstates that615%ofaccidentsarerelatedtoomissions(Baker&McCafferty,2005). Commentsduringinterviews

119

Not using independent reference equipment

18 no contribution 16 14 12 little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Navigation process

Datafromliteraturereview Commentsduringinterviews

120

Over reliance on technical equipment

18 16

no contribution little contribution medium contribution significant contribution very significant contribution

14 12

Responses

10

8 6

2 0 Distracted Asleep Absent Handling error

Datafromliteraturereview Therehavebeenseveralaccidentsthatprobablycouldhavebeenpreventediftheofficeron watchhadlookedoutthroughthewindowandnotonlyreliedoninstruments(Lang2000).This coulddependonhowsituationalawarenessdecreaseswhentheamountoftechnical automationincreases(Grechetal2008).Officersonwatchtendtoplacemorerelianceonradar andARPA(AutomaticRadarPlottingAid)tomaintainalookout.Technologyhasadvancedand thenumberofcrewmembershasdecreasedwhichhaveleadtochangesofthebridge watchkeepingpracticesinrecentyears.(MAIB,2004) Regulationandnewtechnologymayhaveledtotheperceptionthatthemastersresponsibility hasbeenreduced.Thiscanaffecttheirabilitytoprovideclearleadershipandbeselfsufficient. Perceivedownershipofsafetymanagementmayalsohavebeenreduced.(Maritime&Coast GuardAgency,2006) Commentsduringinterviews Severalrespondentsbelievethatitiscommonwithoverrelianceontechnicalequipment(Carl HenricWulff,20081110;StefanLindberg,20081114;MichaelManuel,20081114).

121

Organisational culture

18 16 no contribution little contribution medium contribution significant contribution very significant contribution

14 12

Responses

10

8 6

2 0 Substance abuse Distracted Asleep Absent

Datafromliteraturereview Organisationalcultureismentionedasoneofthemostimportantmanagingandorganisational factorsforgroundingsoftankers(Brown&Haugene,1998).Thereexistsanimportant relationshipbetweensafetyclimateandperformance(Hetheringtonetal,2006).Individual behaviourisinfluencedbytheorganisationandonewayofinducingoptimumbehaviouristo developagoodsafetyculture(Grech,2008). Commentsduringinterviews

122

Perception of negative effects of alcohol

18 16 14 12 no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Substance abuse

Datafromliteraturereview Wang&Zhang(2000)areconsideringoverconfidenceasaleadingcauseforhumanerrorwhich perhapsalsocouldbeconnectedtotheperceptionofnegativeeffectsofalcohol(orlackofit). Commentsduringinterviews

123

Personal stress

18 16 14 12

no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Substance abuse

Distracted

Datafromliteraturereview Overtheyears,therehavebeenanincreasingnumberofstudiesinvestigatingstressatsea. Stressorslikebeingawayfromfamilyandfriendsduringlongperiodsatseacanaffectmost crewmembers(Grechetal,2008).Personaltaskssuchastelephoningorwritinghomehaveto becompleted(MAIB,2004).Itisalsostatedthatstressisnotastrangertotheaveragemariner whereasstressmanagementhasnofocuswithinthemarinecommunity(Lang,2000). Commentsduringinterviews Itwasindicatedduringaninterviewthatworkpressureandpersonalstressisveryspecifictoan individual(JensUweSchrder,20081113).

124

Reporting and follow up

18 16 14 12

no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Substance abuse

Datafromliteraturereview Thereisdataabouttheimportanceofreportingandfollowup(e.g.Maritime&CoastGuard Agency,2006)butnotconnectedtoanyaccidentstatistics. Commentsduringinterviews

125


Technical failure of communication equipment

18 16 14 12

no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

External communication

Datafromliteraturereview InareportbyDelaCampaPortela(2003)itisdescribedhow18%ofallcommunication problemsarerelatedtothetechnicalequipment. Commentsduringinterviews Aconclusionisdrawnthatatechnicalfailureofthecommunicationequipmentisnotalikely reasontoerrorsincommunication,duetohowseveralmeansofredundancyexists(CarlHenric Wulff,20081110).

126

Technical failure of navigation equipment

18 16 14 12

no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Navigation process

Datafromliteraturereview Sourcesofliteratureindicatethattheimpactoftechnicalfailuresonthenavigationprocessis verysmall,lessthan1%(TSB,1998). Commentsduringinterviews Itwasmentionedbyoneoftheparticipantsintheexpertjudgmentthatthereisredundancyin thenavigationequipmentandatechnicalfailurewouldthereforenotbelikelytodirectlycause anavigationerror(StevenSawhill,20081107).

127

Time of day

18 16 14 12 no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Personal injury

Asleep

Datafromliteraturereview Mostofthestatisticalmaterialaboutaccidentsandtimeofdayisconnectedtofatigue.Itisfor examplestatedthatthenumberofincidentsisincreasingduringearlymorningsandafternoons (Grechetal,2008).Approximately77%oftheaccidentswhensleepwasidentifiedasthe primarycauseoccurredbetween0008(Philips,2000).Researchhasshownthatalertnessand performancetendtobelowestduringtheearlyhoursofthemorning(MAIB2004).

Typicalexampleofthenumberoferrors/accidentsasafunctionoftimeoftheday(Grechetal,2008).

128

Referencesfromtheliteraturereviewareregardingearlymorningasthetimewhenmost accidentoccurandtimeofdayisthereforealsoanimportantfactortowhyanofficeronwatch fallsasleep. Commentsduringinterviews Itisaviewamongstseveraloftherespondentsthatthehoursbetweenmidnightandmorning arethetoughest(HelgeSamuelsen,20081104;DavidWendel,20081107;MichaelManuel, 20081114;JensUweSchrder,20081113).

129

Time into the watch

18 16 14 12

no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Personal injury

Asleep

Absent

Datafromliteraturereview Performancetestshaveshownthatthealertnessandconcentrationoflookoutsisdiminished afterabout30minutesonwatch(MAIB,2004).Sleepinessismorefrequentintheendofa watch,especiallywithatwowatchsystem(Ltzhftetal,2007).Thereisafairlywidespread acceptancebytheresearchcommunitythatlonghourscontributetofatigueandthereforealso toerrors,incidentsandaccidentsatsea(Grechetal,2008). Commentsduringinterviews Timeintothewatchshouldnotbeaproblemiftheshiphasa4/8watchsystem(CarlHenric Wulff,20081110).

130

Type of watch system

18 16 14 12 no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Asleep

Datafromliteraturereview Itismostlikelythatanaccidenttakesplaceonthethirdwatchina4/8watchsystem,i.e.04.00 08.00(Nielsen&Jungnickel,2003).Thetypeofwatchsystemimplementedonashipismost oftendiscussedinrelationtofatigueandisthereforeconsideredtobecloselyconnectedto accidents.Thetypeofwatchsystemisconsequentlyperceivedasanessentialfactorintherisk forcollisions.Officersinatwowatchsystemaresleepierthanofficersinathreewatchsystem, especiallyinearlymorningandafternoon.Sleepqualityislowforbothshiftsystems.(Ltzhft etal,2007) Commentsduringinterviews Thetypeofwatchsystemisimportantand4/8watchesareconsideredtobebetterthan6/6 (TorEgilHopenSaue,20081103;HelgeSamuelsen,20081104).

131

Unclear roles and responsibility

18 16 no contribution 14 12 little contribution medium contribution significant contribution very significant contribution 10 8

Responses

6 4 2

Handling error

Datafromliteraturereview - Commentsduringinterviews

132

Weather

18 16 14 12 no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Personal injury

Navigation process

Datafromliteraturereview Someinconsistencyisfoundwithinliteraturerelatedtotheinfluenceofweatherinaccidents.A majorityofallincidentsactuallyhappeningoodvisibilityaccordingtoaccidentreports(e.g. MAIB,2004).Theweatherisalsofoundtobeanunderlyingfactorande.g.cause11%ofall accidentsinUSCGdata(Baker&McCafferty,2005). Commentsduringinterviews

133

Wishful thinking

18 16 14 12 no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Wishful thinking

Datafromliteraturereview Commentsduringinterviews

134

Work pressure

18 16 14 12 no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Substance abuse

Handling error

Datafromliteraturereview TimepressureismentionedasacontributingreasoninaccidentreportsfromtheSwedish MaritimeAdministration(2008).Otherthanthis,theimpairmentofahigheconomicpressureor timepressurewithinamaritimeorganisationisnotoftenreferredto.MAIB(2004)however mentionsworkpressureasacontributingfactorforfatigue. Commentsduringinterviews Itmaysometimesbeafactthateconomicalvaluesareprioritisedoversafety(DavidWendel, 20081107).

135

Workload too high

18 16 14 12 no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Personal injury

Distracted

Asleep

Datafromliteraturereview AhighworkloadisoneoffourmanagementandorganisationalfactorsthatBrown&Haugene (1998)estimatedashavingthegreatestimpactongroundings.Accordingtoanotherresearch project,workloadislikelytobetheoriginof32%ofallscenarioswhenanofficeronwatchis incapacitated(Kristiansen&Soma,1999).Paperworkassociatedwithregulationsand requirementsforship/shorereportingcanincreasetheworkload,hencehavinganegative effectonsafety(Maritime&CoastGuardAgency,2006). Workloadisalsodiscussedasafactorforfatigueintheliteratureandassumedtobea contributingfactorforapersonfallingasleep. Commentsduringinterviews

136

Workload too low

18 16 14 12 no contribution little contribution medium contribution significant contribution very significant contribution

Responses

10 8 6 4 2 0

Distracted

Asleep

Datafromliteraturereview Havingsofewtasksthatapersongetsunderstimulatedandboredislikelytodependonthe geographicallocation,theactivityofashipandthedurationofavoyage.Alowworkloadis oftendiscussedinrelationtoautomationandtheboredomthatthismaycreate,butthereare nostatisticsofhowoftenthiswouldhappenortowhatextentalowworkloadisacontributing factortoaccidents(Ltzhftetal,2007). Commentsduringinterviews Situationsrelatedtoalowworkloadhavebeenmentionedduringtheinterviews,forexample howcrewmemberswatchvideosduringtheirwatch.Itwaspointedoutthaterrorsusually happenwhentheworkloadislow,afteralongperiodwithahighworkload(Pettervers, 20081104;TorEgilHopenSaue,20081103).

137