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Safety Science 110 (2018) 102–109

Contents lists available at ScienceDirect

Safety Science
journal homepage: www.elsevier.com/locate/safety

Prediction of human error probabilities in a critical marine engineering T


operation on-board chemical tanker ship: The case of ship bunkering

Emre Akyuza, , Metin Celikb, Ilker Akgunc, Kadir Cicekb
a
Department of Maritime Transportation and Management Engineering, Istanbul Technical University, Tuzla 34940, Istanbul, Turkey
b
Department of Marine Engineering, Istanbul Technical University, Tuzla 34940, Istanbul, Turkey
c
Department of Business Administration, Marmara University, Bakirkoy, Istanbul, Turkey

A R T I C LE I N FO A B S T R A C T

Keywords: Ship bunkering, a safety critical operation in marine engineering, can cause drastic environmental damage at
Maritime safety sea. Though bunkering presents high safety procedures, minor accidents also can pose potential harm for marine
Human reliability environment and human life. Indeed, it is well-known that numerous bunker accidents can be attributed to
Bunkering operation different types of human error. Therefore, control of human factor during bunkering operation plays critical role
Chemical tanker ship
to enhance safety aboard and prevent environmental pollution at sea. This study presents a comprehensive
Decision-making
human error prediction during bunkering operation demonstrated with a case study at chemical tanker platform.
To achieve this purpose, a Shipboard Operation Human Reliability Analysis (SOHRA) method, which has been
developed as a marine-specific approach to quantify human error, is employed. In the view of outcomes, human
error reduction measures are recommended. In conclusion, the paper is expected to give practical contribution to
the systematically prediction of human error for designated tasks, enhancement of safety control level in op-
erational aspect and protection of the marine environment.

1. Introduction errors related to grounding and collision accidents at sea (Akyuz, 2017).
Furthermore, a couple of scientific research papers have been con-
Human factor is one of paramount topics in maritime industry since ducted through human error and system failure in maritime and off-
it may directly influence the operational performance. The majority of shore industries (Hou et al., 2017; Abbassi et al., 2015; Akyuz and
failures are attributed to the human factors which may cause serious Celik, 2015; Lavasani et al., 2015; Noroozi et al., 2014; Deacon et al.,
consequences such as environment pollution. The findings show that 2013; Abascal et al., 2010). The papers contributed guidelines to adopt
most of maritime accidents are due to human errors (Akyuz, 2017; various human error assessment techniques such as HEART (Human
Corovic and Djurovic, 2013; Akyuz, 2015a). In order to minimize Error Assessment and Reduction Technique), SLIM (Success Likelihood
maritime accidents, it is essential to focus on the types of human errors Index Method) and THERP (Technique of Human Error Rate Prediction)
(Abujaafar, 2012; Akyuz, 2016). The maritime authorities have been in the application of numerous procedures on maritime and offshore
adopting a set of rules and regulations to minimize human error and industries in order to reduce human error and improve operational
enhance safety awareness such as SOLAS, STCW, ISM Code (Akyuz safety. Akyuz and Celik (2014) proposed a hybrid tool to analyse
et al., 2016; Karahalios, 2014; Chauvin, 2013; Karahalios, 2011). On human error during maritime events. Another study was performed to
the other hand, maritime safety practitioners are also seeking creative systematically estimate human error probability towards the gas in-
solutions to reduce human error. However, human error prediction is erting process in crude oil tanker ships (Akyuz, 2015b).
quite onerous task in maritime transportation due to the uncertainty Although a set of researches on human error prediction have been
and inadequacy of quantitative human error data (Akyuz and Celik, carried out in the past decade, those dedicated to critical shipboard
2018). To overcome these limitations, some scientific researches have operations in maritime transportation have remained very limited. The
been undertaken in the past decades. For instance, Macrae (2009) assessment of human error probability is a critical task to enhance
conducted an extensive study to identify potential human error in the safety. Bunkering, for example, is one of the critical shipboard opera-
event of two major types of marine accident: grounding and collision. A tions under the ISM Code (SOLAS, 1974) since adverse consequences
similar study has been performed in recent time to quantify human can pose potential harm to marine environment and human life.


Corresponding author.
E-mail addresses: emreakyuz@hotmail.com.tr, eakyuz@itu.edu.tr (E. Akyuz).

https://doi.org/10.1016/j.ssci.2018.08.002
Received 17 October 2017; Received in revised form 25 June 2018; Accepted 3 August 2018
0925-7535/ © 2018 Elsevier Ltd. All rights reserved.
E. Akyuz et al. Safety Science 110 (2018) 102–109

Bunkering operation is a critical shipboard process and also known as Table 1


ship to ship transfer including fuel oil, diesel oil, etc. The operation Nomenclature.
requires utmost care to prevent any kind of oil spill or fire on-board A Matrix MARPOL Maritime pollution
chemical tanker ship. It may be conducted either in berth or at an- prevention convention
chorage. The bunker barge come alongside of ship and secured properly aij Each criteria MSDS Material safety data sheet
prior to operation. All chemical tanker ships are governed by MARPOL A/B Able seaman n Constant in Eq. (3)
AHP Analytic hierarchy process PSF Performance shaping factor
Annex I and VI during bunkering operation. The statistics show that APOA Assessed proportion of affect SLIM Success likelihood index
ship-sourced oil spill incidents are still a major source of oil pollution method
during bunkering operation. An extensive oil spill may spread out CI Consistency index SOHRA Shipboard human reliability
hundreds nautical miles from the source of accident and cause cata- analysis
CR Consistency ratio SOPEP Shipboard Oil Pollution
strophic pollution for marine environment. Since consequences of oil
Emergency Plan
spill are severely damaging to marine environment, performance of EPC Error-producing condition SOLAS Safety of life at sea
ship crew become a critical concern during bunkering operation. Ship m-EPC Marine-specific error SPM Single point mooring
crew performance become a serious concern at this point. The ship producing condition
crew must exercise particular caution when attending a bunkering op- GEP Generic error probability STCW Standard training
certification Watchkeeping
eration. In this context, prediction of human error probabilities pose a
GTT Generic task type STS Ship to ship
major challenge to retain a high level of safety in the maritime industry. HEP Human error probability SMS Safety Management System
The ship crew must perform utmost care during bunkering proce- HEART Human error assessment and RI Random index
dure. The operation follows a bunkering plan including agreed cargo reduction technique
HTA Hierarchical task analysis wi Priority weight
quantity, pumping rate, time of completion and sampling. Master of
HRA Human reliability analysis λmax. Maximum matrix eigenvalue
ship carries out a safety meeting with all ship crew to discuss the op- vector
eration and emergency response procedures. The bunkering operation i Constant in Eq. (2) THERP Technique of human error
is monitored by responsible ship crew in accordance with agreed bun- rate prediction
kering plan. Watchkeeping during the entire operation is provided by j Constant in Eq. (2)

engine and deck crew rating. All events are properly recorded to log
books. The sampling of cargo is carefully carried out throughout the
The SOHRA provides a consistent approach to quantify human
operation. Cargo intake quantity is calculated at the end of transfer.
error. It is quite applicable tool to calculate HEP in the critical ship-
In the literature, most of studies concerning the bunkering opera-
board operations such as cargo loading, discharging, berthing, un-
tions have focused on management strategies such optimal costs, ports,
berthing, bunkering, ballasting, gas inerting, tank cleaning, hold
ship routes or contracts to minimize fuel-related costs (Zhen et al.,
cleaning, etc (Akyuz et al, 2018). The method is comprised of two
2016; Pedrielli et al., 2015; Wang et al., 2014) rather than focusing on
fundamental parameters: generic task type (GTT) and m-EPC respec-
operational aspect to enhance safety control level on-board ships. To
tively (Akyuz et al., 2016). The GTT allows user to select appropriate
remedy the gap, this paper aims at conducting a systematic human
task in perfect condition. The GTT is associated with generic error
error prediction and assessment during bunkering operation in che-
probability (GEP) which is provided in Table 2 (Williams, 1988).
mical tanker ship. The SOHRA (Shipboard Operation Human Reliability
The second parameter is the m-EPC which influences ship crew
Analysis), a marine-specific human error prediction technique, is
adopted to assess human error for designated tasks in bunkering op-
eration. The human error probabilities are evaluated and necessary Table 2
human error control measures are recommended to improve perfor- GTT and GEP values.
mance of ship crew. Within this context, the paper is organised as fol- Generic task type (GTT) Generic error probability
lows. Section 1 gives motivation and brief literature reviewing about (GEP)
human error prediction and bunkering operation in the maritime in- (5th–95th percentile
dustry. Section 2 explains theoretical background of method. Section 3 Bounds)

demonstrates model application through bunkering operation at che- A Totally unfamiliar; performed at speed with no 0.55
mical tanker ships. Section 4 gives conclusion, contribution and future real idea of likely consequences (0.35–0.97)
researches. A list of symbols and abbreviations, meantime, is provided B Shift or restore system to a new or original state 0.26
in Table 1 for easy perusal of readers. on a single attempt without supervision or (0.14–0.42)
procedures
C Complex task requiring high level of 0.16
2. Methodology comprehension and skill (0.12–0.28)
D Fairly simple task performed rapidly or given 0.09
2.1. Theoretical background of SOHRA scant attention (0.06–0.13)
E Routine, highly practiced, rapid task involving 0.02
relatively low level of skill (0.07–0.045)
Shipboard Operation Human Reliability Analysis (SOHRA) was de- F Restore or shift a system to original or new state 0.003
veloped to quantify human error and predict human reliability in cri- following procedures with some checking (0.0008–0.007)
tical shipboard operations (Celik et al., 2014; Akyuz et al., 2016). The G Completely familiar, well-designed, highly 0.0004
method introduces m- EPC (marine specific error producing condition) practiced, routine task occurring several times (0.00008 – 0.009)
per day, performed to highest possible standards
values which was validated by analysing a hundred of real-marine ac-
by highly motivated, highly trained, and
cident cases (Akyuz et al., 2016). The SOHRA is based on tailoring the experienced personnel, with time to correct
basic principle of human error assessment and reduction technique potential error, but without the benefit of
(HEART) (Williams, 1988; Akyuz et al., 2018). The method has a si- significant job aid.
milar structure with HEART. It presents consistency of usage during H Respond correctly to system command even 0.00002
when there is an augment or automated (0.000006–0.0009)
assessed proportion of affect (APOA) calculation which is the key aspect supervisory system providing accurate
of human error weighting in m-EPC calculation. Also, the SOHRA interpretation of system state
adopts the m-EPCs to define the performance shaping factors (PSF) of
M Miscellaneous task for which no description can 0.03
human beings for specific tasks in the maritime industry (Kirwan and be found (0.008–0.11)
Gibson, 2008; Kirwan, 1987).

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E. Akyuz et al. Safety Science 110 (2018) 102–109

Table 3 familiarity to task, time of day, etc.


List of m-EPC. Step 3. GTT selection: The GTT selection is applied to determine
No Error producing condition Max. affect generic human error probability which were extracted from a variety of
sources in the area of petrochemical and offshore industries. A decision-
EPC1 Unfamiliarity 17.00 maker selects appropriate GTT for each sub-task with respect to the task
EPC2 Time shortage 14.01
analysis. Thus, the GEP value is determined for each sub-task in ac-
EPC3 Low signal–noise ratio 3.31
EPC4 Features over-ride allowed 8.72
cordance with relevant GTT which best matches the specific task being
EPC5 Spatial and functional incompatibility 5.76 assessed (Kirwan and Gibson, 2008).
EPC6 Model mismatch 2.64 Step 4. m-EPC selection: In this step, decision-maker selects the
EPC7 Irreversibility 2.23 most appropriate m-EPC based on the identified scenario for each sub-
EPC8 Channel overload 14.45
task. The m-EPC is selected from the list of thirty-eight possible state-
EPC9 Technique unlearning 5.29
EPC10 Knowledge transfer 11.00 ments elicited in the SOHRA approach for each sub-task. The decision-
EPC11 Performance ambiguity 8.60 maker choses more than one m-EPC based on the scenario. If the de-
EPC12 Misperception of risk 12.51 cision-maker nominates more than one m-EPC for sub-task, the APOA
EPC13 Poor feedback 12.55
calculation is needed to determine weight priorities.
EPC14 Delayed/incomplete feedback 6.72
EPC15 Operator inexperience 10.03
Step 5. APOA calculation: The APOA calculation nominates pro-
EPC16 Impoverished information 8.42 portion effect of each m-EPC. The SOHRA adopts a sensitive weighting
EPC17 Inadequate checking 2.79 process by adopting Analytic Hierarchy Process (AHP) to enhance
EPC18 Objectives conflict 2.15 consistency of calculation. The AHP is a powerful multi-criteria deci-
EPC19 No diversity 2.74
sion making (MCDM) tool to quantify the subjective judgment and
EPC20 Educational mismatch 2.88
EPC21 Dangerous incentives 3.62 confirm the consistency of collected data (Saaty, 1980). It enables user
EPC22 Lack of exercise 1.64 to generate ratio scale from comparison pair-wise matrix. The tech-
EPC23 Unreliable instruments 5.69 nique is considerably reliable as the consistency of evaluation can be
EPC24 Absolute judgements required 1.17 calculated through consistency and random index (Soner et al., 2017).
EPC25 Unclear allocation of function 1.22
EPC26 Progress tracking lack 3.28
The process of method is comprised of three steps.
EPC27 Physical capabilities 4.35 I. Composing a pair-wise comparison matrix: In the first step, a
EPC28 Low meaning 2.56 pair-wise comparison matrix is established to obtain relative weight of
EPC29 Emotional stress 1.59 each m-EPC. In this context, Saaty’s 1–9 linguistic relative importance
EPC30 ill-health 0.89
scale is used (Saaty, 1986). A comparison matrix matrix A is a n × n
EPC31 Low morale 3.00
EPC32 Inconsistency of displays 9.43 real matrix, where n states the number of evaluated m-EPC. Each m-EPC
EPC33 Poor environment 9.90 aij (i, j = 1, 2, 3,…, n) is inserted in the matrix A represents the relative
EPC34 Low mental workload 2.63 importance of the ith against to the jth. It means that ith m-EPC is more
EPC35 Sleep cycles disruption 10.30 important than jth, if the aij > 1. Otherwise, ith m-EPC is less important
EPC36 Task pacing 3.85
EPC37 Supernumeraries 4.14
than jth in case aij < 1. Within this context, in case two m-EPCs have
EPC38 Age 3.61 similar relative weight, then aij = 1. In the view of above definition, the
following Eq. (1) is used to compose a comparison matrix A (Saaty,
1986).
performance negatively and leads to increase GEP value (Gibson et al., aij × aji = 1 (1)
2012). The m-EPC is addressed to internal or external factors that in-
fluence the crew performance at shipboard environment. A list of m- II. Calculating criteria weights: The aim of this step is to calculate
EPCs are generated for SOHRA approach and relevant m-EPCs are relative weight (w) of each m-EPC. At this point, Eq. (2) is used.
chosen from the list of SOHRA (Akyuz et al., 2016). Table 3 illustrates n
1 aij
the list of the m-EPC and their maximum effect. The m-EPC reflects wi =
n
∑ n
∑k = 1 akj (2)
performance shaping factors such as crew experiences, organisation j=1

quality, workforce moral, time limitation, working environment, age,


III. Checking consistency rate: This step is to check consistency of
crew collaboration, familiarity, etc. and shows how these conditions data inserted in a pair-wise comparison matrix. The consistency rate
affect relevant task (Akyuz et al., 2018). The SOHRA method involves
(CR) is calculated in accordance with Eqs. (3)–(5) respectively (Saaty,
seven main steps to quantify human error. The steps of SOHRA are as 1994; Vargas, 1982). If the CR (consistency ration) value is less than
follows.
0.10(10%) or equal to 0.10 (10%), the consistency of expert judgments
is acceptable.
2.2. Process of SOHRA
λmax.−n
CI =
A flow diagram of SOHRA methodology is depicted in Fig. 1. The n−1 (3)
main steps of methodology are explained as follows. n
Step 1. Task analysis: The purpose of this step is to identify re- ∑ αij wj = λmax wi
levant task with respect to the scenario. A task can be defined as an j=1 (4)
activity or step which needs to be completed by ship crew within a CR = CI / RI (5)
period. This is performed in accordance with hierarchical task analysis
(HTA) where main tasks are divided into sub-tasks respectively (Akyuz Step 6. HEP calculation: After performed sensitive APOA calcu-
and Celik, 2016a; Shepherd, 2001). The HEP value is calculated for lation, the HEP value is determined for each sub-task. To achieve this
each sub-task to monitor human error changes. purpose, Eq. (6) is used (Williams, 1988). In the equation, EPCi is the ith
Step 2. Scenario definition: In this step, a set of shipboard sce- (i = 1, 2, 3, …n; n ≤ 38) m-EPC and APOApi (0 < pi ≤ 1) is ith the
narios representing various situations are defined to nominate the GTT assessed of proportion affect which has been calculated in APOA.
and m-EPC properly. The scenario involves a wide range of environ-

mental conditions such as experience, working environment, stress HEP = GEP × ∏ [(EPCi−1) APOApi + 1]⎫⎬
⎨ i
level, time availability, noise level, weather condition, fatigue, ⎩ ⎭ (6)

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E. Akyuz et al. Safety Science 110 (2018) 102–109

Task analysis

Scenario definition

GTT selection

m-EPC selection

Composing a pair-wise
comparison matrix APOA calculation HEP reduction measures

HEP prediction
Calculating criteria weights

Checking consistency rate Yes No


HEP
acceptable
?

No CR Yes
acceptable
?
Do operation

Fig. 1. Flow diagram of SOHRA.

Table 4 3. Application
HTA of bunkering operation.
Bunkering operation
In this section, prediction of human error probabilities during
bunkering operation on-board chemical tanker ships is demonstrated.
1. Prior to bunkering The use of expert judgements is one of the techniques in most of human
1.1 Keep safety meeting reliability analysis (HRA) since there is a scarcity of numerical data on
1.2 Take sounding and record bunker quantities
1.3 Check if crew on deck use PPE
human error for maritime transportation (Modarres, 2006). To de-
1.4 Make sure that all deck scupper are plugged monstrate the model, a real-shipboard bunkering operation was se-
1.5 Check if overflow tanks are empty lected. In this context, master of a chemical tanker ship cooperatively
1.6 Make sure that smoking notice is positioned provided opinions. The ship is an oil/chemical tanker and cargo car-
1.7 Hoist necessary warning sign
rying capacity is about 10,745 dwt. The master has wide experience
1.8 Make sure that other bunker manifold valves are shut-off and blanked
1.9 Check if all equipments in SOPEP are in position about bunkering operation. A comprehensive survey forms was sent to
1.10 Make sure that bunker barge is safely secured to the ship master of ship and asked to select the most appropriate GTT and m-EPC
1.11 Make sure that proper communication is established with bunker barge for each sub-task being completed.
1.12 Agree on bunkering procedure with bunker barge
1.13 Verify pumping rate
1.14 Connect flexible hose to the ship’s manifold 3.1. A real-shipboard environment definition and task analysis
2. During bunkering
2.1 Open manifold valve and start bunkering A real-shipboard bunkering operation was performed at Ceuta an-
2.2 Make sure that pumping rate is kept low at the beginning chorage. The chemical tanker ship arrived early morning at Ceuta an-
2.3 Monitor bunkering process continuously
chorage area to intake about 845 mt IFO180 CST. The weather was
2.4 Take sounding regularly
2.5 Check temperature of bunker
partly cloudy and sea state was calm at the time of operation. According
2.6 Take sampling to the deck log book, the wind speed was about 10–12 knots per hour as
2.7 Check trim and draft of ship frequently per Beaufort scale. There were small waves with breaking crests. The
2.8 Close manifold valve ship’s crew took rest enough prior to bunkering operation. Chief en-
3. After bunkering gineer, chief officer, third engineer, bosun, pumper and able seamen
3.1 Take sounding of all the tanks bunkered (A/B) participated bunkering operation. A bunker barge came along-
3.2 Calculate final bunker intake quantity
side to chemical tanker and bunkering commenced around morning
3.3 Sign bunker receipt
3.4 Disconnect flexible hose from ship’s manifold time. The bunkering operation took about 9 h. After confirmed the
3.5 Cast off bunker barge moorings from the ship amount of bunker intake, flexible hose was disconnected and bunker
barge left. The bunkering operation in accordance with HTA is provided
in Table 4 (BIMCO, 2016). The master of ship selected relevant GTT and
Step 7. HEP reduction measures: The aim of this step is to take m-EPC/s for each sub-tasks during bunkering. Since a real-shipboard
control measures for minimizing human error. The experts evaluate bunkering operation was handled, the master of ship (expert) simulta-
impacts of HEP over the critical shipboard operation. The control neously performed assessment by considering instant shipboard en-
measures are recommended for the highest HEP values. vironment condition and crew performance. The operating

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E. Akyuz et al. Safety Science 110 (2018) 102–109

Table 5 Table 6
Selected GTT and m-EPC/s. m-EPCs prioritization weights and CR values.
Sub-task GTT Selected EPC/s Sub-task m-EPC m-EPC weight (APOA) CR

Prior to bunkering 1.1 EPC2 0.334 0.046


1.1 G EPC2, EPC13, EPC14 EPC13 0.525
1.2 E EPC22, EPC17 EPC14 0.142
1.3 E EPC17, EPC20 1.2 EPC17 0.817 0.001
1.4 D EPC17, EPC22 EPC22 0.183
1.5 G EPC1, EPC10, EPC14, EPC33 1.3 EPC17 0.750 0.001
1.6 H EPC2, EPC15, EPC17 EPC20 0.250
1.7 H EPC1, EPC14, EPC35 1.4 EPC17 0.398 0.024
1.8 E EPC14, EPC23 EPC22 0.602
1.9 F EPC14, EPC33 1.5 EPC1 0.311 0.035
1.10 G EPC13, EPC15, EPC17 EPC10 0.100
1.11 E EPC3 EPC22 EPC14 0.182
1.12 G EPC2, EPC11, EPC25 EPC33 0.406
1.13 D EPC14, EPC17 1.6 EPC2 0.320 0.015
1.14 E EPC23 EPC15 0.557
EPC17 0.123
During bunkering
1.7 EPC1 0.125 0.045
2.1 G EPC3, EPC33
EPC14 0.369
2.2 D EPC15, EPC17
EPC35 0.506
2.3 E EPC2, EPC17
1.8 EPC14 0.315 0.06
2.4 G EPC1, EPC14
EPC23 0.685
2.5 H EPC22, EPC23, EPC27
1.9 EPC14 0.290 0.003
2.6 G EPC15, EPC33, EPC34
EPC33 0.710
2.7 H EPC2, EPC17
1.10 EPC13 0.320 0.026
2.8 F EPC14
EPC15 0.123
After bunkering EPC17 0.557
3.1 G EPC2, EPC27, EPC33 1.11 EPC3 0.250 0.016
3.2 H EPC14 EPC22 0.750
3.3 G – 1.12 EPC2 0.320 0.014
3.4 E EPC23 EPC11 0.557
3.5 G EPC27, EPC33 EPC25 0.123
1.13 EPC14 0.366 0.008
EPC17 0.634
1.14 EPC23 1
environment is depending on the system installation (Celik, 2008; Cebi
2.1 EPC3 0.31 0.007
et al., 2012) and procedural implementations (Celik, 2009; Celik and EPC33 0.69
Topcu, 2009). 2.2 EPC15 0.375 0.004
EPC17 0.625
2.3 EPC2 0.299 0.005
3.2. GTT and m-EPC selection EPC17 0.701
2.4 EPC1 0.389 0.004
The master of ship selected relevant GTT and m-EPC/s for each sub- EPC14 0.611
tasks during bunkering. A comprehensive survey forms in excel format 2.5 EPC22 0.308 0.009
EPC23 0.453
was sent to master by email. Table 5 shows selected GTT and m-EPC/s.
EPC27 0.239
2.6 EPC15 0.478 0.025
3.3. APOA calculation EPC33 0.366
EPC34 0.156
2.7 EPC2 0.685 0.06
After received evaluation of master for each sub-task, the APOA EPC17 0.315
calculation is conducted to increase consistency of HEP calculation. 2.8 EPC14 1
This process quantifies the subjective judgement of expert and confirms 3.1 EPC2 0.406 0.007
consistency of collected data. Except sub-tasks 1.14 (Connect flexible EPC27 0.182
EPC33 0.412
hose to the ship’s manifold), 2.8 (Close manifold valve), 3.2 (Calculate 3.2 EPC14 1
final bunker intake quantity), 3.3(Sign bunker receipt) and 3.3 –
3.4(Disconnect flexible hose from ship’s manifold); the rest of sub-steps 3.4 EPC23 1
have more than one m-EPCs. Accordingly, a pair-wise comparison 3.5 EPC27 0.31 0.07
EPC33 0.69
matrices were established in excel form and sent to master of ship along
with Saaty’s 1–9 linguistic relative importance scale. One week later,
the master sent back pair-wise comparison matrices. Furthermore, cri-
3.5. Findings and discussion
teria weight of each m-EPC is calculated by using Eq. (2). The CR is
calculated by using Eqs. (3)–(5) respectively. Table 6 illustrates the m-
In the view of the HEP for bunkering operation on-board chemical
EPCs prioritization weights and CR values. Since CR values (Table 6)
tanker ship, human error probability intervals are in the range of
are smaller than 0.1 (10%), the judgments inserted in expert are con-
1.34E−04 and 8.36E−01. Fig. 2 shows a graph where probability of
sidered to consistent.
human errors goes up and down bunkering operation. The centre of
graph shows the most reliable area where the HEP value of each sub-
3.4. HEP calculation task is depicted by the node.
The maximum HEP values are related to pre-operational and op-
The HEP value of each sub-task is calculated by using Eq. (6). erational activities. In order to categorize HEP values, a risk matrix can
Table 7 shows HEP results for bunkering operation on-board chemical be used (Deacon et al., 2013). In the matrix, probability of human error
tanker ship.

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E. Akyuz et al. Safety Science 110 (2018) 102–109

Table 7 HEP chart


HEP results.
1.1
3.5
9.00E-01 1.2
Sub-task GEP m-EPC Max. m-EPC effect m-EPC APOA HEP 3.4 8.00E-01 1.3
3.3 7.00E-01 1.4
1.1 4.00E−04 EPC2 14.01 0.334 2.74E−02
EPC13 12.55 0.525 3.2 6.00E-01 1.5
5.00E-01
EPC14 6.72 0.142
3.1 4.00E-01 1.6
1.2 2.00E−02 EPC17 2.79 0.817 5.50E−02
3.00E-01
EPC22 1.64 0.183
2.8 2.00E-01 1.7
1.3 2.00E−02 EPC17 2.79 0.750 6.89E−02
1.00E-01
EPC20 2.88 0.250 0.00E+00
1.4 9.00E−02 EPC17 2.79 0.398 2.13E−01 2.7 1.8
EPC22 1.64 0.602
1.5 4.00E−04 EPC1 17 0.311 4.50E−02 2.6 1.9
EPC10 11 0.100
EPC14 6.72 0.182 2.5 1.10
EPC33 9.9 0.406
2.4 1.11
1.6 2.00E−05 EPC2 14.01 0.320 7.60E−04
EPC15 10.03 0.557 2.3 1.12
EPC17 2.79 0.123 2.2 1.13
2.1 1.14
1.7 2.00E−05 EPC1 17 0.125 1.06E−03
EPC14 6.72 0.369 Fig. 2. HEP distribution through sub-taks.
EPC35 10.3 0.506
1.8 2.00E−02 EPC14 6.72 0.315 2.36E−01
EPC23 5.69 0.685 (Keeping low pumping rate), 2.3 (Monitoring bunkering continuously)
1.9 3.00E−03 EPC14 6.72 0.290 5.84E−02 and 3.4 (Hose disconnection from the manifold) respectively. In this
EPC33 9.9 0.710 context, sub-task 2.2 (Make sure that pumping rate is kept low at the
1.10 4.00E−04 EPC13 12.55 0.320 7.92E−03
beginning) has the highest HEP value among the all tasks. Prior to
EPC15 10.03 0.123
EPC17 2.79 0.557 bunkering operation, the pumping rate agreed and is requested barge to
1.11 2.00E−02 EPC3 3.31 0.250 4.64E−02 keep low pumping rate at the beginning. In this task, inexperience duty
EPC22 1.64 0.750 engineer may skip to remind skipper of barge for low pumping rate.
1.12 4.00E−04 EPC2 14.01 0.320 1.11E−02 This failure may cause overflowing or pipeline bursting.
EPC11 8.6 0.557
EPC25 1.22 0.123
The consequences of such human error may cause serious oil spill
1.13 9.00E−02 EPC14 6.72 0.366 5.94E−01 around the ship and have fatal effects on marine and costal environ-
EPC17 2.79 0.634 ment. Sub-task 1.13(Verify pumping rate) has the second highest HEP
1.14 2.00E−02 EPC23 5.69 1 1.14E−01 value during bunkering operation. Excessive bunker pumping rate may
2.1 4.00E−04 EPC3 3.31 0.310 4.90E−03
cause overflowing and overpressure splitting the bunker pipeline. The
EPC33 9.9 0.690
2.2 9.00E−02 EPC15 10.03 0.375 8.36E−01 consequences of such human failure can cause to burst line and mani-
EPC17 2.79 0.625 fold. The responsible duty engineer and pumper sometimes does not
2.3 2.00E−02 EPC2 14.01 0.299 2.21E−01 report the situation or monitor operation adequately. Likewise, sub-task
EPC17 2.79 0.701 1.8(Make sure that other bunker manifold valves are shut-off and
2.4 4.00E−04 EPC1 17 0.389 1.30E−02
EPC14 6.72 0.611
blanked) ranks in the third place since delayed or inadequate feedback
2.5 2.00E−05 EPC22 1.64 0.308 1.35E−04 and lack of exercise are the main contributory factors. Prior to com-
EPC23 5.69 0.453 mencement of the bunkering operations, unused manifold connections
EPC27 4.35 0.239 should be isolated and blanked off. The consequences of this human
2.6 4.00E−04 EPC15 10.03 0.478 1.14E−02
error can be crew injury or oil spill to the maritime environment. This
EPC33 9.9 0.366
EPC34 2.63 0.156 task is normally performed by duty engineer. However, he may some-
2.7 2.00E−05 EPC2 14.01 0.685 3.10E−04 times delegated task of blanking to the pumper or A/B. The delegated
EPC17 2.79 0.315 crew member are not able to perform blanking.
2.8 3.00E−03 EPC14 6.72 1 2.02E−02 Furthermore, sub-task 2.3(Monitor bunkering operation con-
3.1 4.00E−04 EPC2 14.01 0.406 1.89E−02
EPC27 4.35 0.182
tinuously) is another critical activity where time limitation and in-
EPC33 9.9 0.412 adequate checking are the major contributory conditions. The con-
3.2 2.00E−05 EPC14 6.72 1 1.34E−04 sequences of such human failure can be overflowing of fuel oil. Duty
3.3 4.00E−04 4.00E−04 engineer and A/B is the responsible crew to monitor bunkering op-
3.4 2.00E−02 EPC23 5.69 1 1.14E−01
eration. However, they may postpone the tasks due to time limitation.
3.5 4.00E−04 EPC27 4.35 0.310 5.82E−03
EPC33 9.9 0.690 Sub-task 1.4(Connect flexible hose to the ship’s manifold) has also very
high HEP values among the operation. The human errors can have fatal
consequences since overflowing of fuel oil into sea or serious crew in-
combines with consequence severity of a sub-task in order to determine jury can emerge The A/B is a responsible crew to plug all deck scuppers
the tolerability of the risk. High severity was assigned by marine experts in position and ensure they are oil and watertight. However, the op-
since consequences of oil spill could potentially harm. The fuel oil eration is sometimes skipped or not executed properly due to in-
(petroleum product) contains various volatile compounds which cause adequate inspection. Most of ship crew are still not familiar to place
to health risks for marine environment and human. Contamination to deck scupper in position due to lack of practical training. Sub-tasks
the sea water and soil is another fatal consequences of oil spill due to 1.14(Connect flexible hose to the ship’s manifold) and 3.4(Disconnect
human error on-board ship. flexible hose from ship’s manifold) have also high HEP values. In these
In the view of risk matrix, the HEP values are in the range of activities, unreliable equipment is the major contributing factor.
1.00E−01 and 1.00E+00 considered risky activities. They are sub-task Connection or disconnection of flexible hose is under responsibility of
1.4 (Plugging scuppers on deck), 1.8 (Blanking other bunker manifold), duty engineer, pumper and A/B. Although utmost care is exercised by
1.13 (Verifying pumping rate), 1.14 (Hose connection to manifold), 2.2 responsible ship crew in the process of hose connection/disconnection,

107
E. Akyuz et al. Safety Science 110 (2018) 102–109

Table 8
Human error reduction measures.
Sub-task HEP HEP reduction strategies

2.2 8.36E−01 Agreement should be made with bunker barge for low pumping rate and line pressure at start, at maximum flow and at the end.
A sequence should be prepared for pumping rate, including initial, maximum and topping off rate.
A regular inspection should be carried out and minimum one watch-keeper should be on duty.
1.13 5.94E−01 Agreement should be made for pumping rate.
Regular inspection should be made for monitoring pumping rates and gauges to ensure that line pressures are not too high.
1.8 2.36E−01 An acknowledge report to duty engineer should be given by crew after finishing relevant task.
A visual notice should be positioned at appropriate place to remind task.
Responsible ship crew should be aware that the equipment is not completely reliable.
2.3 2.21E−01 Monitoring of the operation should be carried out as per ship's SMS.
Minimum one watch-keeper should be effectively duty during the entire operation.
A regular inspection should be carried out by chief engineer that the control measures are effectively in place.
Watch handovers should be kept minimum to save the time.
1.4 2.13E−01 A practical training should be provided for ship crew who are not familiar scuppers.
Chief officer should re-check whether deck scuppers are all in position or not.
Scuppers are well maintained fit for deck.
1.14 1.14E−01 A comprehensive inspection should be performed by duty engineer for flexible hose.
Duty engineer should carefully inspect the hose and ensure the gasket is fitted bolts.
Responsible ship crew should be aware that the equipment is not completely reliable.
3.4 1.14E−01 A comprehensive inspection should be performed by duty engineer for flexible hose.
Duty engineer should support pumper and A/B in the process of disconnection.
Responsible ship crew should be aware that the equipment is not completely reliable.

most of bunker barges have substandard equipments such as gasket or the maritime operations. The method can also be used to focus on
bolts. This may cause a leakage in the vicinity of the connection/dis- evaluating human error during critical operations in offshore and ocean
connection to the manifold on the installation. engineering since the m-EPC reflects general characteristics of seafarers
employed in the maritime, ocean and offshore environment. The further
work will include fuzzy logic approach to tackle with ambiguity and
3.6. Human error reduction measures
vagueness during APAO calculation.
In order to enhance safety level and reduce the probability of human
Acknowledgment
error occurrence in bunkering operation, the human error control
measures are recommended for the sub-tasks with high HEP values.
The author wishes to thank the reviewers and editor in charge for
Table 8 depicts some control measures human error during bunkering
their very constructive feedback.
operation at chemical tanker ships.
Appendix A. Supplementary material
4. Conclusion
Supplementary data associated with this article can be found, in the
Environmental sensitiveness is one of the most important concerns online version, at https://doi.org/10.1016/j.ssci.2018.08.002.
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