Incident Investigation

Assessment task 2

1. Task description:

Attilio Levoli a 6,239 dwt oil/chemical tanker built in 1995 was owned and managed by an Italian company, Marnavi S.p.A. The tanker was registered in Italy and had a crew of 16 people from different nationalities. Often the vessel engaged in trade between North European and the Mediterranean ports with Antwerp to Rotterdam, Tarragona to Antwerp, and Rotterdam to Fawley being her last three voyages. On one Thursday afternoon, Attilio Levoli was involved in an accident she was on passage to Barcelona after grounding in Southampton Water. The casualty occurred at around 1500hours local time while she was on route from Falwey to Barcelona with a crew of 16 people aboard and was refloated with the rising tide by around 1900 hours, without tug assistance (Attilio Levoli 1-35).

A report from a Marine Accident Investigation Branch has concluded that the grounding of the loaded tanker in the West Solent was as a result of poor bridge management with the master being distracted from navigational duties by long conversations on his mobile telephone. The grounding come about when the master of the Attilio Ievoli designated to navigate the vessel through the Needles channel and west Solent between the Hampshire coast and the Isle of Wight after they had dropped the pilot, who had taken the ship from Fawley (Attilio Levoli 1-35).

This channel had no available pilotage service, with draught ships that are bigger and deep invariably using the east Solent passage. In addition, the Marnavi S.p.A Company had provided instructions for their vessels to use the east Solent passage, but by using the 'shortcut' to Spain, the master had hoped to save four hours.

After dropping the pilot, the master was conning the ship on autopilot and clearly the ship drifted off the channel and it moved northward until it grounded, thus causing the plate on the bottom to indentation frontward but there was no hull penetration. Although chemical tanker was loaded with styrene and toluene monomer the bunkers and cargo did not leak and eventually the tanker refloated on the tide (Attilio Levoli 1-35).

The report concluded that there was inappropriate division of tasks and poor bridge team management between second officer, the cadet, master, and the chief engineer of the vessel who was seated in one of the two seats at the navigational console.

Evidently, the master had been alerted by the second officer, when he discovered that the vessel was off the track to the north, but at that critical moment he was occupied on his mobile phone.

2. Explain how accident causation has changed over time from individual models such as domino theory to more complex models such as the 'Swiss-Cheese' model.

Heinrich developed one of the earliest formal accident causation theories in 1931. He developed the 'domino' theory of accident causation after analyzing 75,000 accident reports from companies insured with Travelers Insurance Company. From this analysis, he concluded that 88% of all happens as a result of unsafe acts by human beings, 10% were caused by unsafe conditions while two percent of the accidents could be attributed to an act of God (Heinrich, Roos and Petersen, 1980).

Heinrich came up with five factors in the accident sequences based on his analysis. These factors include the social environment and ancestry; unsafe act and or physical/mechanical conditions; human fault and carelessness; the accident; and the injury. Social environment and ancestry included learning custom and social practice in the workplace. The factor of 'carelessness' included negative personal characteristics of the individual. Unsafe acts of physical conditions included the errors and technical failures, which resulted into the accident (Mark 23).

Heinrich's accident causation theory is a simple linear sequence of events that explains what happened, but it does not provide much information on why the accidents occurred and lays the responsibility squarely on the unsafe act or mechanical conditions without considering other underlying contributory factors.

Early accident causation theory has been superseded by current and more sophisticated theories of accident causation. A more complex domino theory suggests that adverse events have immediate causes, underlying causes and, root causes. The theory provides a succinct description of how the organizational aspects of accident causes link with individual losses, and how human errors can be the result of series of incident sequence. The theory implies that unsafe acts are more frequently involved in incidents more than unsafe conditions.  Therefore, its philosophy of incident prevention emphasized unsafe acts and person related factors leading to them. Domino theory of accident causation provided the first suitable ideological match in that his approach emphasized the financial costs involved in accidents rather than providing a comprehensive understanding of accident causations.

A more complex linear model was developed in 1997 by Reason. The Swiss cheese theory is currently one of the most complex influential and widely used theories of accident causation among safety professionals (Shappell & Weigmann 2). The theory simply suggests that in any organization, defenses are used to prevent hazards from becoming losses (Shappell & Weigmann 2). Organizational defenses can be 'hard' and 'soft'. 'Hard' defenses include automatic warning devices and alarms, engineering technical safety features, and protective weak points designed in to the system. 'Soft' defenses are based on personnel and procedures, and includes legislative and regulatory requirements; assurance inspection and checking; standard operating procedures; training and briefing; permits to work; and supervision and operation. The Swiss Cheese Model offers a positive method of risk reduction, rather than trying to break some invisible chain, simply one just have add layers, or enhances the effectiveness of the layers that exist (Shappell & Weigmann 2). For instance one could add a layer of crew training, or use extra care in passage planning, or find ways on how to improve the effectiveness of the present training.

Contemporary models of accidents acknowledge that accidents are the consequence of a multi-factorial process in which mistakes play a vital role. In addition, the demonstration of hazardous behaviors that, in line, manipulate the probability of an accident is given a pivotal role. The models suggest that varied factors for example, social environment, managerial approach, the system design, equipment, design of the entire job, and personality of the worker(s) influence unsafe behaviors (Shappell & Weigmann 2). Therefore, it is critical to understand the factors that help to prevent errors and accidents. In the article, what follows is the description of the various current approaches to errors; it then discusses factors that contribute to safety, and finally it the factors are used for safety involvements.

3. Explain the four levels of analysis in HFACS.

The Human Factors Analysis and Classification System (HFACS) was specifically developed to define the latent and active failures implicated in Swiss cheese model so it could be used as an accident investigation and analysis tools. Although HFACS initially was designed to be used within the military aviation context, it has proven to be effective within the context of military and civil aviation and has been shown to be effective in both. HFACS specifically describes four levels of failure, each of which corresponds to one of the layers contained within Reason Swiss Cheese model. These consist of: 1) unsafe acts; 2) Unsafe supervision; 3) prerequisites for unsafe acts; and 4) influences of the organization (Shappell and Weigmann 3).

In other words, the HFACS framework goes beyond the simple identification of what an operator did wrong to provide a clear understanding of the reasons for the error occurred in the first place. In this way, errors are viewed as a consequence of system failures and or symptoms of deeper systematic problems and not simply as a fault of the employee working at 'the pointy end of the spear.'

Operators' unsafe acts can be divided into two categories: violations and errors. Generally, errors represent individuals physical or the mental activities that fail to realize their anticipated result. Given that in reality humans by nature make errors, these unsafe acts have been found to dominate most accident databases (Shappell and Weigmann 3).

Preconditions for unsafe acts, which include the condition of the operators, environmental and personal factors describe another level of HFACS framework (Shappell and Weigmann 6). Nearly 80% of maritime accidents can be directly linked to the unsafe acts of aircrew. The condition of an individual can, and often does influence performance on the job. These preconditions are categorized into environmental factors, conditions of the operator in terms of mental, physiological and physical state as well as fitness for duty.

In the Reasons 'Swiss model' of accident causation, supervision influences the conditions of pilots and the type of environment they operate in. Unsafe supervision is the third level of analysis in HFACS. There are four identified types of unsafe supervision: Inadequate supervision, failure to rectify an identified problem, planned inappropriate operations, and supervisory violations (Shappell and Weigmann 9).

Organizational influences are as a result of upper-level management that direct influence on supervisory influences, supervisory practices, in addition to the operators' actions and conditions. In general, the most obscure latent failures resolve around concerns that relates to the climate of the organization, the processes of operation, and resource management (Goetsch 33).

4. HFACS classification for the Atilio Ievoli.

Human Factors Analysis and Classification System (HFACS) can be used to analyze and defined the Atilio Ievoli accident primary causal factors.  Using HFACS, four levels of human failure are identified as follows:

1.      Unsafe Acts (Active Failure)

Decision errors- The human factors failures commenced when the master, contrary to the instruction of the company, choose to use the West Solent. This channel had no available pilotage service, with draught ships with bigger and deeper invariably using the east Solent passage.

Skilled-based error- the master failed to prioritize his attention, being distracted from navigational duties by long conversations on his mobile telephone

Pe-rceptual errors- Vision was not an issue in this accident. Sea conditions and visibility were good

Violations: The Marnavi S.p.A Company had provided instructions for their vessels to use the east Solent passage, but by using the 'shortcut' to Spain, the master had hoped to save four hours.

2.      Preconditions for unsafe acts

The condition of operators- In this accident fatigue was not an issue. The master of Attilio Ievoli was well rested as he had rested the whole night. For the second officer he had also rested, although there was a possibility of slight risk fatigue likelihood. The cadet was also rested as he had kept to his four on, eight off, sea watch schedule while at the port.

3.      Unsafe Supervision

Inadequate supervision:

-There was no briefing that took place, and they made assumptions on the task each was supposed to perform.

-Exacerbated by the differences in culture, was an important factor in this accident. This was as an outcome of the diverse cultural disparity and communications practice while aboard.

-Appropriate procedures are necessary to guarantee that electronics that assists the vessel to navigate are appropriately used. The port radar, thou operational, was unoccupied because the chief engineer who was performing her fuel consumption, examining the UMS alarms and other voyage calculations was seated in front of it.

-The second officer should have occupied the port workstation so that he could monitor the progress of the vessel with the use of parallel indices and the port radar.

-Pre-sailing briefings were not made to define the various responsibilities to be taken by each bridge team member, the echo sounder was not effectively operated, the second officer was not using the port radar, and the usual fixing position of the ship was assumed.

-Improper manning

-The Mission did not follow the rules and regulations to the letter. The only specific instructions that the company made concerning navigation in the Solent were included in the19 November 2003 Company's circular. These stipulated the pilots' embarkation and disembarkation when they approach the Solent at St Helens Box. This was meant to make sure that the eastern Solent was the passage pilots were to use while navigating their vessels. In this case the master disregarded what the company had stipulated, on this occasion and also on his prior visit to Fawley six weeks before.

-The navigators had not planned an independent method that could be used to confirm his cross track error

Organizational Influences -

-The safety management system was effective and the accident would not have happened had if the instructions and procedures concerning the navigational procedures were followed to the letter.

-Marnavi vessels, when the vessel was grounding, had not acquired the full charter party agreement aboard.

5. Discuss the results of the HFACS classification. What are the lessons that need to be applied to navigation and safety management from this accident?

Generally, it is acknowledged that such a marine accident is typically as a result of a chain of events that often culminate with the unsafe acts of operators as already discussed. The HFCA classification framework goes beyond the simple identification of what the marine crew did wrong to provide a clear understanding of the reasons for the error occurred in the first place.

Using HFCA in analyzing Attilio Ievoli accident, errors are examined not simply as a fault of the employee but as consequences of system failures and or systems deeper systematic problems. The HFCA analysis shows that the grounding of the loaded tanker in the West Solent was as a result of poor bridge management, with the master being distracted from navigational duties by long conversations on his mobile telephone. The grounding come about when the master of the Attilio Ievoli designated to navigate the vessel through the Needles channel and west Solent between the Hampshire coast and the Isle of Wight after they had dropped the pilot, who had taken the ship from Fawley. This channel had no available pilotage service, with draught ships that are bigger and deep invariably using the east Solent passage. In addition, the Marnavi S.p.A Company had provided instructions for their vessels to use the east Solent passage, but by using the 'shortcut' to Spain, the master had hoped to save four hours.

In addition, it can be concluded that there was inappropriate division of tasks and poor bridge team management between second officer, the cadet, master, and the chief engineer of the vessel who was seated in one of the two seats at the navigational console.

Action should be taken to guarantee that effective regime is established for the purpose of directing and controlling of all commercial shipping. Those actions should include improved survey of navigable waters, an appropriate pilotage service, and prerequisite of appropriate VTS coverage. Internal procedures should also be in position to substantiate compliance with instructions of the company. Mobile telephones use should also be restricted in pilotage and other restricted waters.