7 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

36
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

38
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.

39
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.

Equipmentrelatedfactors Factorsrelatedto Organisationalfactors

Blackout
Failurerelatedtonavigation
equipment
Inadequatetechnical
equipment
Maintenance
Technicalfailureof
communicationequipment
Technicalfailureof
navigationequipment
Externalfactors
Durationofjourney
Extremeeventonship
Levelofothervesselactivity
Timeofday
Weather
handling
Familiarisationwithship
characteristics
Failuretoensurefitnessat
handover
Lackofcommunication
Misunderstanding
Notfollowingguidance
Notusingindependent
referenceequipment
Overrelianceontechnical
equipment
Personalstress
Wishfulthinking
Bridgeprocedures
Healthmanagement/culture
withintheorganisation
Layoutofthebridge
Organisationalculture
Reportingandfollowup
Timeintothewatch
Typeofwatchsystem
Workloadtoohigh
Workloadtoolow
Workpressure
Personalcharacteristics
Ageandgeneralhealth
Competence
Fatigue
Language
Perceptionofnegative
effectsfromsubstances

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Figure12:Anillustrationofhowtheidentifiedscenarios,causesandfactorsarelinked.

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