FAULT TREE ANALYSIS

The fault trees presented here are a summary of the results from workshops held with
DNV and AMSA. They illustrate the causal mechanisms required for a grounding or
collision incident. To interpret the trees, we should start at the top event (e.g.
‘grounding’) and work downwards.
Where the path is marked ‘AND’, all of the subordinate events are required to occur
simultaneously. Where it is marked ‘OR’, either one of the subordinate events can result
in the event in question.
The event descriptions in the trees are accompanied by two percentages. The
percentage not in brackets represents the team’s estimate of the contribution of the
event in question to the top event frequency (for example, ‘gyro wanders’ represents
1% of the total grounding causes).
The numbers in brackets indicate how these contributions might be reduced if fatigue
were to be totally eliminated. This then provides an indication of the maximum risk
reduction achievable through fatigue
management.
AMSA I.2 Det Norske Veritas
GBR Pilot Fatigue Risk Assessment September 1999

Grounding
or

Bad Weather <=1 Navigation error 43% (24.5) Uncharted danger <1% Fail to change course 43% (36.5) Force to ground by other Hardware Failure
vessel <=1% 11% (11)
or
or or

Wrong Course Incorrect knowledge of Wreck <1% Natural <1% Pilot Crew Other ship
Plotted 1% (1) position 42% (23.5) error Error error
or
And

Gyro wanders Course change Failed to change course

Wrong Pilot Crew 1% (1) incorrect 30% (27) to plan 12% (8.5)
Course fails to fails to
Plotted notice notice And or

Gyro Not
or wanders noticed Pilot forgets to Pilot not Pilot
or change course fetched asleep
8% (5) 3% (3) 1% (0.5)
Hardware Bad Incorrect Incorrect Crew Pilot advises Helmsman And
Failure Weather Interpre- positioning 18% (10) wrong course takes wrong
5% (2.5) 1% (1) tation of 10% (8) course 20%
info 18% (19) Crew fail Own
(10) And to call failure
or And

Failure Failure Advises Crew

Primary Secondary And wrong don’t Forgets Not
course correct And corrected
And
Pilot Crew failure
failure to correct Fail to Wrong
notice Course Not Pilot
woken asleep on
And bridge

Crew Pilot And And or

failure failure
to
correct Pilot fails Crew by by Falls Nap
to notice fails to himself crew asleep
notice

c:\my documents\gbrfatigue.doc 7 September 1999

AMSA I.3 Det Norske Veritas
GBR Pilot Fatigue Risk Assessment September 1999

Collision 100% (80)

Collision, other vessel Collision with no

visible 80% (80) warning 20 (17)

or or

Own (piloted) ship violates Collision from other ship Info. Misinterpretation when Didn’t see 15 (12) Because couldn’t see it 5 (5)
collision regs. 30% (20) violation 45% (35) under radar 5% (2.5)

And And And

Pilot Error Crew Error O S V. Pilot fails to Crew fails to Pilot didn’t see Crew didn’t see Hardware didn’t see it
respond respond (ARPA)
effectively effectively

or And And

‘Intentional’ Unintentional Fails to Pilot takes Vessel Fails to Pilot takes Vessel
error error notice inappropriate incapable of notice inappropriate incapable of
violation action taking violation action taking
evasive evasive
action action

c:\my documents\gbrfatigue.doc 7 September 1999