Candidate number:

Course: Safety and Human Factors

Course code: MMO5002
1. Introduction 2
2. The case 2
3. Theory 3
3.1 SA levels 3
3.2 Team SA 4
4. Analysis 5
4.1 Sleepiness barriers 6
4.2 Technology 6
4.3 SA or Team SA? 6
5. Conclusion 6
6. Bibliography 7

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 1. Introduction

Human error are behind several maritime accidents however the crew is not always to blame.
( Sánchez-Beaskoetxea, J., Basterretxea-Iribar, I., Sotés, I., & Machado, M. de las M. M,
2021, p1). This paper is based on a public accident report ‘Nora Victoria’ , grounding and
founding off Finnøy island on 30 June 2014 due to a skipper fell sleep on watch.
The purpose of this paper is to analyze the advantages and disadvantages of the strategies that
the crew has chosen. To investigate the accident, the theory of situation awareness has been
central to the purpose of giving reliable contributions.

2. The case

‘Nora Victoria’ is a workboat, at 20:59 on Monday 30 June 2014. She left the quay at
Knarholmen in Vestre Bokn with a course to Høna beacon in Finnøy island. The skipper
swicht on the autopilot after 12 or 14 minutes and set the course to her destination and sat
down in the navigator’s seat. (AIBN, 2015, p. 4). At 22:33 ‘Nora Victoria’ grounded close
to the south-west of Høna beacon.

The skipper sustains that he felt sleep and just woke up when the vessel grounded and when
he was conscious of the situation, he performed a check unsuccessful. At 22:45, the skipper
abandoned the vessel. The Accident Investigation Board Norway (AIBN) sustains that the
grounded of the vessel is a result of “the skipper falling asleep and therefore not performing
the intended change of course in time” (AIBN, 2015, p. 4)

Moreover, the skipper presented a deficit of sleep in the last days. Another factor was the
time, where the voyage was at the end of the day. The characteristic of the voyage was a
routine operation with high concentration and without high physic activity.

‘Nora Victoria’ foundered because the vessel had open doors between the engine room and
the fore peaks. (AIBN, 2015, p. 4). The observation of the skipper was not enough due to he
not check for any leak.

No safety management system had been prepared for ‘Nora Victoria’, and the vessel did
neither carry a departure checklist nor an emergency procedure in case of grounding.

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 3. Theory

According to “situation awareness is the perception of the elements in the environment

within a volume of time and space, the comprehension of their meaning, and the projection of
their status in the near future” (Endsley, 1995, pag. 36).

Fig1. Situation awareness. (Endsley, 1995, pag. 35).

Figure 1 shows three levels of situation awareness (SA) which the operator can have while
interacting with the dynamic systems:

3.1 SA levels

Level 1 SA: Perception of elements in the environment. The first level of SA relates about the
perception of information, the elements in the environment and general the status of the
situation . (Endsley, 1995, pag. 36). A skipper or engineer on watch (EOW) will perceived
elements such as the weather, the position of the vessel, speed, course, the status of the
engine, etc. These elements are required to be perceived first in order to made an optimal
performance of the environment. SA is the ability to know what is happening around your
person.

Level 2 SA: Comprehension of the current situation. The second level of SA. This level
refers to the comprehension of the SA, through how the operator comprehends the

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information. (Endsley, 1995, pag. 37). Level 2 SA is about understanding of what is
happening on the basis of previous observations. (Endsley, 1995, pag. 37). In terms of
navigation concepts as for example: Closest point of approach (CPA) is a term that involves a
previous stage of observation. CPA is the distance without changes in course and speed data.
( Wärstila, 2023), to arrive to CPA the skipper should made observations (SA1 level) to arrive
to CPA ( SA2 level)

Level 3 SA. Projection of future status. The third level of SA refers to the ability to make
projections about the elements in the environment. For a skipper, the concepts of radar
simulation provide a reference for future planning of the voyage and the issues that can
involve it. There are many reasons why we may fail to perceive what is happening around us,
for example, "tunnel vision" and "zoning out" are seen as two important factors (Flin,
O'Connor & Crichton., 2008, p. 24). According to Endsley, other factors concerning level 1
are when the information is not available or is difficult to detect/perceive, failure to scan or
observe data or the misperception of data. endsley (Flin, O'Connor & Crichton., 2008, p. 24).

3.2 Team SA

Salas sustain that aa team is « A distinguishable set of two or more people who interact,
dynamically, interdependently, and adaptively toward a common and valued
goal/objective/mission, who have each been assigned specific roles or functions to perform,
and who have a limited life-span of membership”. ( Rouse, Fellow, IEEE, Cannon-Bowers,
Salas, 1992, p. 1297). As a general idea, a team is a group of persons with a common goal.
Team SA concept is “the degree to which every team member possess the SA needed for his
or her job” (Endsley, 1995, p. 39). A group of individuals may work as a team and everyone
has a responsibility. ( Endsley, 1995, p.38-39). It means that for example if two persons need
to collaborate to acquire information, both have responsibility in the team to know the part of
the piece of information. (Endsley, 1995, p. 39). In other words, the individual role that each
person has in a team is decisive for the whole situational awareness.

In a bridge team on a construction vessel, for example, the officer on watch has the
responsibility of the navigation of the vessel, however it depends on the decisions of the
captain and the chief officer. Moreover, the rest of the crew depend on their decisions.

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 4. Analysis

Many studies sustain that despites there are a lot of advances in technology, around 80% of
all accidents are caused by human error. ( Berg, Storgård and Lappalainen, 2013, p.5). This
section starts with a discussion of ‘Nora Victoria’ and the advantages and challenges
between. SA and the SA team. Finally, there are other factors.

As described in section 3, three levels of the SA model consists of Perception of information

elements in the environment, comprehension of the current status and projection of future
status. In the case of ‘Nora Victoria’. Level 1 SA is based on the perception of the skipper is
the route plan: Knarholmen in Vestre Bokn to Høna beacon on Finnøy island. “A pilot would
perceive elements such as aircraft, mountains, or warning lights along with their relevant
characteristics (e.g., color, size, speed location)” (Endsley, 1995, p. 36).

Level 1 SA, skipper observations were insufficient because the door in the forward
compartments was open. This contributes to a total sinking of the ship.

Level 2, it was based on the perception of the skipper of the route. “The operator of a power
plant needs to put together disparate bits of data on individual system variables to determine
how well different system components are working, deviations from expected values, and the
specific locus of any deviant readings.” (Endsley, 1995, p. 37). The skipper arrived at this
level however, it was interrupted by the sleep of the skipper.

Level 3, it is based on the operator’s projection of the meteorological data, the traffic and the
route. “An automobile driver also needs to detect possible future collisions in order to act
effectively” (Endsley, 1995, p. 37). The skipper should anticipate the traffic and the weather
conditions. In the case of Nora Victoria, the skipper arrived at level 2.

Poor performance is expected when the SA is incomplete, due to the skipper incompleted the
level of SA 2, it is easy to deduce the uncomprehending of the perceived data. “An incorrect
situational awareness on the part of the team has in fact been a factor in many of the
accidents that have occurred in the Navy” ( AIBN & , DAIBN, 2019, pag. 191).

Furthermore, there are other factors that can influence the crew:

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4.1 Sleepiness barriers

MAIB finds that all three basic physiological parameters as for example: sleep deficit,
circadian rhythm influence and low activation level; which affect sleepiness may have
contributed to the skipper felt sleep on the night of the accident.

4.2 Technology

Nora Victoria was not equipped with any barrier against accidents. (AIBN, 2015, p.22). For
larger cargo ships, both national and international regulations require such a barrier, in the
form of a bridge watch alarm. In Norway, is not required for cargo ships with a gross tonnage
of less than 150. (AIBN, 2015, p. 22).

4.3 SA or Team SA?

A large vessel requires a major number of crew on the bridge than a minor vessel that
requires a small crew, at the grounding of Nora Victoria, where there was only one person
responsible for navigation safety. (AIBN, 2015, p. 4). On the night of the accident, an extra
person on the bridge could help to avoid the accident. However, a major crew number
represents a challenge, in relation to manage the hours, the communication or competence.
In his study Horck refers that “major reasons for accidents are poor communication, loss of
situation awareness, poor decision- making and lack of effective leadership and breakdown
of team performance”.( Berg, Storgård and Lappalainen, 2013, p.22).

5. Conclusion

SA has been used to analyze the case of ‘Nora Victoria’ due to the characteristics of the
crew, the crew was formed by the skipper. The night of the accident, an extra person on the
crew could help to reduce the probability of the accident. Independently of the other factor as
psychological, technological or for experience.
Human error has been a main factor that has caused the accident due to lack of situational
awareness. (Berg, Storgård and Lappalainen, 2013, p.35). ‘Nora Victoria’ accident is
categorized as a human error that caused a maritime accident.

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 6. Bibliography

Berg, N., Storgärd, J., Lappalainen, J., et al., 2013a. The impact of ship crews on maritime
safety”. Kouvola: Publications of the Centre for Maritime Studies. University of Turku. A
64:42 .
https://www.semanticscholar.org/paper/THE-IMPACT-OF-SHIP-CREWS-ON-MARITIME-
SAFETY-Berg-Storg%C3%A5rd/b8f7fbeebff8828ddf6bd8e5d4a9a18895e6a8e2 .

Endsley, M. R. (1995). Toward a theory of situation awareness in a dynamic system.

Flin, R., O'Connor, P., & Crichton, M. (2008). Safety at the sharp end : a guide to
non-technical skills (pp. X, 317). Ashgate.

Norwegian Safety Investigation Authority (AIBN). (2015). Report on marine accident with
Nora Victoria - LG4311, grounding and foundering off Finnøy island on 30 June 2014. (
Report No 06/2015).

https://havarikommisjonen.no/Sjofart/jAvgitte-rapporter/2015-06

Norwegian Safety Investigation Authorithy (AIBN & DAIBN) & Defence Accident
Investigation Board Norway. (2019) ( Report No 08/2019). November 2019.
https://mtipservices.gov.mt/en/Documents/MSIU-by-other-countries/2019_08.pdf

Sánchez-Beaskoetxea, J., Basterretxea-Iribar, I., Sotés, I., & Machado, M. de las M. M.

(2021). Human error in marine accidents: Is the crew normally to blame? Maritime Transport
Research, 2, 100016. https://doi.org/10.1016/j.martra.2021.100016

W. B. Rouse, J. A. Cannon-Bowers and E. Salas, "The role of mental models in team

performance in complex systems," in IEEE Transactions on Systems, Man, and Cybernetics,
vol. 22, no. 6, pp. 1296-1308, Nov.-Dec. 1992, doi: 10.1109/21.199457.
https://ieeexplore-ieee-org.galanga.hvl.no/stamp/stamp.jsp?tp=&arnumber=199457&tag=1

Wärtsilä. (2023). Wärtsilä encyclopedia.

https://www.wartsila.com/encyclopedia/term/closest-point-of-approach-(cpa)

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